Dr. Richard Walker, a seasoned veteran of emergency medicine and student of history, instinctively sensed what horrors lay ahead one day in late February when a senior member of his team casually said: “You’re about to find out why your grandparents washed and saved tin foil.”

As head of emergency services, Walker has seen every sort of human trauma wheeled into the emergency rooms at both Methodist University and Regional One Health. He’s trained to respond to the utter collapse of life as we know it through earthquake, massive plane crash, even chemical warfare.

Every day of this pandemic – a human tragedy of the same scale – has tried him in some way. His respite is to walk his favorite Memphis spots, frequently 6 feet from his recently widowed mother on the Midtown streets where he grew up.

“Just something to be by yourself or with another person, seeking to return to what we jokingly call normal people stuff,” Walker says quietly.

Number of COVID-positive patients in area ICUs drops below 70

Signs of stress

Six months into the pandemic, the pace has worn into the gut-it-out phase of a marathon for health care workers, the adrenaline of the early anxiety days now firing their muscles in a reflexive response to keep going, to keep serving, with the hope of a vaccine, now perhaps only months away, glowing on the horizon.

Statistically, the stress has hammered the health care workforce, and the signs are everywhere.

But it’s also engendered a survivor’s sense of community among teams that wasn’t always evident before, say Dr. Amber Thacker, medical director of hospital medicine at Regional One and team leader in the COVID-19 wing.

“We have a housekeeper named Alice. Her risk is higher than mine because she’s older than me. She volunteered to be in that unit with us, and she’s been there every day. … 100% of her work has been dedicated to that unit. I get teary-eyed talking about her.

“I just really admire that she cared enough about us to want to be in the unit, just wiping doorknobs, counters and surfaces all day and being right there behind us,” Thacker said.

At Baptist Memorial Health Care, counselors in the employee assistance program saw a real uptick in candor when telehealth – ushered in by COVID-19 – allowed them to counsel employees from their homes, even their cars.

“I think that leads them to letting their guard down because they are in a safe place. They are more authentic and open,” said Melissa Wilkes, a licensed clinical social worker and director of Concern EAP at Baptist.

Opinion: We stand at the crossroads

The counseling staff is seeing 140 employees a week, about 5% more than usual, and far more emergency appointments.

“Those are filling up very quickly, and we’re scheduled out much farther than we normally are just because of the calls coming in,” she said.

“There is a great deal of fatigue and exhaustion,” she said, the effect of months of “being on your toes and aware that something could happen at any moment. It’s like the storm that is constantly brewing. It really takes a toll. 

“When you have to be on a sort of heightened alert, endlessly - I don’t think our nervous systems are made for that.”

In hospitals, Wilkes said, it’s not possible to expect employees to go on working as usual “when riveting things happen.”

Baptist deploys teams to talk to employees who feel traumatized. It also leads group debriefings and has counselors on call. But it also means helping people find other ways to connect socially and creative ways to exercise.

“You’re really just trying to help people find the light at the end of the tunnel,” Wilkes said.

“As you probably well know, alcohol and drugs are through the roof now, so if someone needs something such as a treatment for alcohol and drugs that are beyond our scope, the counselors are able to connect them with that,” she said. “We are seeing those numbers go up.”

Clay Jackson, assistant professor at University of Tennessee Health Science Center and physician at West Cancer Clinic and Methodist Medical Group-Primary Care, says people cry more at work now.

“They’re more willing to say, ‘I’m feeling overwhelmed’ or ‘It’s Wednesday; I need it to be Friday,’” Jackson said.

West Cancer has created a flow-nurse position to float across the clinics to make sure people are taking their breaks and not overworking themselves.

“The clinical imperative to take care of people is so strong,” he said.

Pandemic’s stages

Dr. Stephen Threlkeld has not had a full day off since March 6, two days before his patient became Shelby County’s first COVID-19 case.

“I would say that we’ve been through three major stages,” the infectious disease expert at Baptist Memorial Hospital-Memphis said. “First was this idea that, to paraphrase a movie line, ‘We are going to science this thing to death.’

“We were overconfident. We thought ‘Not in the United States.’ We are going to take care of this very quickly with all of our big technology and critical-care abilities,” Threlkeld said.

Then came the New York horrors and the running Twitter feed of tent morgues and nurses weeping in hospital corridors while ambulances howled in the background.

“And we just very quickly realized that we might not be as terrific as we thought we were, or at least able to overcome things that just can’t be overcome,” Threlkeld said.

“That put us into a bit of a collective depressed state about this. We saw people dying in the hospital without being able to have family there and the emotional trauma that accompanied the physical problems. The medical issues were just sometimes overwhelming.”

