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What is Emotional PPE? Podcast with Dani Chammas



We are delighted to have Dani Chammas, psychiatrist and palliative care physician, back on the GeriPal podcast to talk about emotional PPE.  None of us can recall who originated the term, but we've all heard it bandied about much needed for front line providers treating patients with coronavirus.  Headlines about the New York emergency room doctor committing suicide are likely only the tip of the iceberg in terms of the trauma, distress, and moral injury taking place.

We talk with Dani about key issues and questions, including:
  • What is trauma?  What is moral injury?
  • Is this a big deal?  What evidence do we have?
  • What can we do about it?  Dani goes over 3 broad buckets of responses, organized with the letter C: Connection, Culture, and Coping.
  • Normalizing rather than stigmatizing clinicians seeking mental health support
We also decided to add a page to GeriPal titled "emotional PPE" with a list of resources for providers caring for patients with COVID, and we will link to that page once it's up.

For now, here are some important mental health resources for providers:

The NYC COVID Worker Care Network is a self-organizing network of 2500+ volunteer mental health professionals, spiritual care providers, facilitators, healers, and community builders supporting all essential COVID workers during the evolving crisis. We facilitate individual support encounters, support groups, stress-reduction training, and grief rituals via Zoom or telephone encounters. Centered around a five-member Organizing Team, the network’s daily operations are led by a passionate group of varied volunteers known as The Hub. Volunteer support providers are placed into groups of 10, known as “pods.” A pod facilitator organizes each pod and connects the pod to The Hub. Pods are autonomous and choose how best to support the essential workers as they engage.

Pro-Bono Counseling for Frontline Physicians and APCs A free convenient short-term psychotherapy option for physicians and APCs on the frontline in the COVID-19 pandemic. The COVID19 Pro Bono Counseling Project is devoted to helping Bay Area front-line healthcare workers. All psychotherapy is conducted remotely. The frame is short-term, but the Project organizers anticipate that in some cases the therapy may continue longer-term. In addition to individual therapy, there is also a list of free support groups. The Project’s therapist-volunteers are a diverse group representing a variety of degree backgrounds (including some psychiatrists) and different approaches to psychotherapy. Visit the Pro Bono Counseling Project website for a database of therapists and a calendar tool through which therapists can show the specific free hours they can offer. There are even evening/weekend appointments available, as well as some therapists who are offering short sessions (e.g., 30 minutes). To learn more, see this brief video that explains how our project works.

Physician Support Line.  A national network of mental health workers who provide support for physicians.  See an NBC video about this service.

Disaster Distress Help Line. The Disaster Distress Helpline, 1-800-985-5990, is a 24/7, 365-day-a-year, national hotline dedicated to providing immediate crisis counseling for people who are experiencing emotional distress related to any natural or human-caused disaster. This toll-free, multilingual, and confidential crisis support service is available to all residents in the United States and its territories. Stress, anxiety, and other depression-like symptoms are common reactions after a disaster. Call 1-800-985-5990 or text TalkWithUs to 66746 to connect with a trained crisis counselor.

How to be a Catalyst of Calm in COVID19.  Drs. Keri Brenner, Danielle Chammas, and Mariana Schmajuk share their expertise on the psychological aspects of coping with serious illness. They reflect on what distress looks and feels like during this pandemic and share practical tips and resources for coping. Learn how you can stay connected to your authentic self and most important relationships during times of uncertainty. Speakers: Keri Brenner, MD, MPA, Palliative care physician, psychiatrist and Clinical Assistant Professor of Medicine at Stanford Danielle Chammas, MD, Palliative care physician and psychiatrist at UC San Francisco Mariana Schmajuk, MD, Psychiatrist and Clinical Assistant Professor of Medicine at Stanford)

-@AlexSmithMD



  


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TRANSCRIPT

Eric: Welcome to the GeriPal Podcast, this is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, who is our guest today?

Alex: We're delighted to have Dani Chammas, who's a psychiatrist and palliative care doctor at UCSF. Welcome back to The GeriPal Podcast. Is this your third time?

Dani: Third time.

Alex: Third time's a charm. Delighted to have you back.

Dani: It's good to be back.

Eric: On today's episode, we're going to be talking about emotional PPE for front-lines of coronavirus. Dani, are we going to be talking about donning and doffing emotions?

Dani: We can if you want to.

Eric: Well, we'll talk about what the heck emotional PPE is. But before we do, do you have a song request for Alex?

Dani: My song request is I Got You, Babe, by Sonny and Cher.

Alex: Why I Got You, Babe by Sonny and Cher?

Dani: I'm really hoping that our colleagues on the front-lines know that we got you, babes.

Alex: This is good, I thank the babes.

Dani: Yeah.

Eric: Let's hear it, Alex.

Alex: (singing) They say we're young and we don't know, we won't find out until we grow. Well, I don't know if all that's true because you got me and baby I got you. I got you, babe. I got you, babe. I got you, babe.

Alex: I should've changed to I got you, babes.

Dani: Yeah. Maybe at the end.

Eric: Well, Dani, I want to thank you for coming on our show. For those listeners who haven't listened to your podcast that you did on therapeutic presence in the time of COVID, really strongly encourage our listeners to listen to that. Today we're going to be talking about emotional PPE in the era of coronavirus. Dani, maybe before we get deep-dive in emotional PPE, what do we mean by that?

