Front-line fatigue: ICU nurses taking brutal blows to their mental health

Editor's note: This is the first in a series of stories looking at front-line fatigue among health care workers in Utah.

SALT LAKE CITY — Robin Grigg's patient, struggling to breathe, looked at her and asked what was wrong with him. She showed him his positive COVID-19 test results, knowing it was not the first time he had seen them.

"No," he said. "COVID's not real. I don't have COVID."

He wouldn't budge. Eventually, they just decided not to talk about it, and she continued to provide life-saving medical care for someone who didn't believe his condition was real. She couldn't bring herself to find out what happened to him because it was just too hard.

"Imagine not being able to breathe and still not believing it's real," the former ICU nurse at University of Utah Health said.

"They will have disregarded medical advice and gotten COVID at a party. It makes it nearly impossible to have empathy for them. They'll be on like eight infusions, their toes are turning black, tubes are everywhere, teeth have been knocked out from intubation, they'll be puffy and swollen and bruised, and they still won't believe it."

Grigg comes from a family of health care professionals and she always wanted to work in health care. She felt like she was born to do it. But now she's afraid to tell people she's a nurse because of the backlash that frequently comes with it because of politics.

During the holidays last year, she deleted all her social media because it was too hard on her mental health to see people disregarding public health recommendations when she and her fellow health care workers were pulling out all the stops to try to keep people alive.

"I couldn't see people doing whatever they want when I felt like my sanity was hanging by a thread," she said.

She was already seeing a therapist, but the stress was enough that she started taking prescribed anti-anxiety medication. When even that wasn't enough to keep her mentally healthy, she decided she had to step away from working in the ICU in January. Now she works as a nurse at the Utah Diabetes and Endocrinology Center, where she doesn't treat critical COVID-19 patients.

Health care providers worldwide are facing similar positions of complete and utter burnout to the point of mental illness. ICU nurses in particular are leaving at unprecedented rates after being traumatized by being constantly surrounded by horrific deaths because of COVID-19.

Liz Close, executive director of the Utah Nurses Association, said there are four aspects of pandemic care that are affecting Utah nurses' mental health:

• Having to take care of patients with a disease that's largely preventable "indicates a public disrespect for their time, expertise, dedication and well-being."
• Even experienced nurses are losing many patients to COVID-19.
• The isolation needed to protect their patients and minimize viral spread.
• And serving as "the only conduit between dying COVID patients and their families."

"Not only have (the Utah Nurses Association) and (the American Nurses Association) never before seen this level of distress among nurses, in my 46 years of experience as a nurse, I have not witnessed anything that remotely compares to the current situation. I have never heard nurses speak of being 'broken' like they have been recently," she added.

The promise of effective vaccines brought back some hope to nurses, but the low vaccination rates and corresponding resurgence with the highly contagious delta variant took away any hope that the pandemic might be dying down.

"In January and February, it seemed like there was a light at the end of the tunnel. That light's gone," Grigg said.

'Taking care of corpses'

Kirsten Roberts Pusey describes her typical day in the surge ICU at University of Utah Health as "just straight anxiety all the time."

"You feel anxious. Everyone feels anxious. Everything is in disarray — supplies everywhere," she said.

Nurses ending their shifts catch her up on the patients, all with seemingly identical situations, and then she's off running, securing breathing apparatuses, flipping patients onto their bellies in a prone position and sedating and intubating the critical patients. Because the patients are on their stomachs, the ventilator tube is secured with a string with their faces to the side.

"You always have a lot of anxiety as a nurse when you're around patients on a ventilator because their life depends on that tube being in the right place and you can't get to their airway easily. Anything at any point could ruin this. If it comes out, that would kill them instantly," she said.

She has treated some "big name people" she wouldn't identify for privacy reasons, and she has treated many, many average people. And in the ICU you wouldn't have been able to tell them apart if it weren't for the name on their chart, she explained. In a way, COVID-19 is the ultimate equalizer.

"They're so, so sick, in this completely helpless position in this place in the world: naked, paralyzed, sedated on their stomach, having all their functions done for them," she said.

Grigg explained it as being surrounded by a living graveyard, with the patients being "like dead bodies we were keeping alive on machines."

"I literally felt like I was taking care of corpses," she added.

At the end of the day, Pusey goes home and any professionalism and the to-do lists melt away, and she's left with the trauma. Even if she tries to go to bed at 9 p.m., she will be awake at 2 a.m. dreading going into work the next day.

"I continue to think about those patients when I finally have time to process. I can't sleep, and the scenarios are running through my head and I'm overanalyzing it and end up in tears over how catastrophic these situations are and how vulnerable these real humans are," she said. "I'm constantly on edge, and there's complete sadness all the time at the most minuscule things."

