Mental health and the pandemic

Writing is my therapy. I am not a mental health clinician. I am just a surgeon who grapple with these issues within myself, my colleagues and the patients I see daily. Many of you are much more experienced and better trained to speak into this space. I will not do justice in this blogpost to the breadth, depth and complexity of the spectrum of human mental health conditions. We will never be able to delineate and break things into neat compartments, because we’re humans and that’s what makes us unique.

The words “mental health” have been used a lot during this pandemic. Sometimes to the point of being used as a political weapon. When I ponder and meditate on my big emotions during this pandemic, I realise that there are differences between stress, exhaustion, burnout, moral distress, compassion fatigue & mental illness. What do I mean?


Stress is a natural physiological and psychological response to a challenge. Work is stressful. COVID is stressful. School is stressful. Weightlifting is episodic stress on muscles to build muscle resilience. Life is full of stresses. There is a spectrum of normal stress. Some stress is good for you. Exam stress and work stress train your mind to excel.


Exhaustion is a natural physical side effect of working hard. Training and exercise, long working hours, consecutive shifts, lack of breaks, prolonged exercise, etc all result in physical exhaustion. It’s normal to be exhausted after a marathon at work. You can be exhausted, but be absolutely satisfied as I often experience after a whole day of operating.


Burnout is an occupational psychological state characterised by cynicism/disengagement, emotional exhaustion and lack of efficacy. This is often due to poor work environment or toxic workplace culture. You can be stressed and exhausted, but be happy at work and not burned out. Similarly, you can be burned out in a low productivity job if there was significant prolonged negative culture.

Moral distress

Moral distress (moral injury or anguish) is the state of knowing the right thing to do but the inability to do it because of restrictions. You want to help a patient, but you can’t because there’s no ICU bed is moral distress. Not burnout. Needing PPE but having none is moral distress. Knowing the horrible state of affairs in your institution but being unable to change it is moral injury. Seeing a patient needing oxygen but being unable to offer higher level of respiratory support is moral injury.

Compassion fatigue

Compassion fatigue is a condition characterized by emotional and physical exhaustion leading to a diminished ability to empathize or feel compassion for others, often described as the negative cost of caring. Sometimes referred to as secondary traumatic stress. This is many of us who have seen hundreds of COVID patients turn up in Emergency, ward or ICU. We plug them on oxygen and we move on to the next one without compassion because we know the next patient just needs the same thing again and again.

Mental illness

Mental illness is a medical/psychiatric condition with strict categorical definition based on DSM-V and ICD10. This is a diagnosis made by a mental health professional or a GP/Family Physician much like other medical conditions. I cannot define depression, anxiety, PTSD for you. It is the domain of the GP and mental health professional.


Of course, the above experiences are all valid and interconnected. You can be stressed without having compassion fatigue. You can be diagnosed with depression and not have burnout. You can be burned out but not have moral distress. They are different shades of the human experience. COVID is stressful for all. Health care workers are experiencing stress, exhaustion, moral distress, compassion fatigue, burnout and some even reach a diagnosis of depression.

The solutions?

Stress: manage the amount of work and consider breaks. Exhaustion: rest, sleep, nutrition, exercise. Burnout: occupational cultural change. Moral distress: ethics of resources. Compassion fatigue: rest, social support. Mental illness: mental health professional. The solutions to these challenges are unique. Antidepressant will not fix a toxic workplace. Lack of PPE will not fix compassion fatigue. Cutting workload down will not completely fix depression. Target the right solutions to the right challenge. We’re all humans. The solution to one isn’t the solution to the other. When I’m exhausted, I sleep. When stressed, take a break or call for help. Last year having proper airborne PPE gave me a massive boost against my moral distress. Having close colleagues with similar values and many others who work in the space of cultural change protected me against occupational burnout. We worked collectively to improve occupational health, and I saw purpose at work. My colleagues & team replenished me and protected me against compassion fatigue. Pandemic was stressful, exhausting and pushed us to moral distress and burnout. But these things in themselves did not meet the criteria of mental illness diagnoses.


One other big emotion that we do not often talk about during this pandemic is grief. Grief is mental or emotional suffering or distress caused by loss or regret, usually the sorrow from a death of a loved one. Millions of lives have been lost, and the grief is truly global. In addition, there is also the grief of losing your plans, hopes, dreams, jobs, routines, aspirations, and the fundamental grief and sorrow of losing normality. All of our plans have been cancelled by COVID. That’s been one of the hardest things for many of us to articulate.

Mental health

I share these non-professional thoughts as a human being on the same journey with all of you. There are many causes of our negative emotions and there are unique solutions. Being able to articulate accurately what we are feeling is the first step to finding an appropriate solution. Stress, physical exhaustion, burnout and compassion fatigue affect our mental health but they are not considered mental illness.

Chair of Wellbeing

A simplified way for me to think about my personal wellbeing is considering that my wellbeing is supported by a 4-legged chair. These 4 legs need to support my overall wellbeing. Do not disregard the importance of any of the other legs. These 4 domains and the listed suggestions are the things that have helped me stay healthy. You may have your own unique stool to stand on.

And one more thing,

This blogpost was initially a series of tweets on a Sunday morning. Following the discussions, Dr Nathalie Martinek PhD added her wisdom in this space. She suggested that there are also other things worth considering: Trauma, Moral injury, Burnout, Vicarious trauma, & PTSD. I have attached her article here which brings out some really important concepts of care. Pages 38-39.

Hope this has been a primer for your consideration. Please reach out to your local helpline if some things here have triggered you. I am not a mental health professional so this article is not definitive or exhaustive. I really sincerely just want to share the journey with you. As I have alluded to, there are many things we can do formally and informally to improve our general wellbeing. How are you feeling today? What changes would you implement this week to improve your wellbeing?

Do I need an online presence?

Do I need an online presence?

Short answer: Yes.

Long answer: It depends on the purpose.

Asking if any clinician needs to have an online presence is akin to asking in the 1970s if one needed a fax machine, in 1980s if one needed an email address or in 1990s if one needed a mobile phone. Online and social media engagement is the natural progression of communication technology and media interaction. It is now the norm not the exception. Of course when it all started we did not have a manual, so some of us used it effectively and others poorly. Institutions, legal entities and patients were also learning how to draw boundaries around the use of social media and online communication in the sacred doctor-patient relationship. Social media was once since as a frivolous marketing façade amongst clinicians. We now understand its powerful effect to inform and even influence health outcomes.

