Underlying Cause of Death: Coronavirus or Manslaughter?

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As Covid-19 mortality begins to slow and those infected begin to recover, the disease’s emotional impact on frontline workers is ramping up in the form of frontline burnout and suicide. The U.S. healthcare system was ill-prepared for a pandemic and the fallout will shine an unforgiving light on the notoriously-broken mental health system in this country.

Nurse at Harlem Hospital. PH: Luigi

The author is a Master of Science in Nursing (MSN) and Registered Nurse (RN)

The headlines are ubiquitous, the daily death count, omnipresent: as of this writing (on Friday afternoon, May 8), there are more than 1.3 million cases of Covid-19, and 78,494 people are dead, in the United States. 

 With the immediate focus on such eye-popping numbers, it’s difficult to stop and consider the broader view: What will the long-term effects of this virus look like? In medicine, we call the consequences of a previous disease or injury the sequela. In addition to economic destruction, Covid-19’s sequela is also beginning to present in a very tragic way — the loss of frontline workers.

 In recent news reports, we’ve learned that NYC EMT John Mondello, who was 23 years old, fatally shot himself after less than three months on the job as a paramedic. He worked for EMS Station 18 in the Bronx — a post with some of the city’s highest 911 call volumes. 

 We also know that Dr. Lorna M. Breen, medical director and head of the emergency department at New York-Presbyterian Allen Hospital, also took her own life the same week. Her hospital was part of the epicenter of the outbreak in New York City. She also contracted the coronavirus, likely from her hospital. She returned to work after only a week and a half, but was sent home again for being ill. She tragically committed suicide while recovering at her family’s home in Virginia. Those closest to her said she was tormented by not being able to help more people, stating that patients at her hospital were dying in the emergency room waiting area. 

 First responders are no strangers to tragedy on the job, but this is different. These two heroes saw no logical solution, no way out of the siege of Covid-19 on our front lines other than their own deaths. I have little doubt that their suicides are the result of the trauma healthcare providers are being forced to endure right now at a magnitude that is simply unnecessary. 

“This is what you signed up for” — that’s one of the unsympathetic responses we’ve been hearing lately. But no one signs up for a life-or-death job that doesn’t have the proper protection. We are not okay with the influx of patients resulting directly from top officials downplaying what was coming and preventing people from taking precautions sooner. In the weeks leading up to our first cases, we had no additional training in pandemic response and trauma medicine. We did not sign up to be soldiers who are unshielded, vulnerable, and indefensible because of a criminally poor response and organization by our government and our for-profit healthcare system. The same system that bankrupts the people it serves and tells workers to work harder, faster, more efficiently — as if we are machines impervious to unrealistic staffing ratios. We are fighting a daunting battle while our bosses continue to exacerbate the war.

Everyday working conditions take a toll on the mental and physical well-being of healthcare workers on an everyday basis — even before adding the effects of a poorly-managed healthcare crisis. Nurses and physicians leave the bedside at an alarming rate each year. Demand for healthcare is outpacing the supply of professionals graduating and staying at the bedside in direct patient care. Along with management’s seemingly never-ending efforts to reduce costs and increase their bonuses by cutting staff, these things only perpetuate the vicious cycle of understaffing and poor working conditions. 

Healthcare staff are not as indestructible as we are treated. We’re not expendable. It’s hard not to feel inadequate and responsible for bad patient outcomes when you are a person full of empathy but are left exposed in an impossible fight. There will be many more suicides to come. 

A Sentinel Event

 In healthcare, a sentinel event is any unanticipated event resulting in death or serious physical or psychological injury to a patient that is not related to the natural course of the patient’s illness. It requires immediate investigation and response. 

When a sentinel event happens, it’s a serious occurrence that requires immediate accountability and transparency from all parties involved. The goal is root cause analysis to identify and establish a timeline where the sequence of events caused the error resulting in serious damage to the patient. The same process needs to happen for the death and damage of healthcare workers during this pandemic. Given the amount of money, intelligence, information, informatics, and equipment to which the United States has access to — including advance knowledge of the incoming pandemic — not a single healthcare worker had to die. Not one. If the government and hospitals had acted sooner during the weeks of warning, would it have made things more manageable in the hospitals? Would it have prevented the severity of cluster outbreaks in nursing homes and long-term care facilities? Would our healthcare workers feel they have more of a fighting chance against this outbreak? Of course. This is nothing short of a sentinel event and needs to be treated as such to prevent it from happening again.

