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Doctors and supporting staff at Criticare hospital, Mumbai (Hindustan Times)
Doctors and supporting staff at Criticare hospital, Mumbai (Hindustan Times)

Caring for the carers during the Covid-19 pandemic

The covid-19 crisis is taking a physical and psychological toll on healthcare workers

A recent study by the Indian Journal Of Psychiatry says around 30% of Indian doctors go through depression, and almost 80% face the risk of burnout in the early stages of their careers. The covid-19 pandemic, however, is leading to a whole new level of stress.

Even in normal circumstances, healthcare workers show above-threshold levels of stress. “Around 25% compared to 15-18% in the general population," says Radhika Bapat, a Pune-based clinical psychologist. This holds true not only for doctors but for the entire caregiving team—ward boys, nursing staff, ambulance drivers, sanitation workers. “You can only imagine what the levels must be like right now. Treating covid-19 is not just physical but emotional labour as well," she adds.

Doctors are human too

There are a specific set of anxieties, as Kishore Kumar, founder-chairman and neonatologist, Cloudnine group of hospitals, lists: worry for self and family, shortage of equipment, social stigma.

Already, several instances of resident welfare associations ostracizing doctors have been reported from cities such as Kolkata, Delhi and Pune. Just ahead of the nationwide lockdown from 25 March, the Resident Doctors’ Association (RDA) of the All India Institute of Medical Sciences (Aiims) in Delhi wrote to Union home minister Amit Shah about forceful eviction by landlords fearful of infection. Around the same time, a house surgeon from MGM Hospital, Warangal, put up a post on Facebook: “One owner said that we were dirty...did I study 14 hours a day for this?" The post went viral.

“There is also the fear of being bashed up by relatives if things go downhill," Dr Kumar adds. A doctor on duty at a government hospital in Hyderabad, for instance, was reportedly attacked by the relatives of a 49-year-old who died of covid-19.

A health worker taking a break in Strasbourg, France, 30 March.
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A health worker taking a break in Strasbourg, France, 30 March. (Reuters)

There have been reports of doctors being attacked in cities like Bengaluru, Hyderabad and Indore. According to a 3 April Hindustan Times report, residents of a locality in Indore pelted stones at healthcare workers who had gone there to screen people for covid-19. Two female doctors suffered injuries. A similar incident was reported from Munger, Bihar. More recently, in a video doing the rounds on social media, a doctor working in Surat Civil Hospital was harassed and abused by her neighbour.

The shortage of personal protection equipment (PPE) and N95 masks leaves them even more vulnerable. Some, who are diabetics or suffer from autoimmune diseases, are particularly at risk.

Doctors have vented their frustration on social media. A medical officer at a government-run hospital in Gandhinagar posted on 24 March: “Working at Corona OPD today. No special protective gear provided. No basins to wash hands periodically. I can only hope that no one sneezes on my face." A later tweet noted that change was coming, slowly and steadily.

Rajeev Ranjan, ex-general secretary, RDA, AIIMS, and a laboratory physician, talks of 85 resident doctors at the Nalanda Medical College & Hospital, Bihar, who were not provided PPE. They are all in self-quarantine now. “Healthcare professionals are at the front line of this war. If you don’t give us ammunition, how will we fight?" he asks.

The Union government says it’s working to boost PPE availability.

It’s a crisis, for one infected doctor is worse than five infected patients, with the risk of spread increasing exponentially. By 3 April, there were reports of 50 doctors and medical staff having tested positive for the coronavirus. Several cases have emerged from the Capital itself, in hospitals like Aiims, Safdarjung, the Delhi State Cancer Institute, as well as mohalla clinics. In Mumbai, a 35-year-old doctor from Dharavi has tested positive, as have doctors and nurses in the Wockhardt and Jaslok hospitals. News of the death of a doctor due to covid-19 has come from Indore.

But it’s not just about physical health. Counsellors believe the mental health of healthcare professionals doesn’t get talked about enough. In times such as these, they are likely to suffer from two additional emotional burdens: compassion fatigue and anticipatory grief, or grief for an impending loss.

According to Vikram Beri, who runs the online counselling platform BetterLYF, doctors have become the sole caregivers—both medically and emotionally—in a situation where families are not allowed to stay with patients.

The burden of such overwhelming responsibility is beginning to show up in sleeping and eating disorders as well as substance abuse.