As of Jan 2020, 3.8 Billion people use social media. Facebook reports 2.45 billion users, YouTube 2 billion, Instagram 1 billion, TikTok 800 Million, Twitter 340 Million. If you are not a citizen of any of these online nations, you will lose real estate and therefore you are not searchable by your current and future patients. Worldwide average of daily internet use is 6 hours and 43 minutes (!), and 2 hours 24 minutes of that is spent on social media platforms. How do people access the online world? 53% of the time through smart phones, 44% via laptops/desktops, the rest through tablet devices and others. Full article here.

So, do I need an online presence as a clinician?

Short answer: YES. Because your patients are already there. Your patients are likely to have a social media account, spend hours daily on social media and by the time they walk into your office, they would have googled you, your institution and their medical condition on their smart phones. Embrace that. Being aware of the average patient online behaviour prepares you to be a better assistant to their health needs. If your patient cannot find you anywhere on the internet to check your credentials, then you may well be considered less accessible than another clinician who details their expertise.

One of my biggest reasons for being online is this: my patients and my trainees are already there. I need to understand where they’re coming from.

On the other hand, the longer answer to that question is: it depends on what your purpose is in having an online presence. As clinicians and human beings, we can all have a social media account for personal use. That’s where we connect with our high school friends and relatives. However, if we were going to use our online presence and social media activity professionally, then can I suggest 3 levels of social media usage that you can consider?


At its most basic, your online presence is your virtual real estate. It is to be used to inform patients and other health care providers of your presence. You can have a basic website (free from many website providers), or homepage (linked to your University Departments, Institutions or Private Practices) or a Facebook page (A Facebook personal profile is different to a Facebook public Page). The contents simply need to include your prior training, current practice and specialty interests. You just need to show the world that you are a legitimate clinician expert who can be contacted in real life. The contents can be similar across several platforms (Facebook, Blogsite, Website, Twitter, Instagram, etc.). This is to help patients to find you when they google you. The information is basic and static. For most clinicians, this is sufficient, depending on your geography and local referral processes.


For those who want to take it up a notch, you can turn your static presence into a more dynamic engagement. You can be an educator who could engage the community. Your website can be regularly updated with information specific to your specialties. You can have an interactive dialogue on the Facebook page. You can comment and like, retweet and engage with others. Facebook, Instagram, TikTok, LinkedIn and Twitter all have unique target audiences and therefore require different strategies of engagements. There are pros and cons on using each platforms. Your specialty and your patient will define your method. Doing social media well takes time. Putting up information and expecting the engagement from the community takes time. But the rewards are also great because you will find that as you connect with others, you gain knowledge and network. If you are an educator, putting up good information online would be important for our trainees and our patients. As doctors, we have the privilege of our training and position. Our presence online matters and in this day and age of fake news, I sincerely hope more and more of us would stand together online as a scientific community to continually present reliable and practical information. Whenever there is information vacuum, bad news tend to fill it. We have a moral obligation to our community to be present in this online information market to represent clarity and certainty.  


Finally, a few of us over time will end up being expert users of Social Media. This does not happen overnight and require long term strategy and time investment. You know some people with such great presence online who are powerful influencers. They have refined their presence over many years and reliably present clear information and therefore they become influencers and the go-to individuals. It is not how many followers you have. It’s how you influence them that matters. You can be followed by a handful of news reporters or other specialty clinicians and you can become the point person to connect and mobilise experts. The online connection crosses specialty boundaries, geographical limitations and timelines. You can connect with clinicians from other countries to collaborate on projects. You can be invited to speak at conferences or collaborate on manuscripts through the online networking. Social media is a catalyst and an accelerant when used well.

Some Practical Ground Rules to Note

You are a clinician and therefore the community holds you to a higher standard. Everybody’s watching and recording. Nothing gets deleted. The internet, like taxes, is forever permanent. So total RESPECT has to be first and foremost. You can provide opinions, but the information you provide online and the discussions you engage in has to be guarded by total respect because your words can be printed on the local newspaper and they can be sent to your Department Chief. This also means that jokes on other specialties or stereotyping people has to be done with care.

Never ever talk about patients. You can talk about conditions, but you must never talk about patients. Patient confidentiality rules in any country will be identical. Never break confidentiality, unless of course there is an expressed written permission. You can discuss, applaud, encourage a generic patient, but I would strongly advice against any specifi identifiable entries.

Be human. Be a social and a professional one. You do not have to reveal anything personal at all. You define your limits. Social media is a place where doctors can reveal their human side and engage in some non-medical interests and causes.

What about advertising?

Many clinicians would actually have an online presence for the primary purpose of advertising. In some countries that is normal and expected. In other countries, it is legally not allowed. I have worked in Australia, Canada, and New Zealand. When I flew for several conferences in the USA, I was surprised to see the inflight magazine full of medical advertising from big Institutions and personal doctors. That was foreign to me, but normal and accepted in the US. For the US clinicians where advertising is accepted, having a social media online presence is even more critical for your career. Check your local regulations and you might even engage an advertising company to design an advertising campaign for you. There are multiple measurements and return of investments measures that can be applied.

For those of us in Australia, on the other hand, here are the boundaries set for us:

Section 133 Health Practitioner Regulation National Law on Advertising

A person must not advertise a regulated health service, or a business that provides a regulated health service, in a way that–

(a) is false, misleading or deceptive or is likely to be misleading or deceptive; or

(b) offers a gift, discount or other inducement to attract a person to use the service or the business, unless the advertisement also states the terms and conditions of the offer; or

(c) uses testimonials or purported testimonials about the service or business; or

(d) creates an unreasonable expectation of beneficial treatment; or

(e) directly or indirectly encourages the indiscriminate or unnecessary use of regulated health services.

It’s all fair and logical, in my words:

  • Can’t fake your service. You can’t say you’re the best.
  • Can’t offer gifts or enticements. Can’t say “do facelift and I’ll throw a discount rhinoplasty.”
  • Can’t use testimonials. Can’t get your mum to say nice things about you.
  • Can’t say this surgery or medicine will fix everything.
  • Can’t offer unnecessary treatments.