Dani: What do we mean by that? Well, Eric, for weeks we've been having this intense discussion around the need for personal protective equipment, PPE. To help protect frontline workers who are working with the sick. We have been talking about masks and gowns and shields and all the physical gear that protects from infection. I've been seeing a growing movement that people want to broaden this, not just from physical PPE but from emotional PPE. I wish I knew who to credit, I don't know exactly who first gave birth to this phrase. But I've seen it in a few contexts now from colleagues in mental health that are taking on efforts at their institution to make programs and interventions that focus on protecting the emotional and psychological health and intactness of healthcare workers on the front-lines of this pandemic. My hope, I'll add is that this concept gets discussed sort of far and wide.

Alex: To provide some more context with headlines about doctor committing suicide. "She tried to do her job and it killed her." Said the father of Dr. Lorna Breen, who worked in a Manhattan hospital hit hard by the Coronavirus outbreak. This is from the New York Times. I believe you've heard of other... Here, it goes on. She was in the trenches, in the frontline. He said, "Make sure she's praised as a hero because she was. She's a casualty as much as anyone else who died." I heard that this is not an isolated incident. You've heard Dani of other health care workers in the front lines, who have struggled emotionally and even committed suicide.

Dani: Yeah, I was just reading about an EMT, also in New York who recently killed himself under similar, extremely distressing conditions that he was exposed to. I don't know how you guys feel when you hear those stories but I know I get this really uncomfortable feeling in my chest when we lose someone to suicide. I'm just grappling with what could we have done? How could we have protected you? But yeah, far and wide.

Alex: Suicide, it's like the tip of the iceberg. This is the extreme when it gets to this point. When someone feels like they can't go on living any further and end their life. But it's just a sign of this deep, hidden from view, the rest of the iceberg, which is all of this emotional pain, suffering, moral injury, other... I don't know what the words, help us find the right words to describe what it is we're feeling.

Eric: What are we dealing with, Dani?

Dani: Well, I want to get into the meat of emotional PPE, but I think you guys are right, let's do a little bit of sort of laying the groundwork - background stuff before we get there. You guys are always good sports. So if you guys are game, I'd actually love to throw out a couple of statements that you and ask you to let me know if you think they're true or false. What do you think?

Eric: Okay, we're game.

Alex: True, okay, we're ready.

Dani: Can you do that? Okay, true. No pressure but also don't mess this up, okay?

Eric: I feel like I'm playing code names. We were very playing a lot of code names at home with another family on Zoom. So I feel like this is just like that.

Dani: Okay. Five statements, here it goes. Statement number one.

Eric: I'm going to crush Alex.

Dani: You're going to crush him. Statement number one, true or false? The psychological footprint of a disaster like a pandemic deeply contributes to the morbidity and mortality, both during the disaster and long after it?

Eric: Maybe, more data, more studies are indicated.

Alex: Maybe is not an option.

Dani: Maybe from Eric. Alex, do you think he can beat him?

Alex: True.

Dani: True. Alex is the winner. Yeah, history has taught us so in time and again. All right, good job, Alex. Work harder, Eric. Statement two, true or false, as we speak many frontline medical workers are being impacted by deep sources of emotional distress? These are some of the things you were talking about, Alex. Trauma, secondary trauma, vicarious trauma, moral injury, moral distress.

Eric: True but I don't know if I know all of the definitions for those.

Dani: So true is correct but yeah, let's go ahead and define them. What is trauma? What a great question. When we're talking about trauma, I would say like the strictest most clinical definition would be the DSM criteria of trauma. Which says that a person is exposed to threatened or actual death, threatened or actual serious injury, either by direct exposure or direct witnessing. I would say that most of us in mental health kind of acknowledge that this clinical definition is pretty narrow. That there's a range of really distressing and disturbing things that can be experienced as traumatic. So when we're thinking about a frontline worker, we're talking about a tidal wave of death coming their way, that they're not able to stop. Having to walk past overflowing freezers of dead bodies to get into the hospital. All this stuff, well also worrying like am I going to get sick? Am I going to get my family sick? What's coming next? Are we even at a peak? All of these things are really traumatic.

Dani: When we talk about secondary trauma or vicarious trauma, it's basically indirect exposure to trauma by hearing people's first-hand accounts. We see this all the time in medicine. Then moral distress or moral injury is a unique thing. It's this discrepancy that happens when one's core moral values are not aligned with what somebody is forced to either do or not do because of the constraints of their situation. So this would be more along the lines of being forced to pick who gets lifesaving care. Going to med school doesn't teach us how to deny people care that can save their lives. Being forced to tell a family they can't be with their loved one while that person dies. Then watching that person die alone. Being forced to work outside of your scope of practice in a way that you just don't feel adequate to do.

Alex: Yeah, or coding a person who you feel has near-zero or zero chance of resuscitation. You feel like you're doing harm to this person in their last moments of life.

