This has been a hard reality to wake up to every morning. Stripped of our routines, our social relationships, and any semblance of control, we are left to stare into uncertain futures. In Minnesota, we have been under stay-at-home orders for the last 17 days, though it has felt like an eternity. It’s hard to imagine one month ago the two of us were hanging out poolside at a Universal Studios resort down in Orlando. The coronavirus was just starting to develop in Italy and South Korea at that time, but life was business as usual in the states. It’s bewildering how rapidly things have changed.
As people working in healthcare, it’s admittedly a strange feeling to watch our profession be thrust into public attention during this pandemic. Consumed by the demands of residency training over this past year, it’s been easy to feel separate from the events of the outside world. We had become citizens in the city of medicine, imbued with a new language, new rituals, new rules; a new normal. Time moved in a blurry and binary fashion: there were innumerable hours spent in the hospital or the clinic, and then there were those slivers of time where we reentered society, if only for a moment. We learned to keep our heads down and focus on our patients and our training. By January, we were getting accustomed to the routine and rigor of intern year. Spring was a few months away. But then the coronavirus unfolded. The outside world stopped and shifted its gaze to the world of healthcare, which began to spin faster and faster.
We watched colleagues and hospital leadership share their expertise on national news outlets. Mentors were honored in their local communities for their commitment to patients. We received texts and phone calls thanking us for our service and heroism. Local companies donated food to hospital units. We felt pride.
Healthcare workers across the country were bravely coming out of retirement to join the fight in NYC. Specialists were increasingly redeployed to inpatient wards, the ED and the ICU. Communities were rallying together, sharing resources, contributing however they could to support hospitals and clinicians. We felt empathy and solidarity.
Clinical duties and processes of care were changing at our hospital, much like they were around the country. Our workspaces were transformed. Daily educational conferences were canceled. We became one in a sea of masks and scrubs. We operated in unfamiliar territory. We felt lost.
The world was suffering. People were dying. Reports trickeld in of healthcare heroes on the frontlines becoming severely ill. Some were younger than us. The plea for more PPE (personal protective equipment) was growing across the nation. We felt grief and fear.
The COVID-19 pandemic brought a swirl of emotions hard to process. Moreover, it awoke us from our slumber and caused us to pause and reflect on the work that we do. No doubt healthcare was entering an unprecedented time. What will it look like after this pandemic is over? What could it look like? We turned to a book written by Dr. Victor Montori entitled Why We Revolt to help make sense of things. Dr. Montori is an esteemed physician and researcher here at Mayo Clinic, and in Why We Revolt he identifies the big problems plaguing our industrialized healthcare system - cruelty, greed, dehumanization among others -- and argues for a revolution towards compassionate and deliberate care. Once we started reading, we couldn’t put the book down. We hosted a virtual book club over Zoom alongside our colleagues and with Dr. Montori to help unpack these ideas, and what fruit they could bear in the time of COVID.
We talked about the ways in which the pandemic was seemingly renewing and changing healthcare. A call to action brought solidarity among the professions; rather than finding identity in the divisive silos of title or specialty, we began to identify together as clinicians. In addition, the realization of our own frailty and interdependence united us with our patients. Staring in the face of economic precarity and an immense lack of resources, healthcare also began to put mission before money to serve patients. Profit was no longer the pressing issue. Emboldened by the daily threat of the pandemic, we were innovating, fundraising, sharing resources, disseminating research, and experimenting with new ideas like never before seen - and not for riches or recognition, but because it was what was right. We were seeing integrity return to healthcare. In these extremely isolating and uncertain times, we are beginning to see with new eyes the importance of human connection, of conversations, of careful and timeless care. The virtual book club concluded with a sense of cautious optimism for the state of healthcare. We each committed to do our part to turn these conversations into actions we could carry forward as we practiced medicine.
