Portal de Periódicos da CAPES

Healing the Healer: Protecting Emergency Health Care Workers’ Mental Health During COVID-19

2020; Elsevier BV; Volume: 76; Issue: 4 Linguagem: Inglês

10.1016/j.annemergmed.2020.04.041

1097-6760

Ambrose H. Wong, Maria L. Pacella‐LaBarbara, Jessica Ray, Megan L. Ranney, Bernard Chang,

Healthcare professionals’ stress and burnout

As an emergency clinician, I've always felt ready for any challenge. What I've seen over the last 6 weeks has shaken my core as a doctor and human being. Wave after wave of acutely ill patients come in, and we bear witness to human loss and tragedy on an unprecedented scale. There is an implicit assumption that, as emergency clinicians, we would be calm and unflappable on the front lines to meet any disaster, no matter how grave. It feels entirely different when I see healthy adults my own age bringing in their gravely ill parents who then come back themselves in respiratory arrest mere days later. We struggle over which patient to intubate because we are faced with rationing of limited ventilators. We reuse face masks that are meant to be disposable because our hospitals may run out of them next week. How can we survive in this "whole of society" crisis? I used to say that I could escape work once I left the hospital, but the disease and its impact follows me everywhere I go. The desolate streets and empty restaurants and my inability to see loved ones amplify my helplessness against this relentless invisible threat. Over the last 2 weeks, I have admitted 3 of my friends and fellow emergency clinicians, all relatively young and healthy, into our own hospital. We were just at a potluck 3 months ago, and now I was at the bedside resuscitating one of my friends. Could I have ever thought that one day I would be intubating my friend? And who is to say I won't be next? —Emergency physician, New York, NY, April 2020 The World Health Organization declared the novel coronavirus disease 2019 (COVID-19) a public health emergency in January 2020.1Lai C.C. Shih T.P. Ko W.C. et al.Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): the epidemic and the challenges.Int J Antimicrob Agents. 2020; 55: 105924Crossref PubMed Scopus (3927) Google Scholar In March, the organization further characterized the outbreak as a pandemic with increasing infection rates around the world and within the United States.2Gates B. Responding to Covid-19: a once-in-a-century pandemic?.N Engl J Med. 2020; 382: 1677-1679Crossref PubMed Scopus (716) Google Scholar In addition to the physical mortality and morbidity directly attributed to COVID-19, this pandemic has broad psychosocial and emotional influence.3Wang C. Pan R. Wan X. et al.Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China.Int J Environ Res Public Health. 2020; 17: E1729Crossref PubMed Scopus (6290) Google Scholar,4Wong J.E.L. Leo Y.S. Tan C.C. COVID-19 in Singapore: current experience: critical global issues that require attention and action.JAMA. 2020; 323: 1243-1244Crossref PubMed Scopus (315) Google Scholar Advancements in global connectedness, digital technology, and media coverage have amplified both the spread of the COVID-19 infection and the intensity of associated psychological fear.5Chiolero A. Covid-19: a digital epidemic.BMJ. 2020; 368: m764Crossref PubMed Scopus (27) Google Scholar As front line health care workers in out-of-hospital and emergency department (ED) settings, we are particularly vulnerable to negative mental health effects from COVID-19.6Lai J. Ma S. Wang Y. et al.Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.JAMA Netw Open. 2020; 3e203976Crossref PubMed Scopus (4953) Google Scholar, 7Shanafelt T.D. Boone S. Tan L. et al.Burnout and satisfaction with work-life balance among US physicians relative to the general US population.Arch Intern Med. 2012; 172: 1377-1385Crossref PubMed Scopus (2252) Google Scholar, 8Mull C.C. Bowman W.R. A call to restore your calling: self-care of the emergency physician in the face of life-changing stress: part 5 of 6: physician burnout.Pediatr Emerg Care. 2020; 36: e25-e29Crossref PubMed Scopus (5) Google Scholar Our clinical environments face relentless increases in patient volume and acuity while we experience unprecedented physical and psychological hardship. In addition, conflicting and rapidly changing information regarding personal protective equipment fuels our ongoing fears of exposure and uncertainty about our own safety in the workplace.9Hoe Gan W. Wah Lim J. Koh D. Preventing intra-hospital infection and transmission of COVID-19 in healthcare workers.Saf Health Work. 2020; https://doi.org/10.1016/j.shaw.2020.03.001Crossref PubMed Scopus (172) Google Scholar,10Ong S.W.X. Tan Y.K. Chia P.Y. et al.Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient.JAMA. 2020; 323: 1610-1612Crossref PubMed Scopus (1568) Google Scholar We are asked to comply with novel practices to conserve or reuse personal protective equipment11Livingston E. Desai A. Berkwits M. Sourcing personal protective equipment during the COVID-19 pandemic.JAMA. 2020; https://doi.org/10.1001/jama.2020.5317Crossref Scopus (456) Google Scholar,12Bauchner H. Fontanarosa P.B. Livingston E.H. Conserving supply of personal protective equipment: a call for ideas.JAMA. 2020; https://doi.org/10.1001/jama.2020.4770Crossref Scopus (138) Google Scholar that are not part of the routine practice of our specialty, without any explicit consent. Allowing such expectations to be promulgated without any discussion is not only dubious ethically but also could be a major impediment to the care for future patients as physicians become sick or die as a result of ignoring these violations. Although many of us accept the increased risk of infection as part of our chosen profession, some may have concerns about family transmission or feel pressure to comply because of fear of losing their job, desire to be part of the team, and altruistic goals of caring for patients in need.13Adams J.G. Walls R.M. Supporting the health care workforce during the COVID-19 global epidemic.JAMA. 2020; 323: 1439-1440Crossref PubMed Scopus (1019) Google Scholar As a result of these issues, the COVID-19 crisis has shaken even the most battle hardened of our ranks. The unique paradox of simultaneous global digital interconnectedness and social and physical isolation that mark this epidemic has shifted our normal systems of coping. Across the world, we as frontline health care workers are being challenged both to grapple individually with our emotions and to work collectively to support resilience among our colleagues during this historic event. To help guide us, we can draw on lessons learned in previous pandemics and disasters regarding health care worker mental health.14Lancee W.J. Maunder R.G. Goldbloom D.S. Coauthors for the Impact of SARS Study. Prevalence of psychiatric disorders among Toronto hospital workers one to two years after the SARS outbreak.Psychiatr Serv. 2008; 59: 91-95Crossref PubMed Scopus (0) Google Scholar Many of us across the country have already moved through the phase of "anticipatory traumatic reactions," a future-focused form of distress and grief that has been documented for frontline caregivers in previous pandemics.15Davis E.L. Deane F.P. Lyons G.C.B. et al.Is higher acceptance associated with less anticipatory grief among patients in palliative care?.J Pain Symptom Manage. 2017; 54: 120-125Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar These reactions reflect a sense of fearful waiting, or even terror, about what the future may hold for us while an unfamiliar and uncomfortable quiet fills the halls.16Hopwood T.L. Schutte N.S. Loi N.M. Stress responses to secondary trauma: compassion fatigue and anticipatory traumatic reaction among youth workers.Soc Sci J. 2019; 56: 337-348Crossref Scopus (10) Google Scholar Acute stress disorder and associated symptoms will also likely be common; up to 20% of health care workers had stress-related disorders immediately after the severe acute respiratory syndrome (SARS) epidemic and September 11, 2001.17Biggs Q.M. Fullerton C.S. Reeves J.J. et al.Acute stress disorder, depression, and tobacco use in disaster workers following 9/11.Am J Orthopsychiatry. 