Dr. Alain Bouchard discusses PTSD, or Post Traumatic Stress Disorder, in frontline hospital workers, a ripple effect of the pandemic with special guest Lyndsey Robinson. Lyndsey Robinson is a family emergency medicine nurse practitioner with experience in pediatric and women's health. She's also a former licensed counselor and therapist using yoga expertise for the treatment of mental health and addiction.
Learn more about PTSD in frontline healthcare workers here.
About the Host
Dr. Alain Bouchard is a clinical cardiologist at Cardiology Specialists of Birmingham, AL. He is a native of Quebec, Canada and trained in Internal Medicine at McGill University in Montreal. He continued as a Research Fellow at the Montreal Heart Institute. He did a clinical cardiology fellowship at the University of California in San Francisco. He joined the faculty at the University of Alabama Birmingham from 1986 to 1990. He worked at CardiologyPC and Baptist Medical Center at Princeton from 1990-2019. He is now part of the Cardiology Specialists of Birmingham at St. Vincent’s Health System, Ascension.
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This is the MyHeart.net Podcast. This show is produced by Dr. Philip Johnson in conjunction with VitalEngine.com. Please welcome your host, Dr. Alain Bouchard of Cardiology Specialists in Birmingham, Alabama, at St. Vincent's Medical Center, part of Ascension.Dr. Alain Bouchard:
Welcome to our podcast and MyHeart.net. And today we're going to discuss PTSD, or Post Traumatic Stress Disorder, in frontline hospital workers, a ripple effect of the pandemic. And with us today we have a very special guest. Her name is Lyndsey Robinson. She's a family emergency medicine nurse practitioner with experience in pediatric and women's health. And also what's very interesting is that she's a former licensed counselor and therapist using yoga expertise for the treatment of mental health and addiction. So Lindsey, welcome to MyHeart.net and thank you for taking the time.Lyndsey Robinson:
Sure, glad to be here.Dr. Alain Bouchard:
So today we'll discuss PTSD. We'll discuss a little bit about what is post traumatic stress disorder, we're going to discuss how common is it, you know, among healthcare workers? Who is at risk? How can we prevent PTSD? And finally, we'll discuss a little bit of how can we treat PTSD, and maybe Lindsey will be doing a little yoga session for us to show us how effective this technique is. We usually associate PTSD with wartime veterans, but during the pandemic, frontline hospital workers have seen more deaths than U.S. soldiers have seen during all the wars combined. COVID-19 posed a great challenge to frontline health care workers that were forced to measure themselves against a disease that was risky for their own health as well as their patients, particularly at the beginning when there was a lack of protective equipment. So Lyndsey, let's start by...maybe you could share with us a little bit your experience as being a healthcare worker during the pandemic.Lyndsey Robinson:
Yeah. So it's interesting, I finished my nurse practitioner degree up in, basically, August of 2019, and started working at a student health center. And obviously, three, four months later, 2020 hit and was working basically primary care, student health, but COVID was basically my primary job to protect the students, come up with protocols, and find a way to still treat them while figuring out what we needed to do to protect ourselves. I initially—we implemented a lot of telehealth protocols and testing protocols, because we didn't know how contagious this virus was and how bad it was going to be. But we still wanted to provide care for people. So I did that for about a year, and it was pretty amazing, the volume and the unexpectedness. I actually, I think, was the first provider in the clinic to have a positive patient. And I was scared to death when that patient's test came back, because I had bounced in and out of the room quickly after I had found out her symptoms and was like, "Did I have my mask on? Did I have the right mask on? Have I been exposed?" It's, like, immediately all these questions came up of "Oh, no. Am I am I going to be okay?" So, you know, it was one of those things that were, like you said, we didn't really know what we were getting into. You know, as the year progressed, I started doing an emergency medicine subspecialty, which put me directly in the emergency departments at a local hospital and freestanding here and the Birmingham, kind of, metro area. And it was pretty shocking. I knew what was happening in the ICUs because I used to work in the medical ICU at UAB, which became the COVID unit, and I knew how sick those patients can be there. And then to add COVID, I just couldn't imagine. I was so worried about a lot of my former colleagues that still worked there. But being in the EDs, I had the unfortunate experience of having to find out, you know, did we have enough PPE, did we have the right PPE, going into patients rooms, again, not knowing if if they were sick, or are they not sick. And it's interesting because, you know, I don't feel like I've ever been in the place as a health care worker to where I worried about, "Oh, does somebody have something that's going to make me super ill and kill me?" Even after working in ERs and ICUs as a nurse, I got super sick plenty of times dealing with sick patients, but I never worried that I might die or bring an infectious disease home to my family. So it was one of those things of, you know, you're wearing a mask all the time. You're adding on, you know, all sorts of other gear when you directly interact with patients. And, you know, I'm not used to being a bit scared when I go in rooms, but that happened. And I realized that it impacted how I treated patients initially. And I really had to kind of step back and figure out, "Okay, what can I do to keep myself grounded and