It’s crazy to think less than a year ago we were students, and today we are among the many essential workers contributing to the efforts of helping fight COVID-19. Looking back over this year, there have certainly been difficult and stressful times as a trainee in healthcare, but in this moment, the “calling” of being in medicine seems deeper than ever. Now more than ever, compassion and excellence is needed from healthcare workers. The clock is ticking, those with chronic medical conditions at home are struggling, and people coming into the hospital are desperate and scared. We are seeing that the years of schooling, sacrifice, commitment, and growth have prepared us for this time. We openly embrace it, cling to it, and will work tirelessly to provide hope and healing to our patients.
Today, the hospital feels vastly different from what it did one month ago. Patients are alone in the hospital without a family member by their side as no visitors are allowed. It is a lonely place to be. Multiple people rush in and out of patients’ rooms, poking and prodding at them behind gloves, masks, and gowns. They cannot feel the warmth of our hands or see the expressions on our face. We seem to resemble more of a robot rather than a human being. There is an unspoken understanding among healthcare workers when walking around the hospital or emergency department these days. Despite a mask covering the facial expressions of our fellow colleagues, their eyes tell the story. We are each struggling in our own way, whether we have lost family members, jobs, social connection, or our normal routines. Despite this, we come together day after day to stand as a united front.
We are doing our best to predict how long this will last but we are not sure the prediction models will tell the full story. They may tell us when we will hit our “peak” or when we can lift the stay at home orders. But can they tell us when the fear will subside, how long the financial impact will last, or when a sense of “normal” will return? As we embrace the uncertainty that we face both day-to-day and long term, how do we move forward with hope? There is no simple answer to this question as what brings each of us hope is unique. However, the unifying idea we can all cling to is that there is indeed hope, better days will come, and we will rebound from this as a society. Life may look different in the future, but sometimes it takes monumental moments such as this to create a “new normal”. Let us stand together (yes Facetime/Zoom/etc count), find the good in each day, and grow as we take steps forward, no matter how small a step it may be.
Chris Ha and Josh Romero are PGY-1s in the Department of Physical Medicine and Rehabilitation at the Mayo Clinic. Follow them on Twitter @ChrisHaDO and @JoshuaRomeroMD
The Stress of a Pandemic and Its Impact on Physiatry
by Ramza Malik, DO
Nearly every era has faced a pandemic of its own. Some were caused by pathogens we fear no longer, while others have left behind lingering threats. Irrefutably, microbes carry the power to alter the course of history. Today, we are dealing with the devastating impact of a new pathogen, SARS-CoV-2. What began as an outbreak in late 2019, developed into a pandemic by March 11, 2020 affecting over a hundred countries and 100,000 people. As this number now surpasses 2 million, the world as we knew it a few months ago has transformed entirely.
From the various historic plagues to the more recent viral epidemics, human populations have suffered tremendously. Though the cause and course of disease varies among the different pandemics, one similarity surely exists - the undeniable level of stress imposed by these events upon humanity. Pandemics are marked by death, fear, isolation, uncertainty, as well as destabilization of our social, civil, political and economic pillars. It is no surprise that in these times of catastrophe, stress is at an all-time high.
Biologically speaking, stress has been defined as a state of threatened homeostasis, during which the body responds with various measures to resist unfavorable change.7 Dr. Selye first described biological stress as the response of the body to demands placed upon it, giving rise to the ‘General Adaptation Syndrome’, which he distinguished from acute stress. Dr. Selye’s Syndrome characterized stress as having three stages: alarm, resistance and exhaustion. Over time however, our understanding of biological stress changed and the term itself evolved.11 The word “stress” has become mainstreamed into our daily lives to also indicate physical, mental, or emotional strain or tension.
As we can see, stress is complex in nature, formulated and influenced by a multitude of factors that ultimately contribute to change, either good (eustress) or bad (distress). There seems to be a notable parallel between the biological stress that is challenging our COVID-19 affected patients and the form of stress, we as a healthcare community, are facing during these times. Below, I draw a connection between these unique types of stress as they occurr in the different stages in our affected patients and in our community.
The initial exposure to a stressor results in recruitment of specific and non-specific recruitment of the body’s defensive resources. As our patients are relying on their immune systems to recognize this foreign entity and build up an initial response, we, as a global community, have taken immediate measures in attempts to minimize the spread of this disease. Implementing lock-downs, closures and distancing protocols became our first guards of defense. In the realm of healthcare, our immediate focus is on patient stabilization and provider safety.