The depression eventually gave way to the realization “that now we are in the longer period of time, which science really is, that slow, incremental progression of knowledge and ability to do things – more medicines, better medicines, the promise of a vaccine.

“All of that helps us. It helps us medically. It helps us psychologically,” he said. “We’re in a distance race now.”

Fear on the front end

In the early stages, science wasn’t clear on so many things about the virus, including how it was transmitted. People in emergency departments lived with a heightened sense of their own vulnerability.

“The belief was that pretty much everyone in emergency departments would get it and some people wouldn’t survive it,” said Walker, interim chairman of emergency medicine in University of Tennessee Health Science Center’s College of Medicine. If it opens, he will also be the person in charge of the alternative care hospital in the former Commercial Appeal building. 

“That unknown early on was extraordinarily stressful for all of us as things began to ramp up,” he said.

Walker’s teams at Methodist and Regional One didn’t run completely out of personal protective equipment like hospitals did in New York.

“But we had shortages. We had to reuse things that were supposed to be single-use. That pretty significantly increases the risk,” he said, and compounded the fearful unknown of what going to work suddenly meant.

Walker also was overseeing work to get the newspaper building converted to the alternative care hospital, which for most of April meant working 90 hours a week.

The hardest thing for Threlkeld, on duty now at Baptist-Memphis from 7 a.m. to midnight, has been caring for friends dying of COVID-19.

“You realize that you were the only person that would actually ever see this person in the hospital ... that they knew,” he said. “That strangely applies an additional pressure to their care that you might not think about until you’ve done it.

“When you have become the only family somebody has in the hospital, it was an extra layer of responsibility. I can assure you that the health care workers feel that.”

Nurses, he said, deserve so much more credit than they get, noting that doctors “swoop in” but the nursing staff is with the patients all day.

“Watching the tearful nurses doing FaceTime on their phones so elderly people could be with their families was very touching and sometimes difficult to watch.”

In the beginning, many hospitals and clinics didn’t have enough personal protective equipment (PPE). There also was no treatment beyond administering oxygen.

For health care in one of the richest nations in the world, it was like practicing in the developing world, doctors say.

The hardest day for Jackson was a late-winter day when he had a suspected COVID-19 patient on the phone and not a thing to offer.

“We didn’t have the equipment to protect ourselves or other patients if they did come in,” he said.

“And then, we were being told by the ER staff that they were overrun. There was confusion with administration about where this patient should be seen and how their needs should be met,” he said, his voice trailing off into silence.

“It was jarring to not be able to weigh in and do your best.”

Everyday challenges

Since those early days, health care workers have been masked and gloved in latex, sweating through entire shifts.

“Everyone’s hot, and then, because of the aerosol guidance and some practice environments, we have to wear face shields as well,” Jackson said. 

“It has been very difficult for our patients who are hard of hearing,” he said. “You find yourself repeating things all day long.”

Caring for people when it means putting on and meticulously taking off layers of protective wear adds time to every patient visit, Threlkeld says.

It also a notable physical effort to don and doff all day.

“I would stop short of calling it exercise,” he says.

“You have to be careful because those things certainly protect you in a room with a patient, but wearing the proper protective equipment can also protect your other patients,” which means there can be no shortcuts in technique for how the gear is removed.

“I think it’s human nature to want to simplify things and always find a faster way to do it,” Thelkeld said.

Not possible now.

Baptist has infection prevention nurses on every COVID floor to make sure the layers come off exactly the way they need to in order to prevent contamination.

And while telehealth has saved the day many times since the pandemic hit, there is never any way to know how strong the connection will be, therapeutically or electronically.

“You have to adjust your expectations every day, steeling yourself for what it means to be flexible,” Jackson said.

For Thacker, who spent five months largely separated from her children, who were living down the street with her health-compromised parents, the pandemic gave her a way to dig in, despite her anxiety.

“I don’t think it was the fear of the individual patient or that encounter that really was in my mind,” she said. “For me and the people around me, the fear was the circumstances that we are about to have more patients than we could care for.”

Her worry every minute was that Regional One would run out of resources, forcing her and the rest of the team to use PPE over and over, which she’s never done.

She volunteered to see the hospital’s first COVID-19 patient.

“I was the head of our group and I felt like ‘I don’t want to ask people to do something that I’m not going to do.’”

She was fine until she got to her car that night.

“I had to sit there for a second and take a big breath. It’s not that I was scared of that patient. It was ‘This is real. This is going to come to Memphis. And we might find ourselves in the position that our colleagues in New York are in, and California and Washington.’”