In the end, she scrounges a couple hours of sleep, gets up, gets to work, turns off her emotions and is running again.

In the trenches

After a week full of death of people near her own age, Jane Goodfellow stood with the other ICU nurses at St. Mark's Hospital in Millcreek as a visitor in charge of spiritual care asked them how they were holding up.

"Well," commented one of her co-workers, "I just heard another co-worker say she's gonna have a bottle of sangria for breakfast. So that's about how we're doing."

Drinking has become a commonplace coping mechanism for nurses who are pushed past the limit of their mental capacity to handle trauma every single shift, Goodfellow explained.

"Sometimes I wish I drank," she said.

Health care workers, and nurses in particular, are the ones most closely interacting with patients and contacting their families who can't be present. They are expected to maintain a certain level of calm and collectiveness, Goodfellow said.

"It's like society expects you to not have feelings, to run toward the fire and even if you get burned to not do anything about it," she said.

All of the nurses interviewed for this story frequently used war imagery and combat terms to describe their time in the ICU. All of them mentioned that the one thing that helped them get through during this pandemic has been their "comrades in arms," their fellow nurses who understand what it's like to deal with this level of death and trauma in a way that other people never could.

"We don't care about your opinion on COVID if you have not been in the trenches with us," Goodfellow said.

And like veterans, health care workers are experiencing unprecedented levels of post-traumatic stress disorder and disillusionment when coming back into a society that doesn't understand them.

"I've never been in combat, but there's the idea that only the people there with you really understand what it's like. Only the other ICU nurses," Grigg said, adding that she has been experiencing PTSD symptoms since her time in the ICU.

Still going above and beyond

Even with the exhaustion, burnout, disregard from the community, missed breaks, hours of mandatory overtime without raises and mental illnesses like anxiety and PTSD, nurses still tell stories of their colleagues going above and beyond for their patients.

One nurse told a story of a young couple flown in from out of state because there happened to be a spare ICU bed at her hospital. The husband had COVID-19, and his wife stayed by his side every day during his treatment and built relationships with the nurses.

When he died suddenly and unexpectedly, the nurses arranged for the wife to stay with his body for several hours — one nurse staying past the end of her shift to help care for the woman who didn't have family nearby. Eventually, another nurse drove the woman to a hotel, where the off-duty health care worker spent the night looking after the grieving widow until she could go home to her family.

Heroes and villains

At the beginning of the pandemic, nurses and health care workers were hailed as heroes just because of their job, and now people regularly paint them as villains just because of their job, Grigg said.

While she said she didn't appreciate being placed on a pedestal, she also hates being demonized for risking her life taking care of patients, working long hours with mandatory overtime for low pay and wearing so much protective gear that she suffered an acute kidney injury because it was nearly impossible to take a break long enough to remove all the equipment just to use the bathroom.

Once when Goodfellow needed to pick up her antidepressants from a pharmacy, her supervisor pulled her aside and asked her if there was anything else she could wear. The supervisor recommended Goodfellow not wear her scrubs in public out of fear that she would be targeted.

"She was so concerned. She said she was afraid I was going to get attacked," she said.

According to a guide from the International Committee of the Red Cross during the first six months of the pandemic, 611 incidents of COVID-19-related physical or verbal assaults, threats or discrimination were directed toward health care workers, patients and medical facilities. These incidents show a pattern of increased violence against health care workers, and nurses in particular in, in more than 40 countries, including Nigeria, Mexico, Brazil, Pakistan, Myanmar, India, Colombia, the United Kingdom and the United States.

Close said the Utah Nurses Association has seen that a lack of empathy in the surrounding society is a huge contributing factor in the drastic upsurge in mental illness in nurses across the country and in Utah.

Goodfellow also noted that people seem to care more about their freedoms than about health care workers.

"People will come in and say, 'You'll put me in the ground before you'll vaccinate me.' And then they get their wish," she said. "Now you've turned something from your problem into my problem.

"I'm going to have to be the one to watch you slowly die over the next few weeks. I have to be the one to hold your wife's hand. I have to field your family's calls. People say 'my body, my choice,' but you're not going to have to be the one that puts that body in a body bag."

Close explained that while people tried to demonstrate their support for health care workers through fireworks and light shows at the beginning of the pandemic, the biggest thing that would actually help would be to follow the public health guidelines and stay out of the over-full hospitals.

"The public needs to better understand that the most important and effective way to support nurses right now is to get vaccinated against COVID-19 if eligible and not medically contraindicated.

"Accolades, thanks and prayers for nurses are appreciated, however, to really help is to not get sick with COVID," she said.

Correction: An earlier version incorrectly attributed a quote to Liz Close instead of Jane Goodfellow.

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