During this stage, rehabilitation services are essentially an afterthought and are not often considered in emergency planning. The Conditions, Actions, Needs (CAN) report for Inpatient Rehabilitation Facilities (IRFs) attempts to provide guidance for acute IRFs providers during this public health emergency.6 The report indicates that IRFs are filled with patients who have multiple comorbidities and are at risk of being affected. This promotes early discharge practices for patient safety but also to aid in hospital bed availability efforts. Acute rehab services offered to hospitalized patients (including ICU) and to those admitted to an IRF are being altered to follow current social distancing protocols which means less efficiency and frequency with which staff can work with patients. For example, due to reduced staffing and limited access to protective equipment, patients therapy needs are being sacrificed. Additionally, outpatient rehab facilities are mostly closed or have altered services in accordance with emergency healthcare protocols. Thus, patients will experience significant delays and postponements in their rehab program, resulting in significant burden on their physical health. Although appropriate for emergency situations, these actions affecting both inpatient and outpatient facilities can possibly prohibit their overall recovery.
When the stressor is persistent, the body attempts to return some physiological functions back to normal levels while remaining on high alert. The alarm responses come to a plateau and the body resists further physiologic change. Non-severe COVID-19 patients in this state battling mild-moderate symptoms might begin their journey towards recovery. On the other hand, patients with more severe disease would likely demonstrate worsening respiratory function and possibly even progress towards Acute Respiratory Distress Syndrome (ARDS), requiring ICU admission. These critically ill patients are susceptible to developing further physical, cognitive and mental health problems, otherwise termed post-intensive syndrome. Typical sequelae include myopathy, muscular atrophy, neuropathy, and delirium.10
Neurologic injury has been confirmed in the infection of other coronaviruses in the past such as in SARS-CoV and MERS-CoV. Furthermore, new evidence suggests that patients affected by COVID-19 are experiencing symptoms of neuromuscular disease such as acute stroke (6%), consciousness impairment (15%), and skeletal muscle injury (19%), especially since most of the affected patient have comorbid or underlying neurological conditions. The findings of elevated CPK and proinflammatory cytokines in serum provide supporting evidence for possible skeletal muscle damage.5 A recent case report describes Guillain-Barré Syndrome in association with SARS-CoV-2 infection.12 Undoubtedly, these conditions would create the necessity for physical rehabilitation.
Rehabilitation for patients recovering from a critical illness is a key component of the holistic healthcare approach, which aids in minimizing the risk of developing long-term disabilities. Numerous studies have shown the positive impact of rehabilitation in hospitalized patients, including ICU patients, by improving their mobility status and muscle strength.11 Specifically, there have been studies demonstrating the positive impact of rehab in patients affected by the prior coronavirus, SAR-CoV-1, which was demonstrated to improve cardiorespiratory and musculoskeletal fitness.3 These studies strongly support the anticipated need for physical rehabilitation while caring for patients affected by the novel virus.
Unfortunately, in the case of patients with severe disease, their immune system eventually tires and the disease burden is too grueling to fend off. It is at this stage, where we have lost many of our COVID-19 patients. For those who have survived, the burden of this disease may have a lasting impact; even more for those plagued with severe symptoms. Severe cases require an ICU admission, with a hospital length of stay up to 6 weeks, leading to worse deconditioning. Furthermore, Dr. Selye demonstrated that persistent stress could possibly lead to the development of various other diseases such as stroke and joint disease.13 In fact, one year after the SARS-CoV-1 outbreak, affected patients still had elevated stress levels.4 These findings indicate the potential for development of new illnesses, both physical and psychological, as well as the potential for the aggravation of comorbid chronic conditions.
