'Under Attack': How 7 Clinicians Prep for a Day on the Front Lines

On even the best of days, clinicians have to make difficult decisions, sometimes life-or-death decisions. But these are not the best of days. They are arguably the hardest days some clinicians might face, as COVID-19 pushes them to their limits, again and again.
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How do frontline doctors, nurses, physician assistants, and others steady themselves to spend yet another day fighting COVID-19? How do they get ready for the emotional and physical onslaught they may be about to face?

Medscape Medical News asked seven healthcare professionals to share how they prepare for work each day — and for returning the next.

Joshua D. Miller, MD, 40, assistant dean, Renaissance School of Medicine, Stony Brook University and medical director of diabetes care, Stony Brook Medicine, Long Island, NY. He splits his time between overseeing COVID-19 testing and caring for patients:

"I have to put to rest, or at least triage, the anxiety-provoking thoughts we all have, and I have, about the risk for family, parents, and someone with diabetes. I have type 1 diabetes. I acknowledge the anxiety. I think it's important to acknowledge that fear, to acknowledge that I am, like every single one of us, fearful of bringing the virus home.

"When I get home, I take off all my clothes. My kids are not allowed in my car these days — not that we are going anywhere. I try to allay the fear by telling myself, the same way I do in the hospital, that if I do things that way [with hygiene practices and PPE] I will lower my risk to myself and my wife and my kids.

"There's an ebb and flow to the anxiety. On the days when I am not as successful at triaging those emotions, those are the days when I look around and realize, this is the new normal and we are finding it is really scary, Orwellian and disconcerting.

"The moments that get me most are when I am out on the testing site and I see kids in the cars. I love kids and I am always able to get them to smile. Now, I wave and they don't wave back. I realize I'm wearing a mask and they are surrounded by military personnel. Those are the moments when it has been really, really difficult. When I see a 1-year-old in a car getting swabbed, it gets more challenging to table the emotions.

"When I see a man in his 70s, ventilated, and he is probably never going to leave the hospital…[Typically, you see] a family member holding a spouse, a family member holding the hand of someone when dying [is expected], but now I'm seeing a different manifestation of that humanity. Patients FaceTime with family and we are holding up the iPad when someone's dying.

"I try to leave all that at the door when I get home, and almost pretend the nightmare out there isn't happening before I go back and do it all again."

Robert Glatter, MD, 54, emergency medicine physician, Lenox Hill Hospital, New York City, and a Medscape advisor:
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"I've never faced anything like this, but this is what we train for. This is the pinnacle of our training, so to speak. You rise to the occasion. We all have an innate fear of this virus, but we also have a healthy respect. We are well aware of the risks.

"Part of the mental preparation is the PPE. We have to take the extra precautions; we do everything carefully. You don't want to make any errors. If you think too much about [the fear] you can't function. Yes, it's here. There's no question I think about it. But the repetition of a process or procedures, that makes you feel secure. It leads to a sense of reassurance.

"I think [clinicians] get into the zone, like athletes get into the zone. When you are there, in the zone, that intensity helps to allay the fear. But when you see someone your own age who walks in the door and crashes — I'm 54 and in good health — it hits you in the rawest of ways."

Ziggy Ignacio, RN, CCRN, ICU critical care nurse, 28, Providence Holy Cross, Mission Hills, CA:

"My morning routines have changed dramatically since this whole thing happened. Before, I'd wake up at 6:00, have to leave at 6:30, so I'd have a quick brush [of my teeth], put on my scrubs and go. That was before. Now, I start to wake up at 4:45…just to mentally prepare myself.
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"I wake up, have coffee and kind of meditate, in a way…not think about anything except the coffee. Then I move on to brushing my teeth, taking a shower. I am really taking my time in the morning. It helps me prepare emotionally, mentally. I give myself time because it is something I do not have at work. Time is of the essence [there] and you have to do everything quick. I cannot control how the patients are going to respond, but I can control how my day starts.

"So much is going on, not just with your patients, but on the management side. There are so many changes [with procedures and policies]. I have all this in my head when I get on the freeway. I've called a friend on the way to work, crying. Or I call my family, telling them how much I love and care for them, because you don't know what is going to happen. They say it [affects people] mostly over 65, but I've had just one patient over 65 in the past 5 weeks.

"I do have a positive outlook toward life in general. But even with my type of personality, it gets me crying, it gets me down on my knees and praying. It's a heavy, heavy thing we are going through. I cannot prepare myself for anything of this nature. You just deal with it. You cry later. I mostly cry on the way to or from work. And you can't really choose [which time]. You just get very overwhelmed and then you break down and cry.

