key: cord-0059012-z9mnsgxk
authors: Hecht, Patricia
title: Repurposed, Reassigned, Redeployed
date: 2020-09-29
journal: Shared Trauma, Shared Resilience During a Pandemic
DOI: 10.1007/978-3-030-61442-3_2
sha: 36a6ddf5e9454b7373aba3f686c40d66c1bee13a
doc_id: 59012
cord_uid: z9mnsgxk

In this warzone of the new coronavirus, nurses, doctors, and healthcare workers are being moved to units they are unfamiliar with. They are frightened and experiencing feelings of inadequacy and helplessness they haven’t known since their early postgraduate days. My patient, an OR nurse of 30 years, is one of those reassigned from her place of comfort to the trenches of the intensive care unit (ICU). Her years of nursing expertise are sorely needed, but the need competes with her overwhelming feelings of deficiency. She feels held hostage by all she does not know about critical care nursing. This case study addresses the patient’s move in therapy from paralysis to a position of resilience that enables her to recognize and use her skills to move forward and contribute in her own unique way. It also ties in to how the general population has had to find ways to reconfigure their lives to survive and thrive.

bed sheets and bedclothes and hoping the same would be done for her should she be diagnosed. Meanwhile her colleagues continue to disappear, not from illness but from fear. "What's killing me is that nobody thinks it's their duty. We need to do the right thing. We're nurses and that's the meat of who we are." Nursing is more than Thea's job; it's her duty.

There is an almost daily changing of rules, procedures, policies, and guidelines. There is the "donning" and "doffing" of personal protective equipment (PPE), the mask, the hair covering, the face shield, and the hazmat jumpsuit and repeat, the horrible headaches from all the protective gear, and washing hands 50-60 times a day until they're dry, sore, and chapped.

The nightly news reports were comparing this viral pandemic to the AIDS crisis of the 1970s and 1980s, no cure, lives lost with staff standing by helpless. Voices over the hospital intercom announced "codes" for dying patients. Staff was terrified, terrified of getting sick, terrified of not being able to do their jobs. It created a palpable sense of anxiety within the hospital walls. The anxiety rivaled the virus for airtime. "We're all on edge. Our patients are the virus that inhabits them. They are both our enemies and our charges."

In addition to reinventing herself as a critical care nurse, Thea is struggling with moral injury in the context of a trauma (Jones 2020, pp. 127-128) . This is a term that originated in the military and describes the violation of a person's deepest and most closely held values and moral standards. Thea and her coworkers have lost trust in their boss and become suspicious of her unwillingness to tell them whether other staff members have tested positive for the virus. The boss denies that she knows of any testing results but Thea knows that can't be true. She also knows that her boss is working with the pressure of only a skeletal staff and fears that with spiking test results others will flee.

There is a "cultural dissonance" that allows moral injury to develop. Often this dissonance develops within a specific culture. For veterans it is the military culture, the culture of war. For these nurses it is the hospital culture that has now turned into a battle zone. Working in an environment where both leadership and staff put their own fears above their responsibilities to patients can induce a sense of powerlessness and hopelessness, gateway feelings to depression. The entire country is struggling with toxic leadership, caregivers, and caretakers. Those who stay at the hospital could soon be patients, too, as could Thea. The stress increases exponentially.

Much of this work feels so familiar to me from my days working with the American Red Cross disaster mental health team. We worked with families who lost loved ones in air disasters, fires, and of course the Twin Towers. We were instructed, in fact required, to debrief one another every day, reviewing our experiences, our feelings, and what lay in store for us as we returned home; what were our responsibilities, our worries, and our supports? Listening to Thea revived my own memories and complex emotions from those days.

It wasn't hard to identify with Thea's experience; in fact, identification was inescapable. In the early part of my career, I worked nearly 10 years in both psychiatric emergency and inpatient psychiatry units. Seeing 300 patients a day in the emergency room of a midtown NYC hospital was often harrowing. Families of victims of gunshot wounds and knifings, heart attacks, and strokes were more often than not inconsolable. Memories of one particular day working with five different families of dead on arrival (DOA) had sent my autonomic nervous system spiraling. My neck and chest were covered with hives. After passing my boss in the hallway, I was sent home to recover, taken out of the line of fire. But Thea couldn't just be sent home or walk away to recover. Exhausted, she had to remain fighting.