2010; 80: 586-592Crossref PubMed Scopus (52) Google Scholar,18Bai Y. Lin C.C. Lin C.Y. et al.Survey of stress reactions among health care workers involved with the SARS outbreak.Psychiatr Serv. 2004; 55: 1055-1057Crossref PubMed Scopus (711) Google Scholar These acute psychological symptoms may lead to the development of long-term mental health problems among a particularly vulnerable populations of health care workers, including those of us directly involved with treating or caring for the critically ill or diagnosing their diseases.6Lai J. Ma S. Wang Y. et al.Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.JAMA Netw Open. 2020; 3e203976Crossref PubMed Scopus (4953) Google Scholar Posttraumatic stress disorder (PTSD)—characterized by greater than 1 month of intense intrusive or reexperienced thoughts (eg, nightmares or flashbacks), avoidance of trauma-related reminders, alteration of mood and cognition (eg, self-blame, negative views about oneself or the world), and heightened sense of threat19Fullerton C.S. Ursano R.J. Wang L. Acute stress disorder, posttraumatic stress disorder, and depression in disaster or rescue workers.Am J Psychiatry. 2004; 161: 1370-1376Crossref PubMed Scopus (378) Google Scholar—is the most common long-term consequence of disaster exposure among health care workers and first responders.20Neria Y. DiGrande L. Adams B.G. Posttraumatic stress disorder following the September 11, 2001, terrorist attacks: a review of the literature among highly exposed populations.Am Psychol. 2011; 66: 429-446Crossref PubMed Scopus (214) Google Scholar,21Armagan E. Engindeniz Z. Devay A.O. et al.Frequency of post-traumatic stress disorder among relief force workers after the tsunami in Asia: do rescuers become victims?.Prehosp Disaster Med. 2006; 21: 168-172Crossref PubMed Scopus (59) Google Scholar We know that our risk for PTSD will increase with factors that are inherent to COVID-19, such as the intensity of exposure, the perception of danger, and the perception that the experience is unexpected or uncontrollable.22Shalev A. Liberzon I. Marmar C. Post-traumatic stress disorder.N Engl J Med. 2017; 376: 2459-2469Crossref PubMed Scopus (485) Google Scholar We also know that high rates of PTSD after disasters reflect our repeated direct and indirect traumatic stress during patient care.23Zimering R. Gulliver S.B. Knight J. et al.Posttraumatic stress disorder in disaster relief workers following direct and indirect trauma exposure to Ground Zero.J Trauma Stress. 2006; 19: 553-557Crossref PubMed Scopus (65) Google Scholar,24Chang B. Can hospitalization be hazardous to your health? a nosocomial based stress model for hospitalization.Gen Hosp Psychiatry. 2019; 60: 83-89Crossref PubMed Scopus (30) Google Scholar Previous research suggests that exposure to a disaster situation may also have positive psychological effects for some of us. Improved adaptability to stressful stimuli and posttraumatic growth (positive emotional and psychological changes in response to trauma) have been reported after major crises.25Brooks S. Amlot R. Rubin G.J. et al.Psychological resilience and post-traumatic growth in disaster-exposed organisations: overview of the literature.BMJ Mil Health. 2020; 166: 52-56Crossref PubMed Scopus (155) Google Scholar Factors associated with these positive responses among health care workers included adequate preparedness (eg, training and crisis preparation), greater social support (particularly familial and collegial support), and adaptive coping behaviors that involve acceptance rather than avoidance (eg, taking charge of the situation and viewing obstacles as positive challenges).26Brooks S.K. Dunn R. Amlot R. et al.Social and occupational factors associated with psychological wellbeing among occupational groups affected by disaster: a systematic review.J Ment Health. 