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IC@N Project ECHO

Integrated Care at NEOMED (IC@N)

COVID-19 & Project ECHO

By Nichole Ammon, MSEd, LPCC-S

04/14/2020

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Serendipity is a word I find myself using a lot since coming to NEOMED in 2013.  I will come back to that.  You may or may not recall that Northeast Ohio Medical University (NEOMED) is transitioning from a Project ECHO® hub to a Project ECHO® superhub.  Our team was slated to attend superhub training in Albuquerque, New Mexico at the ECHO Institute TM the week of March 16-20, 2020.  As we were preparing for this training, the world was being hit by a public health crisis- the novel coronavirus, SARS-CoV-2.  

By the time I left campus on Friday, March 13th, not only was the training canceled, but I felt like the whole world was being canceled too.  Except Project ECHO, of course, which has always used Zoom.  Project ECHO was gearing up to think bigger.  

Project ECHO is dedicated to demonopolizing knowledge and bringing real solutions to complex problems fast.  With partners in 48 states in the U.S. and across 39 countries, the entire global ECHO community immediately mobilized to respond to this new viral threat.  The NEOMED ECHO team was already planning its first pop-up COVID-19 session before our campus shut down.  Despite knowing little to nothing about COVID-19 before the planning of these sessions, my role within NEOMED’s Project ECHO program made me the de facto facilitator.  

We hosted this session, COVID-19: What Medical Professionals Need to Know, on March 27, 2020, which featured NEOMED faculty and local experts.  In two weeks, we all had already begun to see the impact of COVID-19 on our colleagues and communities.  Regular ECHO participants were reaching out to share fears and anxieties about the virus, financial uncertainties and the impacts upon our society.  I received a message from a colleague saying “It’s been absolute hell here at (name of practice redacted for anonymity).”

So, on April 1st, NEOMED hosted a second pop-up session, Coping for Health Care Workers During COVID-19.   One of the participants that day noted seeing “reports of hospitals running out of PPE, providers feeling unsafe, and even resigning from their positions in some highly affected hospitals.”  Our panelists and participants shared resources and suggestions for coping.  One participant reminded us that, “we have to find ways to operationalize these with our staff and a check-in process to support each other to see if we are practicing self-care.” 

Then there was the story shared about a nurse technician that was 1-to-1 with a patient reporting suicidal ideation and had tested positive for COVID-19. It was shared that when the tech requested assistance from the nursing staff, the nurses and other techs refused to take the assignment.  Even though this was a moment where team members and emotional supports were needed the most, this tech was left isolated to handle the case on their own.  This story brought to life the impact of the fears and stigma that health care providers are experiencing right now and highlights the need for project ECHO to help unify our protocols for keeping ourselves and our colleagues safe and resilient. 

On April 2nd, I received an email (quoted below) message from the friend of a colleague.  I am sharing it because the author, Dr. David Sharp, summarized what we are going to have to plan for so well.

“I very much enjoyed the ECHO lecture from April 1st. This was a good start and it dealt primarily with PTSD. I’m sure that more courses are forthcoming but I’m not sure which topics will be covered. A larger issue is that when the world returns to normal, there will be a small population of medical professionals who literally went to war for 6-18 months, a larger population that got sick but recovered, and a huge population that spent the entire time trying to stay home but never really understood the battles that were fought 24-hours per day by exhausted health workers who watched an unusual number of people die while being unable to be cared for or supported by their families due to risk of infecting them.

Your students’ first real experiences upon graduation will to have been thrust into a global health crisis similar to how our enlisted military are sent to war. They will attach to a medical group that may have some percentage of team quarantined and possibly have already lost teammates or loved ones to COVID19. Their first year of service will likely be spent tending primarily to COVID19 patients. Triaging the fallout from a novel virus is not specifically what our medical students have been preparing for these past 4 years.