''One thing that helps me is getting off Facebook and getting off the news. If New York is doing badly, I feel bad for them, but I cannot do anything about New York right now. I can't. My hospital is already going through its own crisis."

Eric Cioe-Pena, MD, MPH, 37, emergency physician and director of global health, Northwell Health, New Hyde Park, NY, stationed at Staten Island's COVID-19 hospital housed in the South Beach Psychiatric Center:
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"Some days I need a pep talk, some days I don't. One of the hardest things about this job is how much of our lives feel under attack by this virus. It's directly [under attack] at work, it's threatening the security of my family. We in the medical community all know somebody who is struggling for their life right now. My wife is a professor at Montclair State, and one of her students lost her father. My daughter's nursery school teacher lost her husband. It feels like an attack on all areas of our life.

"Every once in a while, I need a pump-up song. That's been a ritual ever since I was a resident in Brooklyn, at Kings' County…Right now I like a song called Fantasias by Rauw Alejandro. That's the cool one. The corny one is Speechless by Naomi Scott, from Aladdin.

"A lot of times, it's me telling myself I have been uniquely trained for this position, and there is a reason I am doing this. At the end of the day, there is no other choice. That feeling is often not reconciled with the concept that I am putting myself and my family at risk.

"We need to beat this virus, we need to give everyone the best options to fight this and keep staff safe. I'm really good at that. I need to focus on that. Despite all the worry, at the end of the day, I focus on the fact that I have a unique talent for beating it…As emergency room doctors, we are good at this, we are good at compartmentalizing it, or zip-locking it as I like to call it. Freeze [the worry] and deal with the emergency at hand.

"When I go home, I can focus on sick friends and sick mentors."

Sarah Frances McClure, DO, NRP, 33, third-year resident, emergency department, Lincoln Medical and Mental Health Center, The Bronx, NY:
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"I have been waking up a little bit earlier than normal. I get up around 5:30 and take Annie, my 10-year-old, blind, Brittany Spaniel–Golden Retriever mix, out to Central Park, and we walk around the lake and I try to think about what I want to do differently from the previous shift. I try to think about where did I make a difference and what would I do differently the next shift.

"One thing I have struggled with is being called a hero. Heroes save lives and I didn't feel like I was saving a lot of lives. [The other day] I was doing chart review and realized only one patient of mine was alive [that shift]. I broke down.

"Then I realized it was COVID killing them, not me. So I could change that definition of a hero. What could I do to live up to that hero reputation? I decided I would hand them my phone, the ones I was going to intubate, and let them talk to their families. I never talked to the families, but I heard them saying their goodbyes. I knew that they [the patients] knew they were going to die. They didn't ask me [for my phone]. I just handed them the phone. Hearing them being able to talk to their family members was a big thing for me."

Stephen Lewis, PA, 33, emergency department, Arrowhead Regional Medical Center, Colton, CA:​

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"I tell myself it is business as normal for me. Before I became a PA, I was a paramedic. I finished a fellowship in emergency medicine. This is what I am trained to do. When I was training to be an EMT when I was 18, my mentor told me, 'This is not your emergency.' If I think it is my emergency, I am not going to be able to think as objectively as I need to.

"Sure, I get anxious. If I can separate my emotional responses from the actual problem at hand, I can be a better practitioner. So I try to meditate before work but sometimes after. In the past 2 weeks, I started increasing it. I am not a yogi or anything [but] I see the need to get back into this, to separate the emotional from the problem domain.

"I also usually talk to my girlfriend, who is also a PA, and she's in Kansas. So it's good and refreshing to talk to her.''

Tina O'Hare, RN, CCRN, 50, Stony Brook (NY) University Hospital:​

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"I do 100 sit-ups every day before I go to work. I have the local news on in the background, to hear what the statistics are, not that I pay that much attention to them. Then, my mantra is 'Be the best nurse you can be.' When I walk in, I think, 'Maybe things will be a little better today, maybe fewer intubations, maybe more discharges, maybe more extubations.'

"I am anxious in the sense that I don't know what I am walking into. I'm concerned about my health, but more concerned about coworkers — some because of age, some because they work so much.

"You have to trust your PPE. I've been fortunate. We are very well supplied. So, trust your PPE, make sure it is on right, don't fog up your glasses when you put it on. When everything is working the way it is supposed to, I am not thinking about me. I am thinking about what I am going to fix when I walk in the door. It's not about how I feel, it's about what I am going to do when I get to the patient."

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