How do I maneuver around these reasonable practical limits? Education. In health industry, education is the best form of marketing. You can’t talk about patients, but you can talk about conditions. You can’t say how awesome you are, but you can talk about the procedures you do for certain conditions. Ultimately the more educational materials you put up on your Facebook, YouTube, Twitter, LinkedIn, Instagram and even TikTok, the more likely it is for the google algorithm to discover you. All these things are generally free. The main cost is time and effort. The internet records activities. The more active you are on any platform, the more likely you will rise on search engine rankings.

So there you go. Do you need an online presence?

The answer is “yes”. But what for?

I hope the answer to that is “for my patients and my trainees.” Our greatest satisfaction is seeing people get better. Help them get better information and better health.

See you online.

Tips for Virtual Presentation

Thanks to COVID19, we now live in a physically-distanced virtual world. Online virtual conferences and meetings are becoming the norm. This is a great opportunity to increase our worldwide connectivity across geographical lines. Virtual meetings mean that more people can attend and less unnecessary travels are undertaken (good for the earth!). Of course the social connections are missed but with every major change there will be positives and negatives.

Here are 5 pointers to help you increase the value of your online presentations. These are by no means exhaustive, prescriptive or conclusive. These are things I’ve learned as I have spent hundreds of hours in meetings, conferences and listening to talks. Virtual conferences are different to real live conferences and therefore we need to modify our techniques: Ready, Set, Lights, Camera, Action!

  1. Ready. Get ready by simplifying your content. Focus on 1, 2 or 3 key points. Most of your listeners are listening in an office between activities, lounge room, or even while they’re driving. No longer do we have the full attention of a conference hall. Most of us are juggling parallel activities while listening to talks. So leave one big message if possible. Keep slides to a minimum. Keep words on slides to a minimum as people may well be watching on a phone. (Seriously, no one is going to remember your talk details in 3 days.)
  2. Set. Set your timer. The most respectful thing you can do for your listeners, meeting organisers and other conference speakers is to stick to time. Speaking beyond your allocated time is basically rude. When time is up, speak forth the big message and drop the mic.
  3. Lights. Have light shining on your face from the front. Background lighting results on your face looking dark. Either have your desk light behind the computer you’re speaking to (like my pictured set up above) or get yourself some cheap “selfie” light you can buy and attach to your computer.
  4. Camera. Keep your camera level with your eyes. Elevate your computer on a platform or a box. Looking down to a camera below your eyes means that your listeners are going to look up at your nostrils. Also watch your background and sound. Headphones/earphones may improve the clarity and gain of your speech. Careful with bluetooth headphones and virtual background as it adds workload to the computer processing, which may delay connectivity or quality of your presentation.
  5. Actions. Maintain the tone of your talk as conversational. The elevated public speaking volume that we use when we speak on a big podium will not work too well on virtual conference. Remember that you are now talking directly to one person sitting in their lounge room, office, or car on their headphones. Facial expression matter even more now as they are almost face to face with you. Speak not with the tone of a quiet chat but that of an excited conversation so as to maintain engagement with your listener. Make them feel that you are talking to them directly.

Hope that helps!

Tell me if you have learned other helpful presentation tips too.

Artwork on my screen is a mural at the Royal Children’s Hospital Melbourne by Elizabeth Close.

COVID Roller Coaster

This article was published on the Australian Society of Otolaryngology Head & Neck Surgery Newsletter Summer 2020 Edition.

It was eerie. After finishing up an emergency case at 8pm, I said goodbye to the anaesthetist and the nursing staff. The usual relief of finishing a difficult case was absent. We looked at each other quietly not knowing what’s ahead of us. In my mind, I wasn’t sure if I was going to see some of them ever again. I drove home under the cover of the dark wet windy winter that is Melbourne. Carlton, Fitzroy, Richmond and suburbs that are usually alive with lights and cheer are completely empty. The curfew has begun and my beautiful Melbourne is a ghost town. Its soul has gone. Fear is now locked behind doors.

At its darkest days in July-August, Victoria had 700+ new positive COVID cases a day. The hospitals were starting to get full. At St.Vincent’s Melbourne our PACU is converted into a clean ICU while the formal ICU is the “hot” ICU caring for COVID patients. Anaesthetists get daily briefing on the list of COVID patient in the building and their resuscitation/intubation status. A COVID theatre team is set up daily for emergency intubations or emergency SCOVID (Suspected Covid) cases. On the other side of town at The Royal Children’s Hospital, the NICU is dealing with their own COVID positive inpatient and outbreak, requiring the swabbing of every baby, every parent and every staff member who was in NICU for more than 20 minutes. I had to reflect on how long I was there accumulatively in the last week and which mask I was wearing.

How did Victoria get here?

COVID has certainly revealed where the cracks in the system are. The Chief Health Officer who is responsible for public health is not responsible for hospital responses. Hospitals, PPE and Health Care Workers are under the portfolio of the Chief Medical Officer through Safer Care Victoria. The Aged Care Facilities are the responsibility of the Federal Government, not the State Government. The Hotel Quarantine? Well, we’re still not 100% sure whose responsibility that was. We know a few people have lost their jobs over that. Chronic underfunding of the Public Health Unit at VIC DHHS also meant that only a handful of people were actually employed to manage this pandemic. The system could not bear the load applied to it. In the first wave back in March, the Premier cancelled the Melbourne Grand Prix and we dodged a bullet. The second wave, or the first tsunami, came about through cracks that, on hindsight, were pretty obvious.

More than 95% of all infections could be traced genomically to a family in quarantine. COVID came through a family from overseas, then a hotel worker was exposed. In a casualied work that is hotel quarantine, with lack of proper training, it was easy to see how COVID could leak through hotel staff to community. These workers are often from lower socioeconomic backgrounds and live in large households where there are others in the household who work in health care. Some religious holidays were occurring at that time which translated to very quick household to household transmission. The pandemic highlighted the structural inequities, the lack of coordinated response and the underfunded system.

Two weeks is a very long year in a pandemic. Multiple families across different suburbs were infected. COVID entered aged care facilities and hospitals, and because there was a lack of appreciation of aerosol spread at that time, PPE guidelines and ventilation were less than ideal. Once in a facility, COVID spread was rapid due to the nature of our physical contact. Delayed response to aged care outbreak meant that we had high morbidity and mortality situation occurring in that context. Aged Care workers were getting infected and the Government had to move Aged Care Residents to Private Hospitals. It was both scary and amazing to see the hospital response in Victoria.