Dani: Absolutely. I was talking just yesterday to a psyche resident in New York who's been tasked with taking care of a super intense ICU case. That they just didn't feel like they were trained to do. Repeatedly, this resident was telling me, "I can't do this, I can't do this." It was so distressing because they just were so aware of this feeling that they were hurting the person by not being able to give them the right kind of care. Joan... Yeah, you go.

Eric: So I'm just trying to think about this, like in medicine, let's separate medicine and psychiatry. I know I probably shouldn't be saying that.

Dani: You just have had a lot of enemies, Eric. [laughter]

Eric: When we talk about trauma, we think about like trauma bed, they're coming to the emergency room, there's trauma. Exposure to trauma in my head is like exposure to that type of medicine. I'm also hearing when we're thinking about in psychiatry, there's this kind of broader emotional trauma that you're also talking about. Is that right, am I getting that right?

Dani: Yeah, I think you're talking about trauma to the body, right?

Eric: Yeah, very medicine thing, we try to devoid ourselves from all emotions.

Dani: That's too funny. Yeah, no when we're talking about trauma in psychiatry, we're talking about the psychological experience of being exposed to what you're talking about. So the psychological experience of thinking my life is on the line or watching someone else die or have their arm cut off. Whatever physical thing you're thinking about, we're just talking about the psychological experience of witnessing or experiencing it.

Eric: Yeah, I guess we also don't think that much of medicine like the work that we do in the ICU or with dying patients, usually as that being traumatic. But it certainly sounds like it can be.

Dani: Certainly, yeah and it's a good distinction. We're talking about trauma, we're talking about vicarious trauma, we're talking about moral injury. These aren't new things that COVID brought to us, it's just the intensity of how much of it we're having to take in right now. Is definitely apt for the people on the front-lines. So we're going to feel the impacts of it a lot more. Yeah.

Dani: I'll add, this distinction is really important. But for the purposes of us talking, I think we're just going to have to think about all of these a little bit together. Really, anything that someone on the front-lines is forced to experience or do or witness. That has a potential to make them feel like their psychological, moral or physical self is not intact.

Alex: When you mentioned secondary trauma, might not be people on the front-lines? That might be people who are hearing stories from colleagues about their experiences. Is that right?

Dani: Yeah, and I would say that there's a sort of a spectrum. It's not like it is trauma or it isn't. Some of us are closer, some of us are further. Some of us get it for longer and more intensity, some for less. So we're getting different doses. But yeah, secondary trauma, we see it a lot in therapists, we see it all the time because people have to sit and hear these terrible, terrible things happening to other people. But you can certainly have it just hearing the experiences of your colleagues and things like that.

Alex: Okay, all right, great. You got more true false for us?

Dani: I do, I have true or false for us.

Alex: Wait, where are we? I don't know if I got a chance to respond to that one.

Dani: We'll count that one as a tie.

Alex: All right, sounds good.

Dani: Number three, true or false? Many more frontline workers are at risk of being exposed to similar emotionally distressing experiences in the coming weeks and months?

Eric: I see where we're going here, true.

Alex: Wait, many more frontline workers are at risk of being exposed in the coming months than...?

Dani: Than have already been exposed.

Alex: Okay, so we'll have more people in the coming months.

Dani: More to come, yeah.

Alex: Yes, I'm going to say true as well and the reason I say true mine is data-driven. Is that if you look at the US as a whole, the number of hospitalizations for coronavirus is going down. But if you take out New Jersey, New York, and Connecticut, it's going up. So it's going down in the place that's been the epicenter but the rest of the country, it's still rising.

Dani: Remind me to take you to trivia night the next there's a trivia night. I love that.

Eric: Alex is using test-taking skills. I've learned who my professor is on this test, I'm answering in a way I think she would.

Dani: All right, true or false then. Everybody exposed to these emotionally distressing experiences is going to have significant emotional dysfunction as a result?

Eric: False.

Alex: False.

Dani: Good job. I told you not to mess it up and you didn't. False, right, this because you guys work at the VA, so you see this all the time with the veterans. Everybody is deeply affected by disturbing experiences. But we know from the literature that not everybody will respond in the same way. Some get emotional dysfunction, some don't. They've been... Yeah.

Eric: Are there protective factors that we know of or are we going to get into that later?

Dani: Yeah, we are because that's going to be what informs how we pick our PPE. So many people have asked this question. Why do some Israeli kids exposed to war get PTSD and others don't? There are, there some factors there's nothing we can do about. Your genes kind of stuck with those, your personality. Your personal mental health history, there's very little we can do. But there are others that are totally modifiable and interminable and those are the ones we're going to be drawing on today when we think through what goes into emotional PPE.

Alex: PTSD, you mentioned the term, Post Traumatic Stress Disorder. Does that term apply to what we're talking about here or is that a specific term that's used for war or violence?

Dani: So PTSD is one thing that we're trying to protect them. But it's one of many potential outcomes from exposure to trauma. It's not even the most likely outcome from exposure to trauma. For many people, depression is a more likely outcome from exposure to trauma. But there are many places of emotional dysfunction that exposure to trauma can take you to and PTSD is one of them. It just happens to be the only one that actually requires exposure to trauma as part of its definition. The other ones you can get to via other routes if you will. So it's one of the outcomes we are trying to protect people, one of many outcomes we're trying to protect people from.

Alex: Okay, thank you.