Meanwhile, the man in charge of the administration’s coronavirus taskforce, Vice President Mike Pence, is so incompetent that he did not wear a mask while visiting the Mayo Clinic on May 5 — defying both CDC recommendations and the hospital’s own policy. This week, during Trump’s first trip outside Washington since the pandemic began, the president decided to forego wearing a mask while visiting a Honeywell mask plant, later blaming it on the people around him also not wearing masks. Are we to believe that politicians truly did not know until very recently that the virus can spread asymptomatically?  

The behavior of our “leaders” is nothing short of disgusting and offensive to healthcare workers who have given so much to our communities. They insult the intelligence of the rest of the country as they try to lull people into a false sense of security with their very deliberate actions. Wearing a mask in public may be the most important precaution people can take as states begin to reopen, but these officials are reckless and negligent, using public image and perception to downplay the seriousness of this disease. Make no mistake — it will cost people their lives. 

Doctors and nurses can often see the direct and immediate consequences of an error on the job with a sentinel event, but government officials have the luxury of hiding the deaths they cause through their incompetence behind a highly communicable and untraceable disease. 

The Sharp End of Patient Care

Those working directly with Covid-19 patients are terrified of contracting and passing the virus to their families. Some have chosen to isolate themselves while working on the front lines. Being physically separated from your main source of comfort and support during a time of crisis is another form of trauma that contributes to the harmful mental health aftermath for nurses. 

Healthcare workers are already harmed by the immediate psychological effects of watching patients suffer and die. This is then compounded by the psychological harm of being separated from their loved ones. Depression, anxiety, post-traumatic stress disorder (PTSD), and suicide of our frontline and essential workers is going to be the next wave of this pandemic. 

I know this from personal experience. I began my nursing career in New Orleans and have worked through several natural disasters that forced me to stay at work around the clock, away from my family, sleeping on hospital floors, and taking on dangerous patient loads under  dangerous working conditions. More than a decade later, I still struggle with depression, anxiety, and Complex PTSD, in part as a direct result of the stress from a career in bedside nursing and the trauma that comes from natural disasters. I’m not afraid or embarrassed to say that.

I put my notice in at my recent acute care hospital position two weeks into Covid-19 when my workload doubled — with zero assistance or hazard pay. We were told to reuse a paper gown and a single N95 mask for the entire shift.

 The next day when I arrived at work, my temperature was taken at the door. I was sent home with a fever. 

Over the final two weeks of my employment, paid quarantine leave and hazard pay began emerging in varying degrees for different departments. More personal protective equipment (PPE) was brought in. For me, it was too little, too late. I already knew what a few days of such conditions would do to my mental health down the road, and I did not trust my employer to keep me or my patients safe. 

In the beginning of my career, I put my patients’ needs above my own, all in the name of being a nurse. I worked double shifts, second and third jobs, overtime — all while continuing to get three more nursing degrees and accruing more than $100,000 in student loan debt. It took years of mental health treatment to learn to set boundaries; to put it figuratively, put my own oxygen mask on before assisting those around me in the crashing airplane. There is no price, no sense of duty, that could make me stay employed somewhere I feel in danger to my mental and physical well-being as a direct result of the actions of my employer. 

Nurses take on more than feels possible many days because we are conditioned to be “heroes without capes.” Our philanthropy is exploited for profit. The local hospitals gave out yard signs and bumper stickers to employees to recognize us as heroes — of course, with the hospital system’s name in front of the word “heroes.” One company’s sign has its hashtag on it. Many nurses were insulted that they would be used for free advertising during a pandemic. If these hospitals were really on our side, they would instead use the hashtag #TheSystemIsBroken.

This exploitation tactic distracts from placing the real blame for healthcare staff accounting for an estimated 20 percent of the Covid-19 infection rate. Their “thank yous” are the equivalent of the $1,200 stimulus check out of a $2.2 trillion stimulus package. If you really appreciate me getting Covid-19 from my job, being kept from my family, and my coworkers dying, put our needs ahead of your own, just as we nurses put our patients’ needs ahead of our own. Forfeit your executive salaries and bonuses. Give them to the people who prop up your business. Stay around the clock, away from your families, until you straighten out the mess you’ve made. 