We clearly had a context in common and likewise the panoply of responses that go with the territory of being immersed in an emergency universe. We were experiencing a shared trauma (Tosone et al. 2012 ). We'd both been exposed to the same collective trauma -the viral pandemic that had overtaken our world. We were both being impacted by the same event but were working differently with our patients. Thea tended to their physical, medical, and psychological needs. I envied her. My work was limited to my patients' psychological narratives. I coveted Thea's ability to work with the practical and tangible and see immediate results, often relief. My "do-over" wishes to go to medical school to train as a neurosurgeon were manifestly revived and dashed instantaneously; I'm too old for do-overs. Tosone et al. (2012) describe shared trauma as a term first used after 9/11, but note that the phenomenon was described in the psychoanalytic literature in 1942 after the London Blitz. They describe how shared trauma can heighten and strengthen as well as blur the boundaries of the intimacy of the therapeutic connection. I am reminded of a dear friend and colleague's experience with her patient in an Israeli bomb shelter. She was treating a male patient when suddenly the emergency sirens blared and everyone was instructed to go into their shelter and don their gas masks. My colleague struggled with hers as her patient reached over and reassuringly detangled it and gently placed it on her face, sweetly brushing back her hair off her cheek in the process. That experience provided fodder for many sessions to come.

My therapy with Thea involved listening about her days in the ICU, warding off trauma, and reframing her distorted ideas of herself as inadequate and useless. She was being hailed as a hero but felt like an imposter. "I'm posing as a nurse, anyone can change bed linens." She hadn't learned "vent settings" and didn't know how to record medications in the hospital computer system. She felt ill prepared. "Thirty years as an OR nurse and I'm not ready to be thrown into the ICU." Thea used our sessions as debriefings, an apt metaphor as she compared her job to being in a war zone. Military analogies seemed to be everywhere. She described in detail what it was like to treat patients who were dying and who knew they were dying but whose families could not be with them. She reminded herself what she could do. It is with the families that she found her sense of value. She FaceTimed from patients' bedsides with the husbands, the wives, the children, and the grandchildren. She had the therapeutic touch.

She was repurposed in those moments as a pastor, as a giver of hope when she looked into her patients' eyes at the scariest moments of their lives, and acted as the center of calm. She acts as the transitional object (Winnicott 1953) for the families as they say goodbye. She embodies and channels individual family members and absorbs all of their feelings. She is their container, their vessel to move their feelings to their loved ones.

Her low-tech handholding has given her a purpose in her repurposed position. "I am the conduit and I hold everyone's feelings. I come home and stand naked in the shower letting the steaming hot water wash away the day's poison and pain. This is when I realize what my body has absorbed all day. I am the patient's husband, their wife, their child, even God help me -their dog, all crying and pleading for them to pull through. An hour in the shower goes by without my being aware of the constant ticker tape of feelings circling my psyche."

According to a recent article (Lai et al. 2020) , referencing 34 Chinese hospitals, the psychological impact on healthcare workers fell most heavily on the female nursing staff. They worried about contaminating family members and trying to balance their responsibility to family with their responsibility to their patients. Thea knows this feeling all too well, the terror of bringing this virus home to the five millennials who are quarantining with her as well as her husband.

But while she can call me to "debrief," so many of her colleagues don't have therapists and rely solely on any programs their hospitals provide. So much of trauma can be headed off with programs in place -"oasis rooms," meditation breaks, complimentary massages, and even staff dancing breaks to boost morale and discharge the stress. Alcoholics Anonymous's (AA) move a muscle; change a thought never seemed so true. One hospital instituted a program called Check You, Check Two, urging staff to tend to their own needs and then touch base with two colleagues daily (Hoffman 2020) .

