Linda Chokroverty, MD, is the attending physician at the Montefiore Health Systems in Bronx, NY; Clinical Assistant Professor of Psychiatry and Behavioral Sciences and Pediatrics at the Albert Einstein College of Medicine; and Co-Chair of the Disaster and Trauma Issues Committee with the American Academy of Child and Adolescent Psychiatry. In this episode she describes her experiences working with COVID19 providers and advice for clinicians who may face similar issues during the pandemic.

Date Published: 4/29/2020

Date Recorded: 4/23/2020

Duration: 20 minutes, 2 seconds

• CDC COVID19 Resources
• American Academy of Child and Adolescent Psychiatry
• The National Child Traumatic Stress Network
• Center for the Study of Traumatic Stress
• 10 Facts About Physician Suicide and Mental Health, American Foundation for Suicide Prevention
• Previous Episodes on Coronavirus and Mental Health: Part 1 and Part 2.

Schwartz, Michael. (1989). Nurcombe, Barry, and Gallagher, Rollin M., III. The Clinical Process in Psychiatry: Diagnosis and Management Planning. New York: Cambridge University Press, 1986. xvi + 744 pp.. Journal of Nervous & Mental Disease. 177. 57-8. (Link)

Thompson, Neal. (2015) People Skills. London: Red Globe Press (Link)

Westover, Tara. (2018) Educated. New York: Random House (Link)

Thanks for inviting me to speak on this important topic around the experiences in New York City with regards to the coronavirus pandemic and how they can inform other physicians- psychiatrists and especially child and adolescent psychiatrists in particular- about preparedness and response in the very near future for other parts of the country which expect cases to peak in another few weeks, now that the entire U.S., like the rest of the world is profoundly impacted by this event.

Scope of the problem for us regionally:
As we know, New York State has the unfortunate position as leader in the world’s share of COVID-19 cases and deaths, and certainly the most heavily affected region in the United States at the moment. As of yesterday, according to the Johns Hopkins Center for Systems Science and Engineering, in New York State, we had over 263,000 identified COVID-19 cases, and sadly, over 19,000 deaths to date since the onset of the epidemic. New York City alone has more than half of the COVID cases in our state. Our situation of exponential rise in cases and fatalities has been a reminder of what could happen in densely populated areas if measures to control the outbreak are not undertaken in the most timely and aggressive way. It is reassuring to see that states such as yours, Josh- California and Washington- which experienced the earlier cases in the country, have stabilized the spread and flattened their curves. Staying at home and social distancing really work. Our Governor in his daily address yesterday cited that we are at day 53 since our state shut down. As a result, our illness curve is believed to have peaked, and is now on a slow but steady decline, even though cases and casualties remain painfully high, and still uncertain that we won’t have any more upticks in activity. While exact dates of peak and case numbers are rapidly changing by the day, hour, even minute- at our own Montefiore Health System which includes hospitals in Bronx, NY and parts of Westchester county, we experienced a peak about 10 days ago when we had over 2000 hospitalized patients, and now in the 1600’s as of yesterday. A more sobering figure is the number of deaths per day in NYS which went from 800+  at peak, to 400-500 in the last couple of days. The boro in which I work, the Bronx, continues to lead in the number of cases per 100,000 people.

Operationally, how has this situation affected our work- what changes have we experienced?
What do all these COVID-19 numbers mean on a practical level for hospital-based physicians, like me? We have had to operate in a state of emergency, as our Governor issued a mandate to expand not only our hospital beds in the area for critically ill COVID-19 patients, but also expanded the scope of practice for all health care practitioners, regardless of specialty, to enable “all hands on deck” (including retirees and medical students being graduated early) whether as employees in a hospital system, or as volunteers with the state Medical reserve corps to supplement the healthcare workforce. Therefore, we could expect and–in reality–did experience a profound change in the landscape of care- where ill patients are treated, and role changes for doctors. Examples of this landscape change include committing almost all hospital units entirely to COVID-care, which involved changing pediatric areas to COVID care for young adults and older people. Never had we imagined entire ER’s with multiple patients on ventilators, or step-down medical units to have all their patients on oxygen masks, until now. New York City extended hospital programs to provide care in a variety of other places like a sports complex, field hospitals, a psychiatric center, a large convention center, a navy hospital ship.