Dani: Yeah, all right, final quiz question. Winner takes all on this one. True or false, we have a moral imperative to not only protect the physical health of our colleagues?

Alex: True. [laughter]

Dani: I should change the end of the statement now. [laughter]

Dani: ...but to bathe them in jello [laughter]

New Speaker: Help me out, Dani.

Eric: We have a moral imperative to ignore the distress of healthcare workers. I'm going to say false on that one.

Dani: But to protect to the best of our abilities is their emotional health. It was true, Alex wins. I actually would argue that this is the most important of the questions because if it's our duty, then we have to get in action. We should have gotten in action like months ago at this point or weeks ago.

Eric: Well, it's interesting because there's a lot of talk about the imperative to keep health care providers safe by having adequate PPE. We talked about that. We talked about adequate physical PPE. You're arguing also that there is imperative that we dawn this emotional PPE and we have resources for this emotional PPE for healthcare workers.

Dani: Yeah. If anything, I'd say we have more resources, we just have to make use of them. So we can go there.

Alex: Okay, good, so we should go there now? So what is emotional PPE? What can we do?

Dani: What can we do? Well, I'm going to say that there is sort of like a golden... Not a golden rule, a golden caveat in mental health that we have to give credit to really quickly. Which is that you can't tend to the psychological health of anybody if you haven't tended to their basic needs. This is sort of Maslow's thing. So before we go there, let's just all acknowledge together like food, hydration, sleep, being able to go to the bathroom. I would say for frontline workers, I've broaden that, like access to reliable childcare. Not wondering if you're going to have some kind of huge pay-cut while you're working harder than ever and at great risk. There's a lot of basics have to be in place. But if we put those in place if we say that those are like a given, then I would say the rest of what goes into emotional PPE falls into three main sort of organizing buckets in my head. This is when you can ask me about the buckets.

Alex: Yeah.

Eric: What are the buckets?

Dani: What are the buckets? Great question. So I'm going to call the first bucket connection. It's called connection. What do you guys think might fall into the bucket of connection?

Eric: Maintaining contact with family, talking with your team as far as health care providers.

Alex: With your colleagues, particularly, because I think it's harder. There are so many challenges to connection because social distancing requirements, some of us are working from home, doing telephone work. Then-

Eric: Listening to your favorite podcast hosts.

Alex: There you go.

Dani: Best one.

Alex: Right. Connection with... In palliative care, in geriatrics, one of the reason many of us went into this because we love working in teams. We may not be working in teams as much. My understanding is even for people who can go in to see patients who have COVID, sending one person in, not the whole team. So connection with your team, connection with your family. We're talking about emotional connection here too.

Dani: Yeah. No, all of the above. So interpersonal connection is arguably one of the best, strongest psychological buffers to emotional distress that we have. I think you guys are right on, this virus is cruel because it is like the things we need to do to combat it are huge barriers to connection. So I think we have to be thinking about our frontline workers and the fact that the perception of being in the trenches together is always better than the perception of being in the trenches alone. All the things you talked about, I would add when Alex you said emotional connection. I think hand in hand is the idea of validation and empathy. Using our connection to validate, we know how powerful validation is. It helps people be seen, especially validation that doesn't incite extra panic.

Dani: I would say, sort of the flip side of validations importance is the deep, deep risk that comes with invalidation at times of severe emotional distress. So let's go hypothetical together. Let's picture a colleague, let's say New York on the front-lines had just a grueling day. What kind of forms of invalidation, subtle or not subtle, do you think they might be experiencing?

Alex: Well, yeah it could range from everything like in... I think in New York in general people are supportive of healthcare workers like on their way home from the hospital. But I've heard of cases, for example, in Mexico, where healthcare workers actually ostracized because they're viewed as vectors of disease. That they might actually be transmitting the virus and things thrown at them, assaulted. That's probably the epitome, the worst possible invalidation. Here you are working so hard in the front-lines and then you are ostracized from your community or assaulted because of it.

Dani: Yeah, that's definitely the extreme. I hear what you're saying about gratitude being present in New York. But I'll give you a counter-story. I have a friend who's a neurologist who works in New York. He's being asked to work sort of outside of the scope of his practice in the setting of his hospital being in crisis. He put on a mask the other day and decided to go for a run because he really needed to de-stress. As he ran through the city, he came across a group of people partying in the park, hanging out with each other as if nothing was going on. He got the most intense emotional reaction to it. He was livid. He called me so pissed off. I think what was really underneath it for him was this deep sense of disregard, of invalidation, of a world acting like what he was going through wasn't even happening right now.

Dani: Then he probably went home, logged into Facebook and saw that Johnny from high school English class doesn't really get what the big deal is with this whole Corona thing. Opened his email and got like an admin email saying, "Great job, everyone. We're going to need more hours." Flipped on the news and listen to Trump talk. Like layer of layer of subtle and not subtle invalidation all day long as they go through these experiences.

Alex: Yeah, some of these. So the example of the violence in Mexico is extreme. But it's almost like in the concept of microaggressions, for example. I think about this in terms of race or gender. You could make an analogy here and maybe it's not even analogy. Maybe these are sort of microaggressions about invalidating the experience of Coronavirus or the science of it or what healthcare workers are doing. Putting themselves at risk and spending hours and emotional investment and trauma to go through.