Private and Public as one.

The COVID tsunami also occurred with a corresponding email tsunami. Every public and private hospital sent out their own version of COVID modifications. In one hospital, nametag lanyards were bad, in another hospital cloth surgical cap was bad but lanyards were cool. It was easy to see that so many of our protocols were made up along the way. It was a significant period of change. In fact, opportunistic leaders used this opportunity to make good changes within their departments. Private hospitals cared for COVID, SCOVID, and NOVID aged care residents. As elective operations were reduced, many of the theatre nurses I work with were deployed to aged care facilities or to the wards. I must confess, I am deeply impressed by the stories of care they provided. Theatre nurses who are usually in clean environments had to alter their practice and had to manage sick patients and quite a number of deaths, which is not routine business in a typical private hospital. Health care workers just rolled up their sleeves and did the job that was required of them.

In the hospital, universal masking, splitting of teams, routine pre-op swabbing, telehealth, zoom meetings, 50% elective capacity plus emergencies, 3-tiered PPE based on procedural risks, zoning of hospital facilities and many other changes occurred. In the community, 5km bubble, 8pm to 5 am curfew, school closures, stay at home directives, leave home for essentials only, and 1 hour exercise outside home were the enforceable norm. As I write this, South Australia has just entered and finished their mini lockdown. They had a brief taste of queueing for toilet paper. Today, masks outdoors in Victoria are off. We have had 23 straight days of zero transmission. The real test is when the borders are re-opened.

The role of the ENT Surgeon in a pandemic

It has been 6 months since I saw my colleagues’ smile and since I shook hands with my patients. The roller coaster ride meant that things have changed, some for good. Scrubs and masks are becoming the universal norm. Telehealth is well utilised. Meetings are more brief and many voices are better heard as everyone has the same “muteability” on zoom. Information exchange is rapid (How many WhatsApp groups are you in now?). The typical clinician nowadays can pretty much attend any Grand Round and conferences in other hospitals, other countries and other specialties from the comfort of their own home. As an ENT Community, we have also done much advocacy around the protection of our staff. The International ENT Community has published on mortality figures amongst ENT surgeons, which almost certainly influenced the protocols in many places and provided support for our colleagues in Dentistry, Maxillofacial surgery, Respiratory and Oral Cleft Surgery. At the national level, ASOHNS have been in close discussion with Federal Health Officers. At the local level, VIC ASOHNS and ENT Heads of Units advocated for protection.

And at the individual level, despite the heterogenous group that we are, ENT Surgeons have provided the necessary steady leadership influence around our workplaces. Turning up day after day both in public and private, modifying surgical approaches, rearranging clinics, sharing 3D-printed face shields, adapting to new PPE changes, communicating respectfully and many other simple acts that keep us and our community trusted. The fear amongst health care workers were palpable. The porters, theatre technicians, nurses on the ward and even cleaning staff were fearful. Though masks have covered their faces, their eyes speak of fear of uncertainty. Every time I spoke about the changes and the possible future, every eye and every ear was turned towards me. I soon realised early in the pandemic that speaking hope and perspective to my health care colleagues were just as important as talking about PPE and surgical modifications. Hope is a critical PPE armoury in this pandemic.

One theatre nurse said, “You know, I realise that ENT is the worst hit specialty this pandemic. You’ve got a high risk profile. Yet every ENT surgeon I have worked with has remained calm and unflustered. Thank you for being steady. We nurses appreciate that.”

If there is one other big thing I learned this pandemic, one surgical trait I wished I had more and in abundance, it is the lesson of humility. Scientific humility is knowing that we do not know everything about this virus, appreciating that airborne spread is a continuum with droplet, and changing our protocols rapidly based on new evidence. Surgical humility is adapting our surgical approaches to changes, respecting the concerns of every team member and being open to inevitable disruptions in workflow. Corporate humility is knowing that we need to advocate for our team and our patients, and that we need to listen to others (Infection Control, Occupational Health & Safety, Aerosol Scientists, Epidemiologists, Ventilation Engineers, Wellbeing Officers, etc.). Many colleagues and many in our communities suffered heavily through the lockdown. This pandemic showed that although we were all in the same storm, we were in vastly different boats depending on the pre-pandemic resources one had. As ENT surgeons, we are in a very privileged position and we have a moral and a community obligation to use whatever resources we have to support our communities. 

As other countries manage their COVID waves, we do have a good story to tell from Australia. Perhaps we can be that voice of support that other countries need. Many Victorians will not take for granted the freedom we now have after a difficult lockdown. There is still much work to be done in fixing our structural inequities and protecting health care workers but I for one will from now on treasure every Soy Chai Skinny Latte I enjoy with my colleagues face to face.

COVID emotions

Talk presented at #NotYoga2020 Symposium Dec 2020.

I have a question for us. What do you think is our greatest asset in this pandemic?

What is the most important asset that we need to protect during this pandemic? If you’re in leadership positions, you may consider that the team or the institution as something you need to guard. Today you will hear many brilliant ways of engaging the whole system for change. But for you personally, you probably know that the greatest asset in this pandemic is yourself.

Of course, your experience of this pandemic is dependent on where you are, when you are and probably even more importantly, who you’re with. We’re all experiencing different phases of the pandemic. How Melbourne feels right now is different to how Brisbane, London, New York or Warrnambool is feeling. How Melbourne feels right now is different to how Melbourne feels back in August when we were in lockdown. Perhaps most importantly, your team, your leaders, and your institutional authorities determine how you are feeling at this moment. You’ve heard it before: we’re in the same storm, but we’re in different boats, different waves and we’ve got different boat crew members.

In this day of big talks, we are not going to gloss over the little big people, or big little people. This is a private talk. We process this pandemic differently. My experience of this pandemic is very unique to me. I work in several institutions and teams. In one hospital I feel completely protected and appreciated. In another I feel lonely & lost. In one hospital, name tag lanyards are ok, surgical cloth caps are not. In another, surgical cloth caps are ok, but name tag lanyards are not. It’s wild. No wonder it’s been a roller coaster of emotions. I still remember the betrayal & anger I felt when I needed to justify a request for N95 mask for my aerosol generating ENT procedure. We experience & process this pandemic differently on a personal level.