As physicians, our roles have changed- we have been deployed to provide other kinds of care than what we are used to performing due to the massive expansion of hospital beds- I myself- a child psychiatrist- went briefly to a COVID medical unit which opened my eyes as to the extreme levels of stress experienced by frontline COVID unit providers that we read about in the news- will a patient die suddenly, did I properly don my personal protective equipment (my PPE), how can I provide palliative care to a patient who was just recently healthy?  Our house-staff and those at other local institutions, from multiple specialties have been deployed to serve on medical units, and senior trainees fill in for junior ones while they are away providing COVID care. 

In my usual role as a psychiatrist in the emergency room, we have to be mindful now of having sufficient PPE given the ubiquity of COVID at the moment, whether we are consulting with patients who are COVID positive or navigating infectious areas nearby. As we are still very much in the acute stage of this disaster and there is a stay at home mandate, we have been seeing far less psychiatric patients in the ER, only true emergencies and not relative ones otherwise solved by outpatient means, are coming to see us; this is a good thing from a public health infection control standpoint. However, we have yet to see what the effects will now be several weeks into the lockdown, as to what kinds of mental health crises will result in our patients and families from being in confined space for extended time, without regular school, and with high levels of family stress. Sadly, we all now know people- family members of friends, our own colleagues, sometimes our relatives, and people in the lives of our patients, who are losing loved ones to COVID-19.  Death and bereavement are experiences that have become too common during this crisis and what’s worse- we can’t have our usual rituals around death and supporting each other through gatherings due to restrictions, further complicating our grief.

Approaches:
As for an approach to address our current situation as faculty and direct caregivers in the psychiatric setting, we are still in the midst of what we would characterize as the acute phase of this pandemic, and therefore, it is highly important that we apply the principals of psychological first aid or PFA, in our work, which is a public health approach to reduce distress and promote resiliency during the immediate stage of any disaster event.  It includes making sure people are heard and feel supported (LISTEN) , ensuring they are safe by screening for danger such as domestic abuse and increased misuse of alcohol and drugs, sending them home quickly whenever possible and avoiding overexposure in the community so they don’t get sick- (PROTECT), facilitating social connectedness and communication with family and friends, as well as resources such as food and shelter if they need it (CONNECT), model calm and optimistic behavior while promoting a sense of efficacy, and education on expected reactions in the short term, which improve as things stabilize around us, and finally- helpful practices that will help you cope such as limiting your exposure to the news and overstimulating news material (TEACH). 

As a faculty and supervisor to trainees, I have seen my main role at the moment as checking in to see how they are doing, and teaching priorities that include maintaining our own health and resiliency, as well as that of our patients. So many disruptions in the structure and delivery of our care have happened. I haven’t even mentioned the fact that a lot of us- junior and senior people, have gotten sick with coronavirus, many of us are out, leaving less of us to cover for each other. We have to do our best to weather it for the moment. Hopefully, we will be able to get back to some of our usual didactics once our routines are more like what we know, rather than what we have at this challenging time.

Patient Care in the ER:
My usual approach to send psychiatric patients home from the ER whenever possible continues to hold true, especially now more than ever before, since our current goal is “to do no harm”. The main difference now really is the speed at which we would try to move our patients along. Inpatient psychiatric units in the area have had to deal with coronavirus exposure, isolation, and worse, sometimes acute illness; We want to avoid this experience for our patients right now if we can help it. Helping parents understand and avoid the serious risks of having their kids exposed in the community then bringing back potential COVID related illness to vulnerable family members- this is an urgent issue, which parents have been able to appreciate. As a result, I have hospitalized far fewer patients than I have sent home. Other things that have been important right now include reviewing healthy practices with patients that come to the ER – such as handwashing, social distancing, limiting travel and movement, and the correct use of masks. Also, there is a serious educational role we have to play on the importance of routines, sleep hygiene, physical activity and nutrition. Screening for access to educational resources is important too- not all our kids in the public setting have equal access to remote learning and helping them find connections to learning has been appreciated.