In the beginning, the fear was so intense, it was not unusual for patients to try to run from the hospital, she said.

But being in the COVID-19 wing was oddly calming.

“I was able to be proactive. I was involved. And when things were being done, I was able to say, ‘Here’s what we need to do to make this happen.’”

Now, months later, doctors have treatments and understand the disease much better, which has changed much of the day-to-day stress.

Telehealth has added a new layer of support for seeing patients, but it has also blurred the line between work and home and has the effect of extending the workday for practitioners with an insidious, glowing presence that never stops.

“On my last day off, I had at least two or three issues that arose because the day before, patients couldn’t get into the office or couldn’t make their connection on telehealth, and they had medications that were going to be running out,” Jackson said.

“It’s not just a simple phone call. It means getting to a computer, looking up what amount of medicine is needed. Because these are severely ill patients, an interruption in care like this needs to be managed.”

Jackson finds it unproductive to blame the patient, the system, “the internet or Trump or Mrs. Pelosi.”

“At some point, there’s a patient with a need; are you going to help them or not?” he said. “That is the challenge of being in the helping professions.”

On a good day, it’s mission creep, he says. On a bad day, it’s two or three more hours from getting to the things that help people decompress.

“It’s hard to shut the door,” Jackson said.

In an electronic world, it’s hard to know a door even exists.

He also laments a climate that pits doctors and science against political leanings. Besides the day-to-day tension it creates, Jackson feels it chipping away at Americans’ trust in medicine, which he says took centuries to build. 

“We’re trying to be nimble at negotiating what patients' understanding is and sort of sticking with a unified voice when, frankly, in this country, certainly at the national level, there isn’t a unified voice. Facts are black and white, but they get filtered through red and blue.”

Counseling for physicians

In early August, the Memphis Medical Society launched Thrive, a counseling service staffed with a psychologist to help its 2,300 members deal with stress and burnout.

The members contributed $25,000 to get the program going before COVID-19 happened.

“Then it hit,” said executive director Clint Cummins.

“I hate to paint with such a broad stroke, but really, the entire industry was really in a state of disarray.”

A month after the society’s counseling service opened in early August, about 1% of members have used it.

“It’s about what we projected,” Cummins said. “One percent sounds low, but that’s 23 doctors in our community who knew they needed help.”

And because Cummins knows doctors email and voicemail in-boxes are always full, he wasn’t surprised in a survey the society sent out in mid-August that more than half the respondents didn’t know Thrive existed, “even though they had literally been sent an email about it several days before.”

That makes Cummins think usage will increase down the road.

In the survey, 35% of respondents said they were experiencing moderate to severe symptoms of burnout.

And in what Cummins finds even more telling, 43% said COVID-19 had increased their level of burnout.

Next obstacles

There’s little rest in sight, he says. The next obstacle for health care is the flu season.

Last year, fewer than 50% of Memphians got flu shots, and doctors here are worried about what it portends this year.

“After the flu season, it goes to all the preventive stuff that everyone’s behind on – your cancer screenings, your physical, everything we’re supposed to do annually. And we’re all behind on all that,” Cummins said.

Health care workers, lauded as heroes with parades and rallies when the pandemic began, have settled into their own marathons, dealing with the loss and loneliness in their own lives that define the pandemic’s emotional tide on every continent.

Threlkeld’s mother turned 90, alone, this spring. He’s seen her several times, but only from a distance.

“It’s indescribably difficult, and she’ll readily tell you it’s the hardest thing she’s ever seen in her lifetime.”

Even though health care workers have been pressed more than they have been pushed before, Threlkeld finds solace knowing that earlier generations experienced similar calamity and survived.

“Remember, our grandparents’ generation, they lost siblings regularly. We’re not unique in having to face this. We just haven’t had to face it in our time of plenty and technology in the United States,” he said. “We haven’t had too many things make us realize we are just not in control like we thought we were.”

Walker lives with his own optimism.

“It’s stressful now, but you’ve got to wonder if maybe everyone will have a little bit more appreciation for what we had before.”

And he also hopes that people will see what a powerful difference the sacrifices have made and be willing to band together on other systemic fronts. 

“Two or three months ago, I really didn’t think Memphis was going to get its act together,” he said, hoping then that the collective city would pay attention to the international news and get serious about doing what they needed to do to make the city safe.

“I’m pleasantly surprised that everyone has been able to pull together in a pretty reasonable fashion.”

And if the being kept close to home feels interminable, Walker has a different perspective.

“This is actually short for a pandemic. ... “The Spanish flu was a two-year-plus event and during World War II.”