“A lot of doctors are doing self-medication. They are taking medicines for malaria to allegedly build immunity against covid-19, for instance" says Delhi-based mental health expert and columnist Pooja Priyamvada, who offers psychological first-aid and has been taking part in listening circles for healthcare professionals and offering personal active listening support. These sessions are supported by the Bhor Foundation, a Delhi-based trust.

Unprecedented situation

It is imperative, then, for people to understand that it’s a new situation for healthcare staff too—and one they are still learning to grapple with. As 27-year-old KD, a Mumbai-based senior resident in critical care medicine at a government hospital, puts it: “Medically speaking, no one has seen covid-19 before. Doctors and nurses are trained to identify pneumonia and respiratory failure." The doctor did not want to be identified.

This particular infection is being looked at as a game changer; its accelerated course defies the conventional practices of managing severe pneumonia. Not only are physicians under pressure to think outside the box, they need to do so in deeply distressing circumstances. “Many have moved to another accommodation on rent to avoid going home in this crisis, to avoid transmitting infection. This is proving to be very difficult, especially when members of the family, such as the elderly or newborn babies, are dependent on them for care," says Dr KD.

Families of healthcare workers are going through the emotional wringer as well, say Bapat and Priyamvada, who have seen a surge in the number of calls. Priyamvada, for instance, recently received a call from a doctor’s son. His father, a diabetic, is volunteering with hospitals. When he comes home, he locks himself in a room and the family leaves food outside the door. “His son told me that it feels like they have a prisoner in the house. That line has stuck with me," she says. Often, the son sits outside his door to have a chat. “At times it feels to him as if the father’s voice is breaking," she adds.

A crisis intervention plan

The situation needn’t be this dark. For one, hospital administrations can help alleviate stress through proper delegation and sensible decision-making. “Triage is most important—it is the process of assessing if a patient requires ICU, non-ICU, or home care. This way, we can allocate the limited resources to people who need it the most," says Dr KD. Since the decision-making is done by senior doctors, it takes the stress off the juniors.

Mindfulness and relaxation techniques are recommended. Zirak Marker, psychiatrist and adviser, Mpower—a centre and foundation for holistic mental health services—says secondary traumatic stress can impact anyone helping families through a traumatic event. Being in the hospital, witnessing the eerie emptiness or offering consultation to countless patients with flu-like symptoms can cause anxiety. Doctors must seek help if this is impacting their work and families.

What’s also needed is a real-time crisis intervention plan. “This includes group cohesion sessions, in which small groups get together during a 5- or 10-minute break once a day. A team coach—a fellow doctor, head of the institution or someone in the management—then motivates the team," says Bapat. The same coach should ensure the doctors take a break to speak to friends and family. Offering a quiet room would help. “A place where a person can just sit to get relief from the noise and give them a breather. This is called caring for the carers," she says.

Doctors, in turn, need to make a realistic estimate of how far they can push themselves. Priyamvada suggests controlling interaction on social media as, with people in emergency mode, there have been countless requests for medicines on WhatsApp. “You need to know what is in your control. Government policies are not. If your hospital has only two ventilators and the government is not providing more, there is nothing you can do about it. It is not your guilt," she says.

Not everyone needs psychological intervention, just someone who can listen can be enough, says Priyamvada. To ensure this, hospitals such as Cloudnine have installed internal helplines for the staff, to enable calls with experts and seniors. There are also regular meetings on Zoom to keep the conversation going.

“A lot of the resident doctors stay in the hostel or share a flat. We share our problems with each other. At this time of need, everyone is helping. Because together we can, and together we will," says Dr Ranjan.

Handy tips for healers

Zirak Marker, psychiatrist and adviser, Mpower, suggests some easy solutions to manage your anxiety at work

  • Take a break from the news. Hearing about the pandemic repeatedly can be upsetting.
  • Create a constructive routine for personal self-care activities that you enjoy, such as spending time with friends, family and children—online or over the phone, exercising diligently at home, with floor workouts or using Therabands /resistance bands.
  • Speak to other doctors about how they are coping.
  • Understand that this phase will end.
  • Ask for help if you feel overwhelmed or concerned that this is affecting your ability to care for your family and patients as you did before the outbreak. Monitor yourself for symptoms such as difficulty in sleeping and concentrating or a sense of fatalism.

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