The terror of bringing this virus home drove her to a nightly ritual of stripping off her scrubs, socks, underwear, and even her jacket, bagging them, and tossing them into the washing machine even before she entered the main house. She looked forward to the reprieve of the hot shower, hoping the steaming water would cleanse her of any remnants of virus and keep her family safe. "Every day I'm faced with the responsibility I have towards my patients and their families, and my own family, but there is truly nowhere I'd rather be."

Thea's courage moved her from a sense of not being enough to being "good enough" (Winnicott 1953) . Thea is a nurse, woman, wife, and mother person who believes deeply in giving back. She "drags" (her word) her husband and three sons twice a year to a struggling third-world country to help with building housing and infrastructure. She hopes it will build in her children a sense of compassion and empathy for others. But, here, now, she is fighting an unseen, unkillable enemy with small gestures of usefulness and kindness. She learns to "prone" patients, flip them on their stomachs, which relieves pressure on their lungs. Nurses not trained with ventilators can help do this and actually save lives. She hands medications to PPEclad nurses from outside patients' rooms, saving them the trips outside and having to re-gown with all new PPE. That began to feel like enough. The work required a complete subjugation of her ego. As a senior nurse, she was performing tasks she hadn't done since graduation decades before. She was learning to live with being repurposed.

Everyone is evolving in order to survive. Homes have become WE WORK organizations, little corporate worlds with no one paying rent. Five-star hotels house healthcare workers. They become mini-hospital settings where their occupants have their temperatures taken as they enter, mitigating infection. Parents become teachers, camp counselors, and feeders of their adult children who have boomeranged home to wait out the quarantine. Dating morphs into walks in the park 6 feet apart. All people become DIYers (do it yourselfers); artists and dentists make face shields from 3D printers, and mothers form sewing clubs to make masks for their communities.

We all have shifting identities, myself included. Without my daily commute into the office, I've reconnected to my kitchen, finding joy and meditation in recipes I can make for my family. I've become a parent who has dinner with her children, after decades of working late into the evening. We can all become creative with our changing characters.

Everyone's been reassigned. Adult children become ambulance drivers to elderly parents who have tested positive and need a hospital where they won't linger in a hallway for hours. Grocery workers, mail deliverers, and drivers have all become our new emergency essential workers. If we are separated and living apart from loved ones, we find ways to have sex across state lines. TV personalities use makeshift crews often comprised of their own family members. Even the old family bookcase adopts a patina of authority to give anchors and reporters stuck at home a grab at credibility; a gesture toward intellectual depth normally manifests in their book-and diploma-laden offices.

We all reach for some respectability in the midst of our vulnerability. Those navigating sobriety attend virtual AA meetings, making something familiar out of something virtual. Families become animal shelters, adopting "pandemic puppies." We've developed new routines and new habits. We've become bridge learners, online learners, and virtual museumgoers. We plant gardens when we're not gardeners and turn ourselves into techno Zoomers and day traders. Professors teach from their cars to maintain some sense of privacy. We become sleuths to find free and, most of all, reliable Internet. We find hot spots near libraries and schools to cope with an overburdened circuitry.

This pandemic divides the real from the faux. The experts are the new influencers. "Influencers" find themselves with less "influence" as the real medical advice comes from those who have actually earned their influence through hard work, study, research, and education. We ward off the manifestations of grief that come from a collapse of civilization as we've known it. We innovate and become activists, even when we're not. We reinvent, rediscover, and reorganize ourselves, all in the service of survival. We tap into our creativity to survive and to stay sane, healthy, and valuable when we feel just the opposite. We take inventory of our relationship with ourselves and with others. We reorganize our priorities in the service of controlling what we can. Hopefully, like with Thea, our breakdowns become breakthroughs. When a crisis like this pandemic reshuffles our deck, we use it as an opportunity for change. All the research tells us that when we engage in generous and altruistic behavior, we activate circuits in the brain that dictate well-being.

We use humor to dilute the intensity, but not the importance. Thea's husband did just that when he interrupted his wife's most recent tele-session with me. After handing her a cold glass of water, he said, "hey honey, ask the Doc why we're not having more sex!"

I can't turn my brain off. The New York Times

Moral injury in a context of trauma

Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019

Shared trauma: When the professional is personal

Transitional objects and transitional phenomena: A study of the first notme possessions