A recent study published last month looking at “Psychological distress, coping behaviours, and preferences for support among 650 plus New York healthcare workers during the COVID-19 pandemic” reported that 57% screened positive for acute stress, 48% for depressive, and 33% for anxiety symptoms. And what were their biggest concerns? Lack of control, lack of testing and PPE, and transmitting COVID to family.

How are you feeling at the moment? You might well be feeling burned out, because this pandemic is a chronic occupational stress causing us to feel emotionally exhausted, depersonalised and less efficient. You could be feeling a sense of compassion fatigue: an emotional and physical exhaustion leading to a diminished ability to empathize or feel compassion for others, the negative cost of caring. Or perhaps it’s moral injury, moral distress, moral anguish, or moral conflict. In 1984, the term moral distress was first conceptualized by Andrew Jameton in his book on Nursing Practice, to describe the psychological conflict nurses experienced during, “ethical dilemmas.” He wrote that “moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.” I bet many of us here know that feeling.

You may not be able to accurately delineate where burnout, compassion fatigue and moral distress overlap, but I’m sure that you can recognise the primary emotions underneath. Those definitions are scientific, while our emotions are raw and real. Our emotional responses to this pandemic are native and inherent to who we are as human beings and health care workers. May I help you define some of those things you’re feeling right now? Can I confess that I have felt mad, bad, sad and scared?

I have felt mad. I was angry at the state we found ourselves in. I was mad at certain protocols. I was angry at some decisions made by our leaders. I have written emails I should not have, and tweeted thoughts I should not have. Has anyone else done this? Or is it just me?

Because of that and a few other things I also have felt bad. A sense of shame that I wasn’t good enough. A feeling of guilt that I did not do more for that patient who died or that colleague who got infected. I felt bad I did not advocate more.

Of course, I have felt sad. I’m sad that I see worldwide carnage from this virus and yet many who still deny its existence. I am sad that I have not seen some of my colleagues’ smiles for a long time or hug some of my patients and my family members. This sadness can explain some of the days when I just wake up feeling blue. When will this marathon end? When will this pandemic be over? When can I hug my patients again?

Perhaps the one emotion that has driven a lot of actions during this pandemic is fear. We are scared. The uncertainty of the future makes us feel scared. The words “toilet paper” has triggered some primitive emotions and actions. When I’m doing rigid bronchoscopies on my tracheostomy patients, I feel close to danger and I’m scared. When I’m holding the face of my patients and examining their noses and throats, I’m scared & anxious. It only takes one breath for the patient to pass on their covid to me when we are that intimate in an ENT examination. That’s why my psychological safety is strongly linked to my physical safety.

I’m not so good at writing cards. So you know when you look for a greeting card in the shops, you are looking for one that encapsulates how you feel about the recipient. Perhaps the emotional confusion you feel can be defined by one of these words? Am I feeling mad, bad, sad or scared? This is not an attempt to belittle these emotions or its impact on the individual. This is my way of simplifying and clarifying how I feel. I need simplicity to help my simple surgeon brain to comprehend my complex emotions.

Here’s the thing: are these emotions negative, positive or neutral? None of the above. These emotions are not negative, positive, or neutral. These emotions are human. These are human emotions in a pandemic. Feeling mad, bad, sad or scared is human in this unprecedented year we are experiencing together. The challenge is how we navigate and manage these fundamental emotions for positive impact. My anger is a trigger that something does not sit right me. I need to find a solution. My shame or guilt is a mirror to remind me to be humble and to accept that I am good enough where I am. My disappointment is a reminder that I do not have everything under my control. I should focus on things I can influence. My fear is a reminder that I need to redirect my excitement for advocacy work. Use these basic emotions to reorient your thinking and response.

When I look back carefully at the last 11 months, I admit that beside feeling mad, bad, sad or scared, I have also felt glad. I have changed. I learned new ways of doing things. I learned stuff I wouldn’t have learned. Listen to the speakers before me and the speakers after me. I am glad I get to learn from them. I have been impressed by many leaders. I have been touched by the resilience of many of my patients. I have seen the faithfulness of my colleagues. I have seen ordinary people doing extraordinary things. Librarians calling up the elderly in their membership books. Restaurants feeding frontline workers and the marginalised. Airline crew working in aged care facilities. The pandemic has shone a light on social inequities and broken systems, but that light that broke through the cracks mean that we can start fixing things. Like a mosaic art, light will shine through the cracks, and all those colourful pieces can be put together for a better vision.

This pandemic has decluttered my life and reorganised my values. I am learning the art of tidying my life. I have decluttered my possession, my profession and even threw out some friends in the bin. I am learning to focus on things that spark joy. You know, I basically Marie Kondo’ed my way through the pandemic. Marie Kondo says you need to touch every item in your life and keep it if it sparks joy, bin it if it doesn’t. The first thing my dear wife did after reading her book: she laid her hands on me. She said, “I’m just checking if you still spark joy.” For many of us, this pandemic year is a year of re-setting. Pandemic decluttering is good for you.

Feeling mad, bad, sad, scared or glad is not wrong. It is simply being human in this pandemic. Reorienting those emotions for positive effect is what we should strive for. Decluttering our lives, reducing the noise and focusing on things that matter will help us significantly.

One more thing. So by now you know how to don and doff your physical PPE. What’s your emotional and mental PPE? Your mental PPE will look different to mine. It could be exercise, books, meditation, art, spirituality or yoga. My personal PPE include humility, heart (empathy) and hope. To my surprise, one of the greatest emotional PPE I’ve discovered through this pandemic is other people. My colleagues help me debrief. My family helps me see purpose. My team mates make me realise that I’m not alone. We get through this pandemic together.

So perhaps my opening statement is incorrect, or at least, incomplete. Perhaps the greatest asset we have in this pandemic is actually each other. Jump into each other’s boats.

Stay safe. Stay connected. Take care.

Healthcare Workers Australia: Leadership in Uncertain Times

This article is posted on Healthcare Workers Australia.

“We’re over it.” Many of us, health care workers or not, have overtly or covertly expressed this state of being. The ever-changing protocols, the hybrid telehealth clinics, the endless zoom meetings, the cancelled conferences, the restrictions, the distancing, the lack of human touch, the masked smiles. Our day-to-day work and living have fundamentally changed as managers dictate what we can or can’t do. We thought it was going to be a short sprint. It’s turning out to be a marathon that we did not sign up for. And we’re over it.