Eric: You can imagine going home after a shift in the ED in New York or in the ICU now, where a lot of cases are. Having 60%-70% of your hospital ICU now COVID patients. Then seeing a post on next door that it's not much worse than the flu. The flu doesn't do this, folks, the flu doesn't make 60% of your hospital COVID intubated patients.

Dani: Right, yeah. So when we think of emotional PPE, how do we make sure that these workers know that their experiences and sacrifices are seen, that their suffering is real?

Eric: How do you do that?

Dani: How to do it is like the million-dollar question.

Eric: The random emails from your hospital CEO I'm guessing is not the... It's something.

Dani: It's something, let's not take it away.

Eric: Let's not take it away.

Dani: It's a hard one to answer because you can do it on so many levels. Individuals reaching out to check-in, interdisciplinary teams creating spaces to have regular meetings. All the way up to Schwartz rounds, like Zoom Schwartz rounds that bring us together and have these shared experiences be seen and validated. There's now this national anonymous physician support hotline that you can call seven days a week like almost all hours a day and reach a volunteer psychiatrist. If you need someone to hear you out, bear witness to what you're going through. This is also why I reached out to you, guys. I think just last week after you did the GeriPal love letter to our colleagues at Columbia. The reason I reached out was because I'm so grateful for things right now that safeguard connection and validation.

Eric: Alex, we filled the bucket. Well, we really didn't fill it, I got-

Dani: You put a candy in the bucket, I liked it.

Eric: A teaspoon of water into the bucket.

Dani: Yeah.

Eric: Okay, connection, one bucket.

Dani: Wait, before I leave - connection.

Eric: More on connection.

Dani: It's just like one other thing to say about connection, which is just acknowledging the deep power of the language we choose. We talk a lot in palliative care about how important narratives are because the narrative that a person writes, can deeply impact how they experience a situation. So, Alex, I'm going to give you two different lines. You can pick one and you can leave the other one for Eric, okay?

Alex: Okay.

Dani: All right. Option number one. You've been the victim of some deeply intense experiences this month. Option number two. You've survived some deeply intense experiences this month.

Alex: I'm supposed to pick the best one or I'm supposed to pick one that I would use myself?

Dani: Which one would you rather put out into the world to a colleague on the front-lines?

Alex: I would say "the survived".

Dani: Yeah.

Alex: Yeah.

Dani: Yeah, the survived. We know from all the trauma literature and things that people who come through a trauma with the self-concept of the survivor, as opposed to being a victim, do better emotionally. Our language has power. We talk about this all the time in palliative care. Our language helps us find meaning. Now, more than ever, we have to be choosing the words, choosing the messages that are telling people, "Hey, we see, we think what you're doing is heroic and brave and meaningful. Even if you're having to come into contact with some really dark, not so pleasant things in the process."

Alex: It sort of bolsters their sense of resiliency and praises them for getting through the tough time. Rather than setting up the dynamic of victim-hood and-

Dani: Powerlessness.

Alex: Yeah, powerlessness.

Dani: Okay, I think we've done that bucket justice.

Eric: Right, bucket one, connection.

Dani: Bucket one.

Eric: There are three buckets, right?

Dani: Three buckets. I gave them all Cs, so you have some alliteration. So bucket two, C. Bucket two I'm going to call culture. In the setting of frontline healthcare workers, I'm going to say creating a culture in the workplace environment that will be protective at times of emotional distress. So I feel like I'm asking you guys more questions than you might want. But I'm going to do another one.

Alex: I like it.

Dani: Just to flip it around on you, guys. You guys. Eric and Alex, are you 100% safe from this virus?

Eric: No.

Alex: No.

Dani: No. None of us are. Yet we know that creating a sense of safety and security and comfort is deeply helpful in the setting of emotional distress or trauma. It's very buffering for your psyche. So my follow up question is would you say that there are some of our colleagues who are concerned about having adequate resources available to optimally protect their physical health while doing this work?

Eric: Yes.

Alex: Absolutely.

Dani: Yeah. You're like, "Dani, look at the news. We're hearing this, they're screaming it at us. They're so scared that there isn't enough protection, enough PPE, enough reliable guidelines around PPE to feel safe in their monumental work." People are questioning even the motivation behind the guidelines. Is this because of what would really keep me safe or is it because of supply? Is it because of money? They're going home and googling like how do I sterilize my masks? This feeling of being inadequately protected it's bleeding out of the doors of the hospital. Am I going to get my kids sick because of this? Am I going to get my mom sick because of this? I have no doubt whatsoever that this extra bonus level of concern about safety and about if the system values my safety is having a deep psychological impact on people. Far beyond like the safety from the virus itself.

Alex: Right. So the whole... The fact that nursing homes account for about half the deaths in the US, the nursing homes are given far less PPE, testing, et cetera. The people who work in those nursing homes just must feel so devalued, unsupported because of that choice that we're making as a society. The culture within the nursing home must be one of not feeling like you're in a supportive cultural environment. Is that sort of what you're getting?

Dani: Yeah. No, it is heartbreaking to watch people sacrifice so much. At the same time, be questioning if leadership if administration actually even cares about them. Yeah, I think I've talked about... No, we won't go there.

