TRIGGER WARNING
This was written for those in the right head-space to contemplate one of the most intractable challenges within this pandemic. It might not be the best read for my friends who are stressed about me right now, but I put up the trigger warning for the reader’s sake. I want people to care how, when and where they digest the mysteries, and the nightmares, within the disaster.
I work in a hospital, ostensibly on the fringe of the pandemic, in a field that historically has had to fight to avoid neglect. This piece is one contribution to that struggle, though in all honesty, the most unheralded front-line workers are probably the people with the mops.
Forgive me if this comes out discumbobulated. I have little time for writing, so I apologize in advance for leaving this here in the form of disjointed notes.
One of our challenges in psychiatry is that delirium and altered mental status, generally, have yet to be given much credence in the differential diagnosis for COVID19. Emerging research about COVID19-associated encephalopathy, coupled with Chris Cuomo's reports of hallucinations during his peak infection period, suggest that is about to change. Individuals seeking non-CoV medical procedures or their caregivers should communicate with their providers any early warning signs of concern, whether or not there is established peer-reviewed basis for association with the procedure or with viral infections. Disorientation, confusion, sleep disturbances, sensory changes may develop to more advanced symptoms such as illusions, hallucinations, delusions, agitation and severe behavioral disturbances. These all have greater potential to be misinterpreted as strictly psychiatric.
We have yet to fully appreciate the mental healthcare implications of the pandemic, but distinguishing the neurological from the psychiatric is an important step in that direction.
This brief article concludes with a memorable quote, “There’s no ventilator for the brain.”
Chris Cuomo recently described his COVID-19 symptoms, and in addition to the fever, shivering, and body aches typically associated with the coronavirus, the CNN anchor relayed a "freaky" anecdote about hallucinating images of his late father and other people from his past. It's not clear exactly what happened in his case, but it may sync with a New York Times report about a small group of virus patients around the world who've shown an "altered mental status," or encephalopathy. These patients are exhibiting signs of confusion, seizures, dizziness, headaches, stroke, and other neurologically linked symptoms—one COVID-19 patient cited by the Times couldn't tell doctors his name or what ailed him, because he'd apparently "lost his ability to speak."
I had to run to my first behavioral code on the COVID19 unit last night. When running to a code grey, you have no way of knowing whether a client is trying to kill themselves, kill someone else, push their way to the elevator so they can go have a smoke or just pushing their nurses buttons. I was relieved it was the latter and resolved with verbal deescalation only. The flimsy paper gowns available on the precaution cart would have been laughably useless if it were one of the others. Although there's nothing funny about it. The last thing I wanted was to have to lay hands on someone already in the grip of the virus, and not just out of empathy for their struggle. I think I'm bringing a change of clothes with me tonight, and dressing with the expectation that the clothes I wear will offer me more protection than anything the hospital is going to provide.
It's dawning on me that the pop-up community mental health clinics I dreamed of a week ago should be outside the hospital itself. This is only slightly influenced by the small sample size of providers that have required psychiatric hospitalizations recently. Most of the people I work with have at least one close friend or family member who has died in the last month, or is in critical care. None of us are taking bereavement leave except for my co-worker whose baby died in hospice just yesterday. I feel like I need a debriefing every time I finish a shift these days.
Full disclosure: Suicide is the furthest thing from my mind (for myself), and yet it's never far from my mind (because that's my occupation).
Some people that survive with chronic suicidal ideation metamorphose into the most compassionate people you'll ever meet. Others deflect it into all sorts of reprehensible behavior. What makes the difference? Some people have cultivated skills that help them positively transform despair. People may be even more capable of massive transformations when under prolonged duress. Few manage to do it in isolation.
Compassion does not resolve suicidality, and may in fact perpetuate it. Those who work hardest to probe the unanswerable questions can overburden the subconscious. One of Goya's most famous prints from the Disasters of War series is entitled The Sleep of Reason Produces Monsters. This is a cautionary allegory for those who work themselves beyond the point of exhaustion. We can't get it all done today. Take a bath. Listen to a symphony start to finish. Or if you're like me, do both at once, as I did before going to work yesterday.
Finally, some information about the correlation between unemployment and suicide rates:
https://www.psychologytoday.com/...
The U.S. suicide rate was 12.1 per 100,000 from 1920 to 1928 during the Roaring Twenties. After the stock market crash of 1929, the suicide rate skyrocketed 50% to 18.1 per 100,000. The suicide rate over the next decade of economic depression (1930-1940) stayed at a terribly high 15.4 per 100,000, until the national emergency of World War II, when it declined significantly. Unemployment is a well-established risk factor for suicide. In fact, 1 in 3 people who die by suicide are unemployed at the time of their deaths. For every one-point increase in the unemployment rate, the suicide rate tends to increase .78 points.
One final thought, about this community which means so much to me:
Please be kind to one another in this community. Last weekend, a contribution by one of my favorite front-page writers took a lot of heat for reasons that were impossible to refute. However, the merits of their article were barely addressed by most critics. The pandemic has radically changed the lens through which we receive perspectives that may be both truthful and counter-productive in their presentation. On top of every other existential crisis we face, it’s difficult to maintain balance and patience.
The magnitude of complexity increases just as the imperative to promote uniform behaviors emerged. Conformity has jumped in front of items that had been top of the agenda just weeks ago. We’re screwed if we lose sight of nuance, tolerance, diversity and the lessons and limitations each of us bring.
Great questions without good answers are the germ of debate. One of my friends faulted the author for not presenting the dynamics behind the article as an open-ended question. If one of us reaches wrong conclusions, the most compassionate thing we can do is to steer the conversation to the debate their perspective warrants.
it is easier to comment than put out a diary of one’s own. While we hold ourselves to ever-higher standards, this can still be an environment where diverse writers can learn from their mistakes, improve their process and still think outside the box. None of those things happen all at once, so be patient, please.
This is all incredibly hard. We’re working on developing thicker skin. Bear in mind that even the warriors and the healers sometimes have their skin worn thin.
For more reading about COVID-19 related encephalopathy
www.livescience.com/…
journals.lww.com/…
www.diagnosticimaging.com/…