A mutated RNA virus measuring a mere 125 nanometres infected a host and went viral. Horror pandemics that made great Hollywood movies suddenly became our story. We’ve lost loved ones. We’ve lost jobs and businesses. We’ve lost our dreams and plans. We’ve lost a sense of control over our personal and professional lives. 

My patients tell me that they’re scared. The theatre technician tells me she’s confused. Fear & confusion spread rapidly in a pandemic. What drives the R0 of fear? As I reflect on the times that I feel fearful in my work as a surgeon, I fall on these 3: lack of cognitive understanding (I don’t know what’s happening), lack of emotional support (I feel alone) and lack of physical protection (I feel I’m at risk). These are real human concerns that many of us have felt internally behind the heroic narrative bestowed unwillingly upon us. So, we put on that mask.

Knowing that there is still the long journey of COVID normal ahead, what can we do to resolve some of those hidden fears? Waiting for surveys, research grant, program approval and administrative intervention can take a long time. What can we do tomorrow for our colleagues, our team and our patients? What antidote can we offer for this pandemic of fear and confusion sometimes manifested in anger and frustration?


In Dr Anthony Fauci’s widely viewed Grand Round Lecture to Harvard Medical School (at 1:02:20), he underlined humility as something that he has learned and has underpinned his approach. Humility is not just an esoteric conceptual idea, it is a courageous practical reality. Not knowing everything there is to know about this virus. Being willing to put aside dogma in light of new evidence. Being quick to admit wrong. Being prompt in changing protocols and guidelines. Considering the alternative view. Listening to those outside of the specialty. I have been wrong. I have criticised my managers. I have been rebuked, corrected and critiqued. We all need to embrace this humility espoused by Dr Fauci. We are not looking for perfect leaders in this pandemic. We’re looking for authentic leaders willing to accept errors and embrace change. I think we could easily trust leaders who are genuinely interested in hearing every voice and who make efforts to adapt and adopt change. Humility starts with us whether we have a position of leadership or not.


What do you do when you feel you don’t know what’s going on, you feel unsupported at work or you feel you are at risk? You go to your leader. At this point in the pandemic your wellbeing is strongly tied to your leader/manager/supervisor. If you work under a poorly performing leader (I do not have to define that, you know what that would look like), you would not bring up your concerns. But if you have a leader with their heart on their sleeves, you will speak up. A compassionate, competent and collaborative leader makes you feel safe at work, in the midst of all the pandemic stress. Mayo Clinic has shown this to be a fact. They ran 2 studies that linked staff wellbeing with leadership scores of their manager. In 2013 they surveyed 2,813 doctors and in 2017 they surveyed 39,896 Mayo Clinic employees, excluding doctors, reporting very similar outcomes. The immediate supervisor leadership score was strongly associated with burnout and satisfaction of individual employees after adjusting for sex, age, duration of employment and job category. Each one-point increase in composite leadership score of the supervisor is associated with a 7% decrease in the likelihood of burnout and an 11% increase in the likelihood of job satisfaction. What does this mean for us? This pandemic is a long-haul journey to COVID normal. If you’re in any position of leadership, have a big heart. Your team depends on you being a good leader. Your leadership influences their levels of burnout and job satisfaction. No fancy campaigns or expensive programs, be a good person. Have heart and humility. If you do not have a formal position of leadership, lead from within. We all have influence on our workplaces.


Stephen Hawking gave this piece of advice to his children during a June 2010 interview on ABC News: “One, remember to look up at the stars and not down at your feet. Two, never give up work. Work gives you meaning and purpose and life is empty without it. Three, if you are lucky enough to find love, remember it is there and don’t throw it away.”

Beyond the pandemonium that is this pandemic, beyond the science and epidemiology that is pursuing this virus, beyond the fear and confusion, are 7.6 billion human hearts that beats with hope. We have seen the cracks in our health system. We have seen the true colours of leadership. We have seen the dark inequities that exist within our society. The fatalistic, nihilistic, catastrophising view is to say “it is what it is.” The clinician scientists with a hopeful world view would say, “let’s rewrite the story beyond the curve”. Let’s build a new normal. Let’s focus on and fix a few things. You say we can’t change the world. Well, the world has already changed. We now have a pandemic momentum to change a few things. For hope to be realistic, it has to be tangible and measurable in the present. We can start by writing down the top 3 things in our workplaces that we can change. How do we support frontline non-clinicians? How do we improve HCW protection? How do we empower team leaders? How do we better communicate the science? How do we reduce inequities?

So today, how can we and our leaders practically apply Humility, Heart & Hope in our workplaces?

Aerosol Generating Procedures and Mask Use in Melbourne

Eric Levi MasksUPDATE BELOW. It happened again the other day. I asked for an N95 mask for my airway operating list. One hospital provided, another said no. Yes, pre-op swabs are negative, but we know that there is a false negative rate and I spend 3-4 hours in multiple patients’ nose, oral cavity, oropharynx, larynx and trachea in one session. The risk for aerosolization is high and I, as the surgeon standing 15-30cm away from the patient’s mouth, am exposed. The mask has become yet another symbol. Not a symbol of freedom or anything, but a symbol of value and trust. How much does a hospital trust your clinical judgement as a frontline clinician?

I am an ENT surgeon. That means I spend a majority of my time face to face in clinic examining patients and performing awake flexible nasoendoscopies. In addition, I spend hours in the operating theatre debriding, cauterising, incising, suturing, debulking and manipulating the airway mucosa. This is the very definition of Aerosol Generating Procedure. Studies show that the viral load is high in the nasal, nasopharynx, oropharynx and tracheal secretions, which all happen to be my daily operating sites. In sinus surgery, oropharyngeal surgery such as tonsillectomy and in bronchoscopies, I am getting splashbacks of patient secretions on to my face mask and face shield. A rigid bronchoscopy or laryngeal surgery is probably the highest risk of aerosolization. The airway is open. Positive pressure ventilation is applied, and the air return is direct from the laryngotracheal lumen on to the surgeon’s face. I am inhaling the air that is expelled from the patient.