Alex: But what can you do about that? So as a health care worker, I could express support for a colleague and try and establish a connection with them. But I can't, other than being activist-

Dani: You don't have a sewing machine over there.

Alex: Right.

Dani: Making little masks.

Eric: I think the concern is that you don't want to tell people don't worry, everything's going to be okay when it's not. That could further increase distrust and it's interesting, we're using the word perception of safety. We also don't want to falsely state that everything is going to be fine.

Dani: Totally. So yeah, we have to actually try to get the equipment that people need. But I think you're right on, Eric. How different would it be if your leadership said something like, "You're right, this is an ideal? We're going to do our best to improve. We want to work with you and troubleshoot the best ways to keep you safe with the resources we have while we're still trying to get more resources." That's such a different message than, "No, you're delusional, this is a non-issue. There's no safety concern here."

Eric: Yeah.

Dani: Either way, we still want to get people more masks but there's a very different cultural feeling based on the message that we're sending around people's sense that they're not cared for, that their safety isn't important.

Eric: So connection culture?

Dani: Well, culture get moving. I would say that just sort of gets at, we have to put words to it, a big piece of culture is effective leadership and communication. Children who experience trauma are incredibly buffered by having a reliable, solid primary caregiver in their lives. It's not totally analogous, it's not the same thing. But I would say that having a reliable, solid leadership, supervisor, administrator in your workplace setting. You feel is trustworthy and has your best interests at heart is going to be huge as a piece of emotional PPE right now. I would even say I think the last time I was here I was dashing algorithms and things like that. But I would say having reliable algorithms in place right now so that people have guidance on how do I manage resources when there aren't enough? How do I manage remains, manage goodbyes, manage all of these things? Is going to protect from the isolation and the moral distress that comes with people having to make these on ideal decisions seemingly alone. That all falls under culture. How do we create a workplace culture where people are protected more emotionally?

Eric: Yeah. Third bucket.

Dani: Third bucket C. Do you have any guesses?

Eric: Carrots, eat carrots.

Dani: Okay. Third bucket I'm going to call coping.

Eric: Connecting, culture, and coping the three buckets.

Dani: Yeah. How do we support coping? Do you guys have go-to coping strategies?

Alex: Yes.

Dani: Wait, let me say it again. Do you have go-to healthy coping strategies?

Eric: No.

Dani: You can change your answer if you need to.

Alex: I bike five or six times a week and love it.

Dani: Actually, I think every time I've seen you, Alex, you've just gotten off a bike ride that's longer than accumulative bike-riding for the last 36 years of my life. Yeah. How about you, Eric, do you have a go-to?

Eric: I did some gardening this weekend and it was great.

Dani: It was great. Yeah. No, they're like so many things we know are effective. Self-compassion, exercise, yoga, meditation, quality time with loved one. I think you talked about donning and doffing emotions but yes, Eric, I'm going to hold you on that. We talked last time about this, using the times when we change our masks and wash our hands. It's like these symbolic rituals to cleanse our inner experience. I just heard that Eric Widera is going to be hosting a guided meditation every Monday at lunchtime.

Eric: Hopefully not.

Dani: Just kidding but Stanford is and it's a real thing, it's opened to everybody. Stanford does these guided meditations that run at lunchtime. Headspace is free now for health care workers. There's so much stuff out there. We know that people who at baseline have healthy coping strategies are going into this pandemic with more of an emotional buffer. That's in part because they decreased stress fair enough. But it's also because there's a sense of empowerment that we feel when we have the belief that there are things we can do to manage and impact our own emotions. That's protective. So we have to be asking how do we encourage frontline workers to access those strategies? How do we create access and education around developing and strengthening coping strategies right now? Then what do we do if that's not enough?

Eric: Now, I think one of the challenge is even when you bring up guided meditation. Is that my work life takes up a large portion of my day. I kind of want to just get done with my work and get home to these other things that are important to me. The idea of doing something, which I know would probably be very healthy for me, like guided meditations. Sounds great but on my list of priorities, it will not fit in. How do you deal with that when your day is already full and then somebody's saying, "Now you have to attend this guided meditation class at noon?"

Dani: Well, in part, I would say, "Hey, pick the things that you like because they're not going to feel like checklist things. There's a menu of stuff that's helpful, so pick the ones that call to you." Maybe the thing you're going to do at home with your family is actually the best form of coping for you. But I think the other thing I would say as an advocate for mental health is what if I asked you, Eric I get it. I don't want to get infected by this virus but the sweating and the discomfort and the edginess of putting on the mask and the gown and stuff. Then taking it off and having to wash my hands, it makes me like three minutes too late and I get this kind of rash on my face. But I get it, it's probably good for me.

Eric: We're saying the PPE burnout, people are just so sick of all of this. I get your argument though, that there are some things that we should do because it does protect us.

Dani: It does protect us. I think the other piece is we need to be ready for like if those things aren't enough. What do we do next? Would you guys say... I don't know but would you say you have a good sense of what symptoms would make you want to test yourself for COVID?

Eric: It's growing day by day.

Dani: It's growing.

Eric: Yeah.

