Can a Program for Combat Veterans Help COVID-19 Frontline Healthcare Workers?
By Susan Elster June 10, 2020
As the Coronavirus Pandemic snuffs out lives and shutters economies around the world, we have had days and now months to hear the voices of frontline healthcare workers tasked with trying to save lives without enough information, protective equipment or even a long-term public health game plan. What they are telling us, point for point, echoes elements of what soldiers describe as their reality during combat.
I have some experience listening to such accounts.
In July of 2014, days after one of our children returned to civilian life following three years serving as a combat soldier in the Israeli army, conflict escalated along the border with Gaza. Focusing on cooking good meals, we pointedly ignored the news. We pretended, with the single-minded selfishness of parents who had already spent years worrying, that the rising tensions would not encircle him. Within days, however, together with thousands of other young people, he was called back into service.
Weeks later, parents and siblings and partners across the country welcomed most of them home. Amidst our joy and relief, it was also clear that many had had life-changing experiences – among them witnessing the injuries and deaths of hundreds of people. Collectively we witnessed their gratitude to and love for those in their units; we also heard their descriptions of exhaustion, stress, fear and grief.
Although combat experiences are unique and ultimately beyond an outsider’s comprehension, there are parallels in the words of healthcare workers at the COVID-19 frontlines.
The Pandemic’s Fog of War
The pandemic’s U.S. healthcare workers point to the toxic brew of exhaustion, stress, unending hours of intense responsiveness, and separation from the family members who would ordinarily help them process emotionally difficult experiences. Dr. James Black, Medical Director of the Phoebe Putney Memorial Hospital in Albany, Georgia understands that his staff is “used to taking care of critically ill patients in the emergency department.” But, he adds, “The sheer numbers… is something that none of us has ever experienced for any sustained period of time.”
In the mad bedlam, everything is beyond control. EMT Austin Magnuson describes this sense precisely: “I don’t think I’ve ever come to work and prepared to be dealing with fatalities and loss on a scale like this…. I’ve never felt so powerless.”
In that chaos, many have had to make split-second life-or-death decisions, with moral consequences. To protect others from the virus, they are enduring long separations from family members. And, like combat soldiers, they are witnessing a lot of death, often terrible deaths, as people die alone.
K P Mendoza, a young ICU Nurse in New York wrote a poignant Facebook post: “I thought I was prepared to see death. I had seen enough of it within my first year in the ICU. Yet in the last two weeks I have seen more people die than most people see in their entire lives.”
Finally, like soldiers, they report feeling pervasive fear. Dr. E. Wesley Eli described this fear while treating a COVID patient at the Nashville VA Hospital: “As I was standing at the foot of his bed, something hit me that I’d rarely been conscious of in 25 years as an ICU physician: raw fear…. Fear from general dread of a new deadly disease with so many unknowns. Fear of repeated exposures for my colleagues, who could become sick and die. And fear that the virus, which was invisibly present throughout the room, would infect my lungs, blood and brain despite my best efforts.”
This fear is entirely rational. Healthcare workers are most likely to encounter the leading end of a disease outbreak, making them acutely vulnerable not only to experiencing the stressors we describe above, but also to untimely death. Although good data are hard to come by, a month ago the World Health Organization estimated that at least 23,000 healthcare workers had already been infected worldwide. In the U.S., a project of KHN and The Guardian documented nearly 600 deaths among healthcare workers in early June. Not only are these likely to be undercounts, but they reflect only physical casualties. The lasting pain is measured also in social and psychological costs. All of these elements sound a lot like reports of combat experiences.
There is Nothing Normal About This
Given the similarities, what do we know about combat veterans that may be helpful to the COVID-19 frontline? To answer this question, our son put us in touch with Alon Weltman, a medical psychologist at the Israel Psychotrauma Center, a nonprofit organization known more commonly by its Hebrew acronym, Metiv.
After more than 10 years as a therapist and now as director of Metiv’s Peace of Mind program, Weltman has worked with hundreds of highly-trained combat veterans – among them our son – whose units were exposed to combat and who experienced the loss of unit members.
It is agonizing to know that some 12-15% of combat veterans in the U.S. and Israel will experience debilitating symptoms of Post-Traumatic Stress Disorder (PTSD). However, Weltman and the Metiv team discovered that an additional 80% don’t have PTSD but nevertheless may experience bad dreams; uninvited memories that trigger a “mindset of warfare or of the need to survive;” relationship difficulties; emotions like aggression, guilt and shame; depression; insomnia; substance abuse – a range of what Weltman describes as ‘mild’ symptoms. In perhaps one of the most pernicious elements of combat experience, most will think they are alone in these experiences.
Says Weltman, “Exposure to extreme stress and distressing life and death experiences can carry hidden scars, and deeply influence human wellbeing, relationships and psychological functioning.”