centered, so that I can be present for my patients," because plenty of the adults I saw, the kids I saw, initially, in the first, you know, first year or two of COVID, they were terrified that they were going to die, because initially, this was well before the vaccine came out. And they didn't know if they were going to have drawn the unlucky card that was going to put them in the hospital. And when families couldn't be present, you know, you were having to communicate that with a sick patient who may be a little bit out of it, because their oxygen was really bad. And so you're then having to call a family member and communicate that and try to calm them down while you yourself try to stay calm while you treat your patient. So, you know, like I said, I worked in a couple of different ERs, pediatric and adult, and, you know, eventually got pretty worn out when the volumes really peaked last summer, especially with kids, and just got super exhausted myself and felt like I needed to take a break and take a step back from it. I had had lots of family get super sick, I had a... My cousin's little girl was four days old and contracted COVID and was intubated and in Children's for three months, and is a year and a half now, but still has, you know, a G-tube and, you know, it's so much better now, but she almost died. She was one of the youngest patients and got this right at the beginning. And it was one of those things of where I knew early on that, yes, mostly older people died, but I was witnessing a newborn that could, and it just really hit home personally and professionally for me throughout the time, because I've lost several family members. And you know, it strikes deeply. I've been able to avoid it and protect my family and my partner from getting sick, but it's only been through being super cautious, and unfortunately, a lot of times, avoiding her, avoiding friends and family, and staying away from them, which, in the middle of stress and trauma, you really need people. And so I know a lot of health care workers have had this same struggle with their own emotional needs and mental health needs and physical needs in the midst of trying to care for super sick patients who were scared and terrified and didn't know what was going to be next for them. So...Dr. Alain Bouchard:
Quite, quite an experience. How do we define PTSD, Lyndsey?Lyndsey Robinson:
Well, there's a fair amount of kind of criteria as far as the DSM goes. Obviously, you have to have a key stressor that happens, and it can either be—oftentimes we think of direct exposures to death or threatened death or serious illness or trauma, but one of the key stressors can also be indirect exposure to adversive events, basically, like health care workers. So an exposure to a stressor, then persistently reoccurring, intrusive symptoms of that trauma, whether it be, you know, flashbacks, remembering memories, emotional upset, nightmares. There's oftentimes, like, avoidance of the trauma and not wanting to talk about it or not wanting to think about the emotions that are triggered. Oftentimes, there are additional, like, inabilities to recall events and emotions. Oftentimes, people will either not want to talk about it or overly talk about it, depending on where they are with it, but it creates a very much a alteration in, like, what they call arousal and reactivity of where they're—or the emotional and the mental and physical symptoms of where people will have mood swings, hypervigilance, panic attacks, heart racing, shortness of breath, stomach issues, almost like any general stressor, but the difference between it and, say, just stress and trauma is the length of it, is that it seems to be persistent for more than a month and causes significant dysfunction and impairment in day-to-day activities. So...Dr. Alain Bouchard:
Well, obviously, you were not the only one affected during the pandemic, and what is—do we have an idea of how many healthcare workers, you know, have this problem this issue with post traumatic stress?Lyndsey Robinson:
Um, I...it's...I feel like it's a bit varied because an actual diagnosis of PTSD is a bit harder to nail down, but there's an estimation that about 20% of health care workers have experienced at least some moderate level of PTSD, you know, definitely increased levels of anxiety and depression and altered coping skills, for sure. I read an article the other day that alcohol use among women in general has gone up, like, 40%. So if you calculate that also with just female health care workers, in particular, I'm sure it's even more so. But one of the analyses looked at that even depression and anxiety rates have gone up over 20%.Dr. Alain Bouchard:
It's quite a common phenomenon among health care workers, you know, frontline workers. It's kind of like, obviously, they're there in the frontline, we can see how they could be affected more, but, you know, in general, who is at risk for developing PTSD?Lyndsey Robinson:
Yeah, so a lot of factors obviously go into that. In general, there are trauma—there are factors of, you know, being female oftentimes is being a single caregiver, you know, having not enough work experience or training in what you're dealing with, but then having a high level of intensity and exposure, kind of like a lot of healthcare workers experienced initially. Not having a good social support system, there's obviously biological symptom—and, you know, and genetic variability, but also socioeconomic status, previous trauma, previous PTSD, a history of anxiety, depression, anything like that can make people more prone, especially healthcare workers, to experiencing PTSD.Dr. Alain Bouchard:
So if you know that there are these these factors, is there a way, actually, to prevent PTSD, or...?Lyndsey Robinson:
