Critical Care
Burnout in unprecedented times
Even in typical times, intensivists have a significantly higher rate of burnout compared with other medical specialties. We fight for lives, dealing with death, dying, and tragedy on a daily basis. Regrettably, we are no longer in ‘typical’ times. This is a prodigious and uncharted era.
Dr. John P. Gaillard
The COVID-19 pandemic has created all new hardships. Added to the complex world of critical care, we undertake lack of appropriate medical equipment and PPE, the possibility of becoming ill or infecting our families, potential financial struggles, and the unpredictability of the future. Additionally, in our efforts to care for patients, we face increasing moral distress when placed in situations in which we cannot do what we feel is right. And we carry the burdens and guilt of patients’ families who cannot be with loved ones during this process, even during death.
What does burnout look like in this new era? Burnout is a continuum and can manifest differently depending on the individual. Even a typical day in the ICU may be cause for the symptoms of burnout including frustration, anger, anxiety, or sadness which can progress to feelings of powerlessness, self-doubt or depersonalization.
This crisis is a test of endurance. But we don’t have to face it alone. The ICU is a team environment, and we can help each other make it to the end. Consider beginning the shift with a group morale boosting activity. Perhaps debrief after the end of each shift to discuss ways of combatting these stressful times. Have a virtual happy hour with colleagues after work. Call on leadership for support. Watch each other’s back. Together we will get through these unprecedented times.
John P. Gaillard, MD
Steering Committee Member
Resources for confronting burnout:
http://ccsconline.org/optimizing-the-workforce/burnout
https://www.ama-assn.org/topics/physician-burnout
https://www.ahrq.gov/prevention/clinician/ahrq-works/burnout/index.html
Home-Based Mechanical Ventilation and Neuromuscular Disease
Use of modified RADs
Investigators have begun exploring ways to convert devices typically used to treat sleep-disordered breathing (respiratory assist device, RAD), with modifications to minimize risk of aerosolization of pathogen in the COVID-19 pandemic. These devices are presently not considered an effective means of treating acute respiratory distress syndrome (ARDS). In an emergency, however, it is reasonable to consider all the options available with a healthy respect for inherent device limitations.
Dr. Jacob F. Collen
A RAD could be converted from an open ventilation single-limb respiratory circuit to a closed ventilation circuit with a passive exhalation valve. This circuit could provide adequate minute ventilation and allow for adequate exhalation of CO2 to prevent rebreathing. Strategic placement of the passive exhalation valve proximal to a viricidal filter would allow the device to be used with either an endotracheal tube or a nonvented oronasal mask (Figure). These devices by design are pressure-regulated, and a backup rate would be necessary to control minute ventilation. Close monitoring would be necessary given lack of alarm capability for a critically ill patient and the need to ensure adequate oxygen bleed-in.
The primary limitation to these devices is the inability to achieve adequate mean airway pressure for ARDS. While such a converted device is not ready for prime time, it could be considered for patients who are close to weaning from conventional mechanical ventilation (i.e., freeing up a ventilator for a sicker patient) or temporizing a patient early in disease to stave off invasive ventilation.
MAJ Brian E. Foster, DO, USA
Fellow Member
COL Jacob F. Collen MD, FCCP, USA
Steering Committee Member