COVID-19: fear and anxiety in frontline clinicians

DR LI Wenliang, the whistle blower ophthalmologist who presciently warned about the outbreak of COVID-19 in Wuhan, died on 7 February 2020 after being infected with SARS-CoV-2. Dr Li, a healthy 33-year-old with a wife, young child and another on the way, worryingly did not fit the profile for adverse outcome of respiratory and multi-organ failure requiring critical care support. He had no high risk features of old age, chronic illness or advanced malignancy.

Of 52 critically ill adult patients with SARS-CoV-2 pneumonia admitted to the intensive care unit (ICU) of Wuhan Jin Yin-tan Hospital between late December 2019 and 26 January 2020, the mean age was 60 years; 40% had chronic illness, and 61% of patients were dead at 28 days. The duration from admission to ICU to death was a brief 7 days, with the fatalities being older (≥ 65 years), with seven of 10 requiring mechanical ventilation. Patients aged 65 years or over with comorbidities faced grim outcomes.

Of 83 731 clinical doctors registered in Australia in 2015, only one in four was aged 55 years or over,  with the average age being 46 years.

Should the medical and nursing staff battling the surge in health care demands of a World Health Organization-declared pandemic be assured that each of us, on average 46 years old, will only experience minor illness should we contract COVID-19 from hourly and daily patient care and screening?

Should colleagues over 65 years with comorbidities be occupationally released as they suffer the impost of greater than two in three risk of dying if they contract COVID-19 and require admission to the ICU?

The March 2020 UK Health Secretary “battle plan” to roll-out emergency registration of retired health professionals to allow them to come back to work in the National Health Service (NHS) is like needlessly sacrificing lives to fight a dangerous war, when our older at-risk doctor colleagues are dealt such appallingly hazardous odds.

As a frontline emergency specialist of younger “vintage” (a healthy 50 years old), I am relieved that of 346 Guangzhou Chest Hospital COVID-19 cases, only 58 (16.76%) deteriorated to being severe, with a single death and no infection among medical staff. Deceptively, however, the average age of this good outcome patient cohort is a relatively youthful 38 years old, 8 years younger than the average Australian doctor in 2015.

Personal protective equipment (PPE) being worn by doctors and nurses manning the fever clinics that have sprouted into life seemingly overnight confer only physical isolation. PPE doesn’t insulate against worry about repeated COVID-19 exposures when a patient gags or coughs while I collect oral- and nasopharyngeal samples for testing. Hourly and daily encounters add up to a cumulatively high threshold, and I know I am not overreacting when even Westmead pathologists with no patient clinical contact are writing about assessing their sample disinfection procedures.

I know that despite my prospects of doing well in the unlikely event of cross-infection, it is only being human to be anxious during Australia’s chaotic surge to pandemic threat, paralleling the intense psychological stress Wuhan’s medical staff endured when that vast nation led the coronavirus infection census during January and February 2020. Up to a quarter of China’s infectious disease clinicians suffered high self-rated anxiety and post-traumatic stress during their peak surge, if the results of a survey at a single tertiary infectious disease hospital can be generalised.

As an Australian emergency physician deployed to screen for and treat potential COVID-19, I am convinced that the gravest single point cross-infection hazard I will have to face is exposure to aerosolised respiratory secretions of critically unwell infected patients when instituting non-invasive ventilation and, even worse, during intubation (here and here).

Frontline clinicians, most so in fever and GP clinics, emergency and critical care areas, remain at highest risk of COVID-19 exposure. However, we’d do well to remember traditional “no patient contact” specialties that also require caution against cross-infection. As COVID-19 diagnoses require chest x-rays and computed tomography chest scans, radiology staff need to remain at heightened vigilance with infection control protocols and practice.

Fear of contagion has in the past, during the SARS outbreaks and the H1N1 outbreak of 2009, led to staff social isolation and intentional absenteeism. Clinicians that turned up for work had to cover for colleagues missing in action. Even without the COVID-19 pandemic, hospitals and clinics would be gutted if doctors stayed at home with minor illness and injury. Battling on through illness and not letting the side down has traditionally been seen as a positive attribute, with taking time off seen as a weakness.

Doctors are wary about their absence forcing increased workload on their peers and view themselves as being difficult to replace at short notice. They are afraid of negative effects on career progress of using sick leave entitlements. In order for doctors who are sick or stressed to take time off work without feeling guilty about appropriately taken absenteeism, hospitals and clinics need to set up contingency plans that can be implemented at short notice to make up for unplanned shortfalls in clinical staff.

Clinicians should not be subjected to the acute stresses, physical and psychological toll exacted by having to compensate for our absent peers. In order to look after vast numbers of infected patients, the medical community and their worried family members facing cross-infection risk need support for psychological distress.

The additional staffing requisite to maintaining essential clinical services when we need time off to recuperate or have imposed absenteeism to adhere to quarantine regulations is critical. We need to look after the physical and psychological wellbeing of coalface clinicians to enhance the health system response to this pandemic.

Dr Joseph Ting is an emergency, prehospital and aeromedical physician as well as adjunct associate professor for clinical research methods and prehospital care at Queensland University of Technology’s School of Public Health and Social Work and Clinical Senior Lecturer in the Division of Anaesthesiology and Critical Care UQ.

 

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.