For kids in already treatment whose care has been disrupted- maybe they are trying to get an appointment with their outpatient clinic but can’t obtain it in a timely fashion- a lot of clinics were closed, and only just up and running now with telehealth appointments, in many cases telephonic only without video, which is less satisfying for many patients. For some of these patients who are in limbo-minor medication adjustments in the ER such as increasing a guanfacine dose or schedule, or titrating an antidepressant up further, are some tactics I have used in the ER. Also perseverance by our ER team in helping patients access services for the first time through new referrals has been important as well, especially as you know we had long wait lists and a short supply of child mental health treatment options well before this epidemic.

Our own self-care as health providers:
We have to practice what we preach around best health practices right now during this prolonged acute phase of the Pandemic. This includes the triumvirate of good health- sleep, nutrition, and exercise. Of these I would say nutrition for us has been the most reasonable thing to accomplish- we are fortunate to have lots of food donations to the hospital, generosity around meals, and importantly, when home, we have a chance to cook more meals and have family dinners since we can’t eat out. Exercise is possible but more challenging as you know, since gyms are closed, and outdoor activities are more restricted with stay-at home orders as well as mandatory masking in public. Sleep has been perhaps most elusive to accomplish reasonably- stress is very high right now, and we are inclined to overuse caffeine, go to bed too late, and not have the best sleep routines. I have found that I can’t read the newspaper at bedtime anymore as I usually do to relax since it contains too much upsetting information. So other sleep rituals have to be found, as do other activities at different times to relax such as meditation, yoga and mindfulness. We are lucky to have a variety of resources for mental health support in our institution such as calming rooms, volunteer short and long term mental health treatment if we need it, and also are involved ourselves in supporting the mental health of other healthcare workers as volunteers. There is also a national physician support line for COVID related stress operated by a small army of volunteer doctors to assist peers who need confidential help during this crisis.

In Summary:
We have to do our best to take care of ourselves, our own families, and our patient families while weathering this Pandemic. If you are in another part of the country that has not yet peaked in COVID-19 cases, or have the misfortune to experience a re-emergence of cases, here is what I think will be helpful based on what has happened here to us in New York:

1. Make sure you know ahead of time where the PPE is available in a given healthcare setting, especially  if you normally work in an ambulatory environment or need to deploy to an unfamiliar hospital.
2. If you are deployed-ask for live training before the deployment if you have not done medicine in 25 years before the age of EMRs and high tech as I did. While they are helpful, it’s not enough to have instructional videos to study on your own under duress, especially for those of us with older than young-adult brains. Maybe we can learn that way with palliative care as it may be closer to our usual work as psychiatrists. 
3. Have a bidirectionally supportive relationship with your trainees- they are often more up to date on technology, social media and efficient use of the EMR than some of us, and we can learn from them as much as we can teach them, especially during a crisis.
4. Work hard to limit our own exposures not only to infection, but also excess work hours, overstimulation in the healthcare setting, and overexposure to news around COVID-19.
5. Take time to do calming activities to ground ourselves, check in on family and friends often, especially those that may be more alone right now, and reach out to existing patients to let them know you are thinking of them and checking in to see how they are.
6. With patient care, make sure we are vigilant around keeping them safe from coronaviral illness, educate them on healthy practices to maintain physical and mental health during this crisis,  but also screen them for vulnerabilities such as previous traumatic events and losses, imminent abuse/neglect, food/housing/economic insecurity, as well as increase in substance abuse, all of which will further complicate already fragile mental health conditions.
7. Finally, because we are a vulnerable group ourselves as healthcare workers during COVID-19, we should ask our colleagues for help if we need it, provide help to them if we can, and consult helpful online resources such as American Academy of Child and Adolescent Psychiatry, the National Child Traumatic Stress Network, Center for Traumatic Stress Studies, and of course, the CDC.

Thanks again today for this opportunity to share my experiences and practical suggestions in managing this unprecedented health crisis. Take care.