And then one day COVID19 will disappear and they will “return home” to being a normal doctor. They will deal with exhaustion, burn out, and PTSD during and directly after, but they will also deal with isolation and loneliness as they will be unable to find physical comfort in friends and family during these times and will be unable to relate to the shared narrative that was formed by most Americans who do not work in a hospital. They will have seen a war fought within the United States and then will walk around the general population who will recall this event as simply social distancing with some loss of life and that doesn’t tell the story of watching patients die isolated and alone that these medical professionals experienced daily for weeks or months. This disconnect from the national narrative will increase depression and suicide rates in our medical staff as they attempt to transition from war to peace.

Simply put, we need to consider training this current crop of medical staff as if they are leaving for and returning from a war-like situation and they should be given training on how to be strong during and resilient after. Our 20 –year engagement in Iraq and Afghanistan has provided ample research on coping strategies when being constantly on guard and constantly around human loss. PTSD is important to consider, but military veterans have found that it is difficult to articulate their experiences in service and believed that others were unable to understand those experiences, leading to perceptions of loneliness and isolation. Humans are social beings. We succeed and thrive in groups and gatherings. This virus strips both the patient and the doctor of this facet of our humanity and forces us to work and to die in a way that runs counter to our natural state. COVID19 is at the same time an attack on our physical as well as our mental health and it is imperative that we recognize and respond to both at the same time or risk saving the patient while losing the doctor.”

NEOMED hosted a third pop-up ECHO session on COVID-19 Masks or No Masks on April 10, 2020.  The conversation returned to concerns about the long-term impact.  One of the questions we received was, “While we are gaining benefits against coronavirus and it is awesome, have we been looking at the negative side effects of the stay at home such as dieting, drinking, drug use changes, loss of homes and poorer housing which has been proven to be harmful to people over the long run?”   Just as it was highlighted in Dr. Sharp’s email, both Drs. Zarconi and Smith emphasized the potential impact of social isolation and loneliness, urging us all to prepare for the aftermath and an uptick in the need for mental health services.Poster by Thomas Wimberly at Amplifier.org titled "Global Forefront English." Depicts a healhcare worker wearing a mask with a print of the world on it, with a subtitle of "thank you"  

Early data coming out of China indicates that health care providers working on the front lines of treating COVID-19 positive patients are at an increased risk of depression, anxiety, and insomnia.  Looking to the U.S., on 4/9/2020, the Primary Care Collaborative (PCC) posted results of a four-week survey “Primary care practices on their response to the COVID-19 crisis.”  The strain being placed on primary care practices demonstrated in the survey responses parallels what we are hearing from our ECHO communities.  The survey pointed out a critical need for mental health services.  It indicated that practices continue to struggle with telemedicine and a shortage of PPE. Simultaneously, providers are being redeployed to new roles and other parts of the health care system.  

All of this and we haven’t even discussed the impact on already vulnerable populations.  We know that health disparities persist across racial and ethnic groups, genders, age, socio-economic status, and disability status.  We know that many people living with serious mental illness are homeless or incarcerated.  Not only do we have to prepare for the aftermath among our health care providers but for the disproportionate impact on the populations we serve.

Where do we even begin?  Serendipity brought me to Project ECHO.  I’ve been accused once or twice of bringing Project ECHO to NEOMED’s Department of Psychiatry.  So, my inclination is to start there. The NEOMED ECHO team is talking with leadership about the robust response we have had to the three pop-up COVID-19 sessions.  Do we continue planning pop-ups or create a temporary program?  In the meantime, I have invited Dr. Sharp to join our Integrated Care @ NEOMED (IC@N) ECHO community and he has some exciting didactic blitz ideas.  Keep watching the LibGuide for curriculum updates (https://libraryguides.neomed.edu/ICAN-ECHO/).  I hope to see you at a session soon.

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Contact our team with your thoughts at integratedcareECHO@neomed.edu

Image Source: Thomas Wimberly for amplifier.org

 

Additional Reading

Project ECHO COVID-19 Video Recordings