In the US, UK and Canada, the Otolaryngology Head & Neck Surgery Societies recommend N95 for all AGPs (links below). In Australia the ASOHNS (Australian Society of Otolaryngology Head & Neck Surgery) on recommendation from the Office of the Federal Chief Medical Officer only recommends standard surgical face mask for AGP (link below). This was back in April when case numbers were low. Here we are now in August in the heart of Melbourne outbreak having thousands of positive covid cases and more than a thousand active Health Care Worker infection. As the community numbers go up, the hospital admissions go up a couple of weeks later and health care worker numbers also follow.

On top of that, there are concerningly more data about COVID19 being an “opportunistic airborne” pathogen (short of calling it a true airborne pathogen), and the published data on the number of ENT surgeons around the world who have caught COVID and many who have succumbed to the disease (See link below).

What about the negative preop swab, you say? Well, the test is not 100% foolproof. There is a known false negative rate. A positive test is helpful to confirm and contact trace. A negative test is not a complete reassurance. One illustrative case in that paper was about a patient who had a mastoidectomy done who had a negative preop covid test. Surgery went on with standard precautions (not N95). The patient developed covid symptoms a few days post op. The patient and the surgeon were then tested and found to be covid positive. Unfortunately the surgeon died as they had comorbidities. This is tragic. Another case is that of a tracheostomy where 3 surgeons and 5 nurses subsequently tested positive.

AGPs are truly high-risk procedures for the surgical and anaesthetic team, even if the patient is low risk. Here in Melbourne our COVID numbers are high and there will be many asymptomatic carriers. As our Premier has said, “This is a public health bushfire, but we cannot smell the smoke or see the fire.”

I am not asking for the protocol for the whole country to be changed. The risk of an AGP as an ENT in Melbourne is much higher as compared to an ENT in Perth, Brisbane or Auckland. I am simply pleading for hospitals to understand that when a surgeon request an N95 for the team (7 staff members, 7 masks for the whole theatre session – we can put a standard mask over it to save money), it’s not to be fancy or to overreact. It’s because there is a real tangible risk. I would like my team performing a high risk AGP to be as safe as possible. What applies to ENT, also applies to Maxillofacial surgery, Dental surgery and any other respiratory mucosal interventions. None of us like wearing the N95. It’s uncomfortable. But we do it because it keeps us safe.

Please don’t say the evidence for N95 use is not strong. What evidence do you need more? Infected health care workers numbers? It’s a small financial investment that would potentially safe a few health care workers from being sick or being furloughed. Not for everyone, just for the high risk activities on covid unknown or covid negative patients. Melbourne today is not where Australia was back in April. We are geographically high risk now for the next few weeks/months.

I know I’m not a clever Public Health or Infectious Disease Physician who can interpret all sorts of epidemiological data, graphs and modelling. I am just a foot soldier on the front lines in people’s noses and mouths every single day. I hope requesting a mask from a hospital will not be met with resistance “Because the protocol says no.” My team down the bottom of the ladder here just need to know that we are valued enough that even an N95 is worth giving to us. We just want to go home safely to our families.


American Guidelines.

Canadian Guidelines.

UK Guidelines.

Australian Guidelines.

High-Risk Aerosol Generating Procedures in COVID-19: Respiratory Protective Equipment Considerations.

Aerosol-generating otolaryngology procedures and the need for enhanced PPE during the COVID-19 pandemic: a literature review.

International Registry of Otolaryngologist ‐ Head and Neck Surgeons with COVID‐19.

 UPDATE 12th August 2020.

As of Monday 10th August, the Australian Society of Otolaryngology Head & Neck Surgery have upgraded their advice in line with the Federal Health Department Recommendations. N95 for AGPs.

The Victorian DHHS so far has not changed their advice (No N95 for AGP, covid clinic or hotel quarantine staff).

Loss of Smell and Taste with COVID19

02D95E17-4823-4E14-897D-68D0A2227DCBLet’s get some terminology correct. COVID19 is the disease. SARS-CoV2 is the specific name given to the actual new virus that has been identified as the cause of COVID19. SARS-Cov2 is a new novel virus from the Coronavirus family. In lay terms, coronavirus is the general term we use to refer to this virus. However, it is worth knowing that Coronaviruses are a large family of viruses that cause respiratory infections. These can range from the common cold to more serious diseases. COVID19 is a completely new disease. We have never met this virus before. Whatever we know about this virus is only 6 months old. We are still learning and discovering.

The virus, like any other virus, is a submicroscopic infectious agent that replicates inside the living cells of an organism. Virus needs a host and gets transmitted from host to host. As far as we know today, the SARS-CoV2 gets transmitted via droplets (not airborne based on current available evidence – which may change), meaning, it is not like a powder that floats in the air, but it travels in suspension form through mucous droplets. A sneeze or a cough can transfer the virus via droplets spread. This virus can hang around on surfaces and be passed on from hand to hand contact. Like any respiratory virus, it enters the mucosal lining of the airway (nose, mouth, throat) and possibly eye mucous membrane. There are studies showing that the virus is alive in mucous secretions, saliva and tracheal airway secretions. Once the virus enters the host through the airway lining, it appears to mainly affect the respiratory airway organs (nose, sinuses, throat, lungs), but in severe forms, the virus seem to also affect the blood system, the heart and other organs. Some autopsy studies show microemboli or small blood clots, affecting the brain, liver and heart.

Loss of taste and loss of smell are officially recognised as symptoms of COVID19. From the Australian Department of Health Website: “People with coronavirus may experience symptoms such as fever, respiratory symptoms (coughing, sore throat, shortness of breath) and other symptoms can include runny nose, headache, muscle or joint pains, nausea, diarrhoea, vomiting, loss of sense of smell, altered sense of taste, loss of appetite and fatigue.” The challenge is that smell and taste are subjective senses that are extremely difficult to scientifically measure, and not everyone with COVID19 will suffer from this deficiency. How good are most people in identifying reduced taste (hypogeusia), change in taste (dysgeusia), loss of taste (ageusia), reduced smell (hyposmia), change in smell (dysosmia), phantom smell (phantosmia) or loss of smell (anosmia).

Smell (olfactory) and taste (gustatory) are overlapping chemical senses. They rely on particles (odorants) to dissolve in respiratory mucous and bind to taste and smell receptors before being turned into an electrical signal that goes through the trigeminal and facial nerves to the brain. Complex magical scientific stuff. Taste and smell are culturally/socially driven and has various degrees of refinements in different people. What smells good to one person may not smell good to another. The taste palate of a sommelier will be very refined compared to a college student who lives on Mac and Cheese as routine. On top of that, we know that smell dysfunction affects 20% of the general population and is most commonly caused by sinonasal disease, upper respiratory tract infections, head trauma, normal aging, and neurodegeneration. Up to 45% of all anosmia in the general population are due to post-infectious cause (following a common cold, viral or bacterial sinusitis, etc.)