Dani: Okay. Would you say-

Alex: A skin rash on my toes.

Dani: On your toes. My husband actually ran in today, he's like, "Look at my toes, are they COVID toes?" I was like, "No, babe, you're good."

Eric: I actually got tested today. Yeah, asymptomatic testing.

Eric: It was oropharyngeal and I gagged so hard that I grabbed the person's arm to push away. I had trauma, Dani.

Dani: What do you think the person experienced? [laughter]

Eric: I know.

Dani: Would you say then, having just been tested, you have like an equally sort of sophisticated understanding about signs and symptoms of stress reactions to be watching for with yourself? That might trigger you like, "Hey, I need more support, I need more mental health screening right now." Personal mental health risk factors, things in that vein.

Eric: If I had to grade myself from elementary school to medical school as far as where I am with that, I'd probably be at somewhere around third or fourth-grade.

Dani: Good, sounds fair, I'll take that. Third or fourth-graders are impressive. But no, we do need to... We've educated people so much around the virus but we haven't done a lot of work educating people about this is what a stress reaction is, this is what a red flag is. That you need a little bit more. This is how you get a mental health screening. All of these things we know about the infection, so little we know about how we protect on the other side of it.

Alex: So what is a stress reaction?

Dani: There's a lot that comes out in stress reactions, I don't think we can go through it all. But some of the big ones that come to my mind are disturbed sleep. If you start seeing disturbed sleep without a clear reason. It's not like a pager going off. If you start getting somatic symptoms, headaches, body aches that aren't normal for you. If you find that you're like irritable, angry, distracted, isolated without a clear reason why. None of these mean you're doing anything wrong, we're in a profoundly stressful situation. But those are the types of things that you see in a stress reaction that would be little red flags for me, saying, "Okay, this person needs more coping. This person needs maybe a mental health evaluation or more support."

Dani: But we should all know this, like I wish that colleague on the front-lines days before she got to where she got knew that and was able to say, "Okay, these red flags are coming up."

Eric: Just because I never thought about before. When psychiatrists like you say the word coping, is there a definition that you use? What is coping? See, I told you I'm a third-grader.

Dani: Yeah. What is that show like am I smarter than a fifth-grader? I can't remember much of it, a third-grader.

Eric: I may have to repeat third-grade here.

Dani: Coping is just how we deal with or process the feelings that we're having. Coping itself is not a good or bad thing. There's unhealthy coping. I have a feeling I don't like, I'm going to go drink and eat 10 Ding-Dongs. Then there's healthy coping, I have this feeling I don't like, what can I do to deal with it, to process it, to be able to tolerate it?

Eric: Yeah. Probably a lot of what people are seeing is rates of alcohol intake pretty much gone up dramatically, pretty much everywhere.

Eric: A lot of people are using alcohol to cope with this, I wouldn't even say social distancing, it's often social isolation, worry about the pandemic, worry about safety. Certainly, where the healthcare providers are doing the same.

Dani: Yeah. I would say then that the last piece of this coping bucket, is that we need to have accessible psychological support very easily available as a form of PPE. Not only just accessible because we know that accessing support, not everyone's going to need it. But for people who do, it's obviously, going to be protective factor. Well, you guys are both in psychiatric treatment right now, right?

Eric: In the last 45 minutes, I've been. [laughter]

Dani: Don't answer the actual question though because I would never ask you that question. But it will lead me to my next question, which is you guys have been working in medicine for a long time. How psychologically easy do you think it is for most of us in medicine to say, "Okay, yeah, I'll sign up for formal mental health care, yeah, sure?"

Eric: Incredibly hard.

Alex: Totally hard.

Eric: Again, going we've got busy schedules, we're working during the day when those things are happening. We are... I think you hear plenty of stories about when people have problems and they submit it. That they're also put in a bureaucratic system that they may have ramifications as far as their career, as far as what they have to do. Yeah.

Alex: Let me add to that. That I remember when I was in residency, I worked with a pair of folks who have been former chief residents of a distinguished hospital, which I won't name. One of the sayings from that hospital was the strong will be strong and the weak will be weak. The strong will be strong and the weak will be weak. So there's this culture if we were going to go back to the other C, of asking for help, showing signs of weakness is not desirable. Working your way through it, toughing it out, grinding it out is a sign of the strength. I think that's true, not just in that hospital because that would be unfair. But sort of culturally, it's part of the hidden curriculum in medicine as we break people down through grueling years of medical school and internship and residency and clinical fellowship. Then we build them back up in ways that are analogous to military bootcamp.

Alex: Yeah, so I think there is this embedded within the culture. We did this study on crying and medicine at one point. We asked people, medical students, and interns, what their experience was with attendees who were crying? Their experience was as soon as they start crying, they leave and they hide and they're embarrassed and they don't talk about it. So there's this hidden curriculum here that sort of ingrains in us. That asking for help is generally not something to be desired in medicine and it's something potentially even to be ashamed of.