Similarly, the global and healthcare communities impacted by the stressor (this pandemic) are under an extended period of vulnerability. These times of uncertainty have been heightened by a tide of unemployment, workplace strain for essential workers, and death of millions of loved ones. Essentially, our world is experiencing a traumatic event, impacting some of us physically but many others emotionally and mentally. Surviving this life-threatening experience will likely reconstruct each of us individually and collectively.8 We should expect to see a significant increase in patients complaining of psycho-somatic pain caused by stress. Rehabilitation, whether physical or psychological, will be of vital component during this stage, not only for the affected patients but also for the general population. Overall, we will experience higher volumes of those requiring rehabilitation. Now more than ever, the connection between mind and body may be the key to holistic recovery.
So, what could we as physiatrists do about all of this? Certainly, our immediate goal during this time should be first-line response for unstable patients. However, addressing disability should not be forgotten. Multiple avenues exist in our modern society to help aid us with this goal. For admitted COVID-19 patients, for example, the International Rehabilitation Forum (IRF) provides guidance for identifying sources of potential patient disability, resource limitations in the hospital, and rehabilitation strategies to be incorporated into the admission process and discharge plan.1 Another great resource for all patients, especially those currently unaffected by COVID-19, is prehabilitation, which it a tool that emerged during World War II to prepare soldiers for battle. Prehabilitation involves interventions to improve patient health in anticipation of a stressor. It is a multimodal approach that includes addressing exercise, nutrition, home safety, mental health, reducing medical risks and pain management skills. This intervention could be essential for patients at high risk of contracting this virus, like the elderly. Lastly, telemedicine is a great asset for our community given the current physical contact limitations. Telemedicine is a medium through which not only prehabilitation could be delivered to our patients, but it can also be used to provide guidance and continuity of care to rehab patients. Studies have shown that tele-rehabilitation is not only feasible, but efficient.2 The resources mentioned above are but a few of the vast majority available to us during this time. Utilizing some of these resources can significantly impact patient recovery, quality of life and improve long-term outcomes.
- International Rehabilitation Forum. http://www.rehabforum.org/tools.html.
- Isernia, S, C Pagliari and J Jonsdottir. "Efficiency and Patient-Reported Outcome Measures from Clnic to Home: The Human Empowerment Aging and Disability Program for Digital-Health Rehabilitation ." Front Neurol (2019): 1206.
- Lau, H M, et al. "A randomised controlled trial of the effectiveness of an exercise training program in patient recovering from severe acute respiratory syndrome." Aust J Physiother (2005): 213-219.
- Lee, A M and al. et. "Stress and psychological distress among SARS survivors 1 year after the outbreak." Can J Psychiatry (2007): 233-240.
- Mao, L, H Jin and M Wang. "Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China." JAMA Neurol (2020).
- McNeary, L. "Navigating Coronavirus Disease 2019 (Covid-19) in Physiatry: A CAN report for." 2020. https://amrpa.org/Portals/0/covid19-for-irf-for-pm-r_1.pdf.
- Melzack, Ronald. "Pain and Stress: A new Perspective ." Gatchel, Robert J and Dennis C Turk. Psychosocial Factors in Pain: Critical Perspectives. Guilford Press, Feb 12, 1999 . 89.
- Ogilvie, R, et al. "The experience of surviving life-threatening injury; a qualitative synthesis." Int Nurs Rev (2012): 312-320.
- Rawal, G, S Yadav and R Kumar. "Post-intensive care syndrome: an overview." Journal of translational internal medicine (2017): 90-92.
- Rosch, Paul J. "The Birth of Stress." n.d. American Institue of Stress. https://www.stress.org/about/hans-selye-birth-of-stress. <https://www.stress.org/about/hans-selye-birth-of-stress>.
- Tipping, C J, et al. "The effects of active mobilisation and rehabilitation in the ICU on mortality and function: a systemic review." Intensive Care Med (2016).
- Toascano, G. "Guillain-Barre Syndrome Associated with SARS-CoV-2." New England Journal of Medicine (2020).
- "What is Stress?" n.d. The American Institute of Stress. 15 April 2020. <https://www.stress.org/what-is-stress>.
Ramza Malik is a PGY-1 at SUNY Upstate Medical University where she will continue in PM&R in July 2020.
Kinetic Chain: A Missing Link in Surfing Rehabilitation after Amputation
by Claudia Jimenez, MD