Eric Levi

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.

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.

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?

Humility

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.

Heart

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.

Hope

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?