The degree to which these experiences do long-term harm can be moderated by an individual’s coping skills, and by supportive families and communities. Time also heals. But often it’s just not enough. Yet, it is not uncommon for combat veterans to wait years, even decades, before processing their experiences.
A Model for Frontline Healthcare Workers? The Peace of Mind Program
The Peace of Mind (POM) program was developed in 2007 by Metiv, prompted by a staff member who shared her concern that, although her son wasn’t experiencing PTSD, there were no supports for him when he returned to civilian life following very difficult experiences during the 2nd Lebanon War in 2006. When a psychology student doing an internship noted that this was also true for members of his army unit, Metiv stepped up. The intern’s unit became what would be POM’s inaugural group.
The program brings together 15-20 veterans from a single high-risk combat unit who, while not experiencing symptoms of PTSD, have had severe combat experiences. Weltman points out that there is often “deep trust” among groups who have shared difficult events. It turns out that this cohesiveness can be protective over life’s long-run. This fact underlies the POM program and is most relevant to healthcare staff now.
POM takes place over nine months, in four phases: a two-day opening workshop, a week-long intensive seminar, a full day of follow-up activities and a concluding workshop. The workshops all take place in non-institutional settings, usually in nature.
The week-long session takes place in sponsoring communities outside of Israel. According to Weltman, this is important. Receiving support from community members is a concrete reminder to veterans of the value of their service. And, being away from Israel and outside the cultural, institutional and hierarchal structures of the army makes honest sharing more likely.
Together, participants receive some 65 hours of group counselling with skilled therapists. Finally, all are invited to partake of up to 12 additional individual therapy sessions after the program is over. Although the program is not intended to replace the intensive individual therapy needed to treat PTSD, Metiv has discovered that most of those who seek the follow-up individual therapy sessions are those experiencing more severe symptoms.
According to Weltman, members of the group share deep emotions and vulnerability when describing their combat experiences and post-army challenges. They learn that most human beings don’t just ‘bounce back’ after experiences like theirs. But they know also how to be alert for symptoms and what strategies may help. Most of all, they know that just as they protected one another during combat, they can continue to support one another in new ways.
Is it helpful? Among the program’s favorable evaluations, none are more meaningful than those of participants – among them our son. One described the week-long session as ‘life-changing.’ Another, a commander, told me that he participated for the sake of others, as he thought he was ‘doing fine.’ Afterwards, he related that he’d benefited enormously: “I realized that there is nothing normal about having someone die next to you.”
Perhaps the most telling signal of the program’s value is the fact that, nearly six years after the last war, there are 135 groups on the POM waiting list. This is true despite the fact that information about the program is spread entirely by word-of-mouth and contact with Metiv must be initiated by the veterans themselves.
Why We Should Care
We rely on healthcare workers in countless personal and economic ways. The healthcare sector represents more than 17% of GDP and 12% of the U.S. workforce. Hardest hit in this pandemic are the 3.1 million working in hospitals and the 431,000 in nursing care facilities. A huge part of COVD-19 patient care is being provided by critical care nurses. According to the American Association of Critical Care Nurses, there are over 500,000 critical care nurses working in the U.S., most of whom work in ICUs and Emergency Departments. Of the more than 800,000 physicians actively engaged in patient care, almost 56,000 are estimated to be employed in emergency medicine. The stress of this time puts at risk their willingness to remain in their professions. We can’t afford to lose any of them.
Articles are beginning to proliferate on the potential for PTSD among healthcare workers. Some are reporting symptoms persistent and extreme enough to warrant a PTSD diagnosis. Others – like the 80% in the POM program – likely have a variety of milder, yet still disturbing symptoms. This squares with recently published data from China finding that a third to a half of those working in hospitals treating people with COVID-19 reported symptoms of depression, anxiety or insomnia, and three-quarters reported symptoms of distress.
Offering teams of frontline healthcare workers supports like the POM program may be a way to say ‘thank you’ that’s far more enduring than nightly cheers. And leveraging the support of the group who experienced stressful times together is a powerful way to build lifelong resilience. Perhaps individual communities will step up to underwrite week-long gatherings of stressed healthcare teams – away from work and facilitated by independent therapists.
Restoring Peace of Mind
Past trauma alters in both large and small ways the lens through which the future is viewed. Doctors, nurses and paramedics will bring that lens to patient care. Soldiers will bring it to their interactions with others while in uniform. But their experiences will play out in countless other ways as well – in their capacity to form healthy relationships; their responses to a demanding child, patient, colleague or spouse; their reactions to the news; their decisions at the voting booth; and their compassion for fallible humans, beginning with themselves.
There will be time to debate whether the spread of the virus was avoidable, just as there is debate about the necessity of war. Meanwhile, there is much work to do to care for those whom we dispatch to care for and protect us. The price in lost peace of mind that both frontlines pay is beyond dispute. The immediate question for the rest of us is who will be there to greet them, and what will we offer, when they step back from the front and return home?