In this context, we meet a new virus that seem to attack the respiratory lining. No surprise that anosmia and ageusia are common presentation. One published study has attempted to design an anosmia reporting tool (Kaye et al Otolaryngology Head & Neck Surgery 2020). They found that anosmia was noted in 73% of patients prior to COVID19 diagnosis and was the initial symptom in 26.6%. Some improvement was noted in 27% of patients (average 7 days). About 85% of patients in their cohort improved within 2 weeks. Several similar studies show that anosmia and ageusia is hard to measure, not 100% accurate and has an uncertain progression in the disease. Another study (Meng et al. American Journal of Otolaryngology 2020) puts the rate of anosmia in COVID19 positive patients to be between 33.9% to 68%. Not everyone with anosmia has COVID19 and not everyone with COVID19 has anosmia. Anosmia is the initial symptom in a minority of patients with COVID19. Children are affected too. The good news is that it does not affect everyone. If it does, the effect seem to only last about 2 weeks for the vast majority of cases. Are there any long-term data on permanent loss of taste or smell? We do not know. The pandemic is only 6 months long and we certainly do not have any long-term data so far on anything related to COVID19.

What if one suffers from long term olfactory and gustatory dysfunction? Social anxiety, nutritional disturbances, and depression are well acknowledged consequences of smell disorders. Moreover, it has been suggested that olfactory function and depression are interdependent (Cummings Otolaryngology Head & Neck Surgery 2019). This means that identifying and treating olfactory and gustatory disorders become critical in the long run.

The stakes are even higher if the sufferer is a chef, food critique or wine professional. Smell and taste are the essence of their art and living. What can we do to help restore the sense of smell and taste in these professionals?

Let me be clear, there is a lot of data on general treatment for loss of smell and taste but none that is directly related to COVID19 anosmia and ageusia. We extrapolate the science to be applied to this particular context. Currently no specific data on successes or failures of any of these recommendations as it relates to COVID 19. But here are some thoughts extrapolated from anosmia research in the past:

  1. Treat the COVID19. Get well from that. That’s the primary goal.
  2. Loss of smell means inability to smell smoke or fire. Ensure that fire alarms and safety devices are available to warn the sufferer of danger.
  3. Steroid oral medications and steroid nasal sprays have been shown to have some good effect for anosmia related to sinusitis. The results have not been universally perfect, but in general the treatment is safe and well tolerated. We do not have a strong scientific evidence to recommend a particular regime or dosing protocol. If smell and taste is critical, a trial of oral and nasal steroids could be considered if there are no contraindications. The nasal steroids need to be administered in Kaiteki position (Google it) to allow better delivery to the olfactory region high up on the roof of the nose.
  4. Olfactory training for severe prolonged loss, or in the context of a smell and taste professional. Olfactory training is a therapeutic approach that involves repeated and deliberate sniffing of a set of odorants on a daily basis over a number of months (usually 3 to 9 months). One of the first studies in relation to the effects of repeated exposure was performed in 2004 using androstenone, and since this time numerous other studies have demonstrated beneficial effects in postinfectious, posttraumatic, idiopathic, and Parkinson-related olfactory dysfunction, as well as in healthy participants. At present, olfactory training is usually performed using four odorants, one from each of the following odor “categories”: flowery, fruity, spicy, and resinous. The current 4 odourants are: phenylethylalcohol (rose), eucalyptol (eucalyptus), citronellal (lemon), and eugenol (cloves). Twice daily for a minmum of 12 weeks, up to 32 weeks. A recent meta-analysis of 13 studies found that the duration of olfactory training was significantly related to its effectiveness (Hummel et al Position Paper on Olfactory Dysfunction ). Quote from their paper : “Given the low associated cost and high safety of olfactory training, it is an attractive treatment modality, which can be employed with relative impunity.” This means that as long as you are not delivering dangerous chemicals up the nose, olfactory training is safe and will probably be beneficial.

Hope this answers some questions you may have in your mind. Remember:

Stay home if you can.

Stay masked if you have to leave the house.

Stay away from others.

We’ll get through this together.

Choose to live well

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This coronavirus pandemic has changed the way we live drastically. This coronavirus is forcing us to choose. To choose to confront ourselves in the stillness and quietness of our homes. When all the bells and whistles have been removed, when our conferences, meetings and speaking engagements have been stripped away from us, we are forced to face our own selves when no one is looking. We have been forced to be still. How are you?

We are all in difficult places. But even in our various forms of difficulties, we can choose to be positive despite the negativity. We can still choose authenticity rather than authoritarianism. We can choose collaboration and connection when we have very little control over what is occurring. We may not change our situations but we can choose to change the way we respond to these difficulties. We cannot control every single thing that happens around us, but we can collaborate and connect to get through all this together.

We’re all in this together. Choose to live well.

The use of Povidone Iodine nasal spray and mouthwash during the current COVID19 pandemic

Evidence Based Medicine is the application of the best available evidence to the clinical problem at hand. We are living in a pandemic. We do not have the luxury of Randomised Controlled Trials. We do not have the luxury of prospective studies, time and resources. We use any good evidence we have, dissect it and see if it is fair and applicable. We rely on basic principles and extrapolate as necessary.

Here’s a paper that seems based on a good basic science foundation and appears to suggest a safe, cheap and readily available additional protection against the virus.

20200323 The use of Povidone Iodine nasal spray and mouthwash during the current COVID-19 pandemic Version 4.pdf

Your choice to take it up or not. You need to critique the evidence yourself.

Because of my front line exposure to examining and operating on patients whose noses and throats may be virus laden, I decided to do this simple nasal therapy.


The mixture has to be diluted. Also, ensure the betadine you’ve got is cleared for oral use/gargle. There are some preparation with phenol mix that should be avoided. Get 1 ml of Betadine (10% Providone Iodine) add 20mls of sterile water. Put the solution into a small nasal spray bottle. 2 sprays each nose, three times a day (before the morning session, right after lunch, and before reaching home). Simple, safe and may well be protective. Stings a little but that’s all.