These extraordinary circumstances are new to many frontline workers, who are racing to bedsides in Code Blue mode without time to consider how this is going to affect them and their families in the future. They are being distracted and bombarded with praise and compliments from the very people who created this situation for us. Using all of this hero rhetoric is aimed at distracting us from organizing and unionizing. 

The Politics of Healthcare

The United States spends more per capita on healthcare than any other country, yet we have some of the poorest outcomes. The way Covid-19 is ravaging our population and spiking the mortality rate due to underlying, preventable diseases is proof enough of the failings of our broken healthcare system. Every day, I see my motivated patients struggling to be in better health despite the bureaucratic system that favors insurance carriers and hospitals sabotaging their efforts.

There’s a saying in medicine: An ounce of prevention is worth a pound of cure. We need that prevention in healthcare as much as we need stay-at-home orders to flatten the curve of this pandemic. Screening for mental illness needs to be a regular component of primary care and prevention and those services also need to be vastly expanded now. The extreme limitations insurance companies place on mental health and addiction treatment need immediate reform. Mental health resources need to be free and easily accessible to all people, especially frontline healthcare workers, and not just a luxury for those with the “best” insurance.

The costs — social and economic — are borne by all of us. It costs three times as much to treat people who have a mental illness along with a physical disorder, to an estimate of $67.8 billion annually.1 Those at high risk for depression, 2 but who did not seek help, had the most healthcare costs over three years after the initial assessment — even higher than those whose health risk factors include smoking or obesity.3. Yet only about 41 percent of people who suffer from mental illness have sought treatment over the last year. Depression can interfere with cognitive and physical function, energy, reasoning, ability to communicate, and overall work performance, which in turn can lead to disability and unemployment — payments for which conservatives decry so ardently. The government says universal healthcare isn’t an option because of the cost, but so much money is wasted on the current formula that it makes no sense to continue without a complete overhaul. It’s time to put the burden of overpriced, overvalued healthcare back on the very government that thwarts our efforts to provide a basic human right to citizens through bullshit lawsuits aimed at dismantling any effort at reform. 

Let me be clear: I hope every person who has lost employer-based health insurance due to Covid-19 applies for Medicaid, which covers most healthcare costs if you are under the income level or unemployed.

Gross Neglect = Manslaughter

Sometimes we struggle with what to put as the underlying cause of death on a patient’s death certificate. Should it be the disease that initiated the sequences of events that lead to death, or is it the sequela? 

What is the direct cause of the United States having the most cases of Covid-19 deaths worldwide, despite having a head start on knowing about the coming outbreak? Early Trump press conferences that downplayed the coming pandemic caused deaths. Delays in shelter-in-place and travel restrictions caused deaths. Lack of appropriate PPE continues to cause deaths. Lack of widespread testing (which still remains problematic) continues to cause deaths. The Trump administration dismantling the U.S. pandemic response team in 2018 to cut costs continues to cause deaths. The lack of affordable insurance, primary care prevention, and healthcare as a human right in this country causes deaths. 

We can readily say that, at the very minimum 78,494 people have died in our country (as of this writing) as a result of Covid-19. The United States doesn’t lead the rest of the world on the number of Covid-19 deaths solely because of the virus.  After all, during this pandemic, not only patients but also healthcare workers are being killed as a result of gross government and system negligence. Perhaps it would be more accurate to list “manslaughter” as the cause of death on their death certificates.

Notes   [ + ]

1. Melek S.P., D.T. Norris, J. Paulus, K. Matthews, A Weaver, and S. Davenport. Potential Economic Impact of Integrated Medical-Behavioral Healthcare: Updated Projections for 2017. Milliman Research Report, 2018.
2. Goetzel R.Z., D.R. Anderson, R.W. Whitmer, R.J. Ozminkowski, R.L. Dunn, J. Wasserman, and Health Enhancement Research Organization (HERO) Research Committee. “The Relationship between Modifiable Health Risks and Health Care Expenditures: An Analysis of the Multi-employer HERO Health Risk and Cost Database. Journal of Occupational and Environmental Medicine 40, no. 10 (1998): 843-54.
3. Goetzel, R.Z., X. Pei, M.J. Tabrizi, R.M. Henke, N. Kowlessar, C.F. Nelson, and R.D. Metz. “Ten Modifiable Health Risk Factors are Linked to More than One-fifth of Employer-Employee Health Care Spending. Health Affairs 31, no. 11 (2012): 2474-84.

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