Dani: Yeah, what a sad commentary. We're like help yourselves but don't. So I think that you guys are kind of spot-on and this is one of my soapboxes. It sounded like a warning, it's like warning she's about to get on a soapbox but this is one of my biggest problems with medical culture. If we really want to have this emotional PPE, then we have to say that as important as access is the need to normalize and even celebrate the importance of mental health care right now. We need to take like an unequivocal strong stance in saying that we would rather a healthcare provider that takes the steps to care for their mental health over the one you described, Alex. Over a healthcare provider that just toughs it out and ignores the problem. Hand in hand with that is the message that we would rather celebrate the bravery of healthcare providers who asked for help than mourn the loss of one more hero for whom suicide is less intimidating, the reaching out.

Dani: There's a reason the doctors have such a high suicide rate. There's a profound impact that our bias against psychological illness has had on ourselves and our colleagues. It's time for us to be accountable for it. I'll come off my soapbox.

Alex: Yeah, well, that's great and in the spirit of normalizing, I've sought psychological health, mental health counseling on three different occasions. I can think of off-hand for myself and relationships and family issues. I found it tremendously helpful in all cases and I encourage people to seek it out and try it. Don't feel like you're shamed or suffering alone. Are there resources, Dani? Are there specific resources for people in the time of Coronavirus? What numbers can they call or who can they reach? How much of this is local or are there national resources?

Dani: Yeah. I want to start just by thanking you for that disclosure because I think that is how we do it. We just have to really own our own vulnerability as humans. We can't expect our colleagues to do it, we can't do it. So thank you, Alex. There are a lot of resources, a lot. I don't know all of them, so there are national hotlines that we can put the numbers too on the podcast page that people can call sort of 24/7. There are, I know in San Francisco we have a whole network of pro-bono psychiatrists, who are willing to do this work for free via video with any healthcare worker that needs that support. I know in New York they have the same thing going on. There are things like apps and stuff that might be less intimidating.

Dani: But what I was wondering and maybe if I just ask you on air, you guys will be less likely to say no. But I was wondering if we could actually make an emotional PPE resources page on GeriPal. Where we could try to put these all together because I can't tell you how many of these efforts I'm seeing on all my different psych pages. I think if people could write in and we could accumulate all the national things available, all the local things available, so people know what they have access to. That'd be a nice organizing thing we could do for everyone because there's a lot.

Eric: Absolutely.

Dani: Yes.

Eric: We're going to rely on you. So our listeners too if you have other resources, we'll have a menu bar titled Emotional PPE. How about that, Dani?

Dani: Love it.

Eric: With all the things that we talked about today. Some of them are great. Dani mentioned things like Headspace, free app for healthcare providers. Dani, the last question I have for you because there is some concern amongst physicians. About like physician health programs, these state programs-

Dani: Caring for the caregiver, yeah.

Eric: Yeah, and your license is also dependent. If you get reported to these, your license's depending on completing them. I've heard that it's like a big business now too.

Dani: Yeah.

Eric: How does that fit into all of this?

Dani: It's a sad commentary on the whole medical field and medical culture. I think how it fits in with emotional PPE? I think we need to, in the short term, make completely anonymous resources available. That physician hotline for any physician across the country that you can call, it's like 7:00 AM to midnight and get a psychiatrist is 100% anonymous. So I think we have to have that there because people aren't just paranoid. Some of these concerns are legitimate. I understand why we're also hesitant to seek out or disclose care. I think on the other end of it, may this be time for a long-overdue change in how we treat these things. We have created a system that would rather like an impaired physician go unchecked. How about every single person you know, hashtag emotional PPE and ask for a call to action? To change the way that healthcare deals with accessing mental health support. I wish I had a better answer for that one.

Eric: Is there anything else, any last thoughts, Dani or last questions, Alex, that you have?

Alex: Not from me.

Dani: I think probably my last thought would just be a call to action. So for the individuals like the three of us who are listening to this podcast, please right after you hear it, reach out non-intrusively check in with somebody that you know who's on the frontline. For the leaders who are listening, please don't just be mindful of emotional PPE, be champions of it. Champions of connection, of culture, of coping. I guess the last one would be that in case there is someone out there who is feeling hopeless right now and listening to us talk. I promise you that I've seen many, many hopeless people that I myself have been deeply hopeless at different parts in my life. It is a feeling and as with all feelings, new feelings await you, even if it's hard to see that right now. So please, please, please reach out for support if you need it because I promise that you are valued and you're cherished. I'll leave it at that.

Eric: That was absolutely wonderful.

Alex: That was beautiful.

Eric: It kind of aligns with our song, I got you, babe.

Dani: I got you, babe. We've got you, babes.

Eric: We've got you, babes.

Alex: We'll see.

Alex: (singing) They say our love won't pay the rent before it's earned, our money's all been spent. I guess that's so we don't have a pot but at least I'm sure all the things we've got. Babe, I've got you, babe, I've got you, babe.

Eric: Nice. Dani, it's always great to have you on.

Alex: So great to have you on, Dani. Thank you so much.

Dani: Always.

Alex: Thank you to our listeners, thank you Archstone Foundation for funding us.

Dani: Thank you to our colleagues on the frontline, we see you, we see the heroic work you're doing.

Dani: Sorry, I wasn't supposed to talk. [laughter]

Alex: No, that was great. That's great, yeah. [laugher]

Eric: That was the first C. [laughter]

Dani: It was...nice.

Eric: With that, good night, everybody.

Alex: Bye, everybody.



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