I mean, for sure. I think, you know, with, you know, everything, the initial step is recognizing, and recognizing, you know, your own history and your own issues. And as you know, people that are treating other folks are the administrators of hospitals and whatnot, I think acknowledging those things are there and then providing some resources to increase communication, to provide support is important. But also, you know, from an administrative standpoint, you know, having things like counseling setup, group support, that kind of thing. But also encouraging as regular of a schedule as possible, obviously, good health and eating, exercise as best as possible, sleep. And then doing things that help relax the body and the mind, like mindfulness things, yoga, meditation, deep breathing, can really help basically shut down and calm the sympathetic nervous system and turn on the parasympathetic nervous system. And that's what we want to try to do in order to decrease PTSD and related symptoms.Dr. Alain Bouchard:
It's, you know, I've seen, for example, at our institution, you know, the difficulty in getting and working with health care workers, you know, within this environment of the pandemic, the resources that we have are limited, and it was very, very difficult to, you know, to kind of provide an environment that is, you know, very supportive, but I find that, you know, a lot of that administrative decisions have really helped with this. Creating, for example, positions that were not available before, like for example, the PRN position, where a nurse could work for 36 hours, every six weeks, and really kind of allowing flexibility, and really helping individuals and nurses being able to continue to work with a schedule that was, you know, allowed them to take care of themselves and their family.Lyndsey Robinson:
Yeah. Yeah. And that's, that's really important. I think that's why there's been a rise in travel nursing, unfortunately, also, because the money is so much better and people feel like they can control their exposure to the trauma so to speak, of going, "I can handle a 12 week assignment, and then I can take a break." It's unfortunate, though, because, actually, some hospitals have done a really good job of creating PRN positions, but there are still plenty that really don't allow PRN positions. And I think that would be a really huge way to save our healthcare workers right now and allow people to be the PRN Flexi, you know, the person that you can kind of tag to come in when somebody needs a mental health day. The facility I work at now, we get a half a day for mental health, like, every month or so. And you don't have to request that off early. You can just be like, I'm not coming tomorrow, I need a mental health day. And they're, like,"Do it." Because they know that in the long term, it's going to save us and enable us to still be able to take care of patients like we want to.Dr. Alain Bouchard:
Yeah, very true. So let's say, for example, you see someone, and they have all the symptoms of PTSD. How do you actually treat a patient with PTSD?Lyndsey Robinson:
Um, so obviously, I feel like the best kind of combination, as with most things, is oftentimes a combination of therapy, like psychotherapy of some form, and medication. And oftentimes, traditional SSRIs are just as good as anything to start. Because there are traditional symptoms of anxiety and depression. Sometimes people need more, like, mood stabilizers, like Abilify and some of the antipsychotic medications that are used off label. But it's super important that there is a therapist or group therapy or some sort of counseling involved. And I feel like kind of somatic body work as well, too, because the thing about PTSD and traumas is that, in my yoga therapy training, we used to talk a lot about "the issue is in your tissue." So we get stuff stuck, kind of, in our bodies, which is oftentimes why people start complaining of physical pain along with emotional pain. And so, I think introducing, you know, different mindfulness techniques, things that bring people back into their body so they can begin to unwind these experiences and process them in a safe and contained manner is super important. You know, there's been a rise in use of, you know, MDMA and micro dosing and things like that of some not really legalized things yet that I think could hold some promise, but, you know, as healthcare workers, we have to be very careful about the things we ingest and expose ourselves to. So you know, it might be something in the future to use, some of these other alternative things, but I feel like, you know, traditional medicine, psychotherapy and body-based therapies are a really great way to start treating people.Dr. Alain Bouchard:
You sounded at some point very much like Professor van der Kolk, you know, in "The Body Keeps the Score." No, the issue is really in the tissue. Do you use— Or are methods like, for example, EMDR, you know, used for treatment of PTSD or other techniques that are employed?Lyndsey Robinson:
Yes. Yeah, EMDR is one of the—is a great one. I'm not trained in it. But I know plenty of people that have used it, and that are trained in it. And it seems to be very effective, because it allows people to kind of connect mind-body and really slowly go back to those experiences. And—but yeah, I mean, it's a great form of therapy as well.Dr. Alain Bouchard:
Can you explain, Lyndsey, a little bit though how it's done?Lyndsey Robinson:
I'm not—since I'm not trained in it, I'm not really great, but it's a use of—often what they'll do is they'll have you recall, but then oftentimes, there's a series of like, basically, tapping that's done, usually somewhere on the face, as people are asked to recall a memory and speak about it. And, you know, I don't really know the mechanism of how all those things come together. But again, we really don't even know how SSRIs truly, really work for people, but it's through slowly bringing back and kind of desensitizing oneself to the experiences and then reprocessing them in a different way through those techniques and through a guide.Dr. Alain Bouchard:
I'm sure sleep is very important, as well.Lyndsey Robinson:
Yes, sleep is a challenge for most healthcare workers, especially people that work the crazy shifts. At one point, I was working on an 11 to an 11 shift, 11 A to 11 P, which I feel like is the worst shift in the entire world. But I think that's just because I'm not a night person. And it really messes your day up. But then there's also the people that work, you know, nights completely. And so, sleep is super vital. But I think it's one of the most challenging things for a lot of healthcare workers, not just from if you have an altered schedule, but just from a winding down because a lot of healthcare workers work twelves, and, from experience, working 12 hours when you get home, you're physically exhausted, but your mind oftentimes is running 100 miles an hour, so, you know, doing things to calm and relax in order to create sleep. Sleep hygiene is super important. Have a cool room, super dark. Some people like melatonin, it can cause crazy dreams, so I tell people if you're already a crazy dreamer, probably don't go that route. You know, chamomile tea, a little meditation or gentle stretching before bed, and then trying to stay on a normal schedule as best you can. You know of getting up at the same time and go into bed at the same time every day, even on days that you're not working to kind of create normalcy. Night shift workers oftentimes will stay up a little bit later on their days off in order so that they're not completely flipping from day to night, because we know from research that people that work swing shift and third shift oftentimes have worse health problems, heart conditions, depression, anxiety, weight gain, and often, too, I think I read something once that it actually decreases lifespan, that there was a research article that it can actually decrease the length of your life if you work night shift for a really long time. So sleeping as much as you can so that the body has a chance to do its healing, that parasympathetic nervous system yet again, getting turned on so that the healing can happen overnight in the body and the mind.Dr. Alain Bouchard:
Yoga is very important, and you used to be a yoga instructor and use yoga as a form of therapy. Do you want to give us maybe a short brief example of some of the sessions you would do to treat someone with PTSD?Lyndsey Robinson:
Yeah, um, so some of the yoga therapy I did was a combination of supported yoga poses. So I would basically, gently— like, it's almost like Thai Yoga, Thai Yoga Therapy, of where I would move people into stretches on the floor and support them, almost like a restorative yoga, and then dialogue with them, of just asking them what they were experiencing. But one of the things we always do is we would start the session with kind of an intention setting, and, if you like, I can kind of guide, talk us through that session. And so, what I have people do is, find a comfortable way to sit, making sure that you're sitting tall with your spine long. And then making sure feet are touching the floor flat flat, or if you'd like to sit cross-legged. Hands are resting in the lap so that the arms and the shoulders can be relaxed. And then slowly close the eyes or let the gaze drop down to the floor. The first thing I want you to do is just notice your breath. The sensation of breath going in and out of your nostrils. And then pay attention to your face, your head and neck, noticing if you're holding any tension in your jaw. As you breathe, paying attention to your shoulders, seeing if you can allow the breath to drop them. Feeling the weight of your arms and your hands resting in your lap or on your legs. Allowing your breath and awareness to drop into your hips. Noticing your breath as it fills your chest and belly. And then breathing awareness all the way down your legs into your feet, feeling them touch the earth beneath you. And as you take a breath, bring your focus into thinking about what you would want to receive in this moment, in this time, in this session, whether it's just to simply be present, be in your body, be with your breath. Maybe it's to let go of something or to receive something that you desperately need. Allow that intention to fill your mind, fill it with breath into your heart, into your chest. And then on your next breath, allow focus on that attention to just kind of fade away like a cloud, knowing that it's here, but you don't have to keep your mind on it. And for this next few moments, just pay attention to what's happening now with your breath with your body. Knowing that thoughts may arise but that you don't have to chase them, follow them, investigate them. You can let them come and float by again, like clouds in the sky, allowing yourself to just be curious about what you sense, what you feel, no need to fix or avoid or even judge the experience or the thought. Simply allowing your attention to be on your breath moving in and out of your body and any physical sensations that may arise and capture your attention. If angst or discomfort or fear arise, allow yourself to focus on your breath, deep and full, feeling your feet grounded, your hips grounded in the seat, knowing that you are present in this moment, in this space, safe and protected.Dr. Alain Bouchard:
Wow, we've never had a therapeutic session at MyHeart.net, but I could see how this really would help, you know, a lot of people. Lyndsey, I want to thank you very much. Lyndsey Robinson, who's a family and emergency medicine nurse practitioner, with this incredible experience, you know, having been a clinical licensed counselor, helping patients and as well as hospital workers in this difficult time in post pandemic. Lyndsey, thank you very much for your time.Lyndsey Robinson:
You're welcome. It was great to be here.Announcer:
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