2017; 26: 373-384Crossref PubMed Scopus (53) Google Scholar Although the COVID-19 pandemic shares similarities with previous disasters and epidemics, it also has unique stressors. As health care workers on the front lines of COVID-19 response, we in emergency medicine struggle with a uniquely high risk of asymptomatic transmission,27Bai Y. Yao L. Wei T. et al.Presumed asymptomatic carrier transmission of COVID-19.JAMA. 2020; 323: 1406-1407Crossref PubMed Scopus (3099) Google Scholar significant knowledge gaps about the viral pathophysiology,28Cascella M, Rajnik M, Cuomo A, et al. Features, evaluation and treatment coronavirus (COVID-19). Treasure Island, FL: StatPearls Publishing; 2020.Google Scholar and an unprecedented local and federal breakdown in supplies of personal protective equipment.11Livingston E. Desai A. Berkwits M. Sourcing personal protective equipment during the COVID-19 pandemic.JAMA. 2020; https://doi.org/10.1001/jama.2020.5317Crossref Scopus (456) Google Scholar In regions of the country with the highest rates of infection and severe shortages in resources, we are exposed to difficult and often unprecedented decisions about rationing of care,29Emanuel E.J. Persad G. Upshur R. et al.Fair allocation of scarce medical resources in the time of Covid-19.N Engl J Med. 2020; https://doi.org/10.1056/NEJMsb2005114Crossref PubMed Scopus (2116) Google Scholar, 30White D.B. Lo B. A framework for rationing ventilators and critical care beds during the COVID-19 Pandemic.JAMA. 2020; 323: 1773-1774Crossref PubMed Scopus (566) Google Scholar, 31Rosenbaum L. Facing Covid-19 in Italy: ethics, logistics, and therapeutics on the epidemic's front line.N Engl J Med. 2020; Crossref Scopus (664) Google Scholar causing a sense of moral injury that often leads to clinician burnout.32Dean W. Talbot S. Dean A. Reframing clinician distress: moral injury not burnout.Fed Pract. 2019; 36: 400-402PubMed Google Scholar Social distancing and other unique aspects of this pandemic further remove us from our normal coping mechanisms, leading to a perfect storm of psychosocial stress. Many of us are experiencing financial strain from paradoxic reductions in income at the moment of highest risk because of overall decreases in ED volume. Finally, COVID-19 is the first pandemic to occur in an age of deep digital integration, exposing us to constant streams of unfiltered clinical information and reinforcing sentiments of angst and despair.33Depoux A. Martin S. Karafillakis E. et al.The pandemic of social media panic travels faster than the COVID-19 outbreak.J Travel Med. 2020; 27: taaa031Crossref PubMed Scopus (642) Google Scholar Each of these elements potentially amplifies our anxiety, hopelessness, and fear, as well as our long-term risk of mental health consequences.6Lai J. Ma S. Wang Y. et al.Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.JAMA Netw Open. 2020; 3e203976Crossref PubMed Scopus (4953) Google Scholar,34Dong L. Bouey J. Public mental health crisis during COVID-19 pandemic, China.Emerg Infect Dis. 2020; https://doi.org/10.3201/eid2607.200407Crossref Scopus (447) Google Scholar Already, Chinese health care workers involved in the COVID-19 response have reported high rates of distress (70%), depression (50%), anxiety (45%), and insomnia (34%); the highest risk factor for distress was being a frontline or emergency care health care worker.6Lai J. Ma S. Wang Y. et al.Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.JAMA Netw Open. 2020; 3e203976Crossref PubMed Scopus (4953) Google Scholar These rates of health care worker distress are surpassing those reported after Ebola, SARS, and other pandemics.35Shultz J.M. Baingana F. Neria Y. The 2014 Ebola outbreak and mental health: current status and recommended response.JAMA. 2015; 313: 567-568Crossref PubMed Scopus (248) Google Scholar,36Chua S.E. Cheung V. Cheung C. et al.Psychological effects of the SARS outbreak in Hong Kong on high-risk health care workers.Can J Psychiatry. 2004; 49: 391-393Crossref PubMed Scopus (304) Google Scholar Strategies to counteract stressors and challenges during this outbreak will continue to evolve, but efforts to improve well-being and ensure our needs are met are rooted in psychological principles that remain unchanged. Specifically, stress management techniques that use principles of trauma-informed care have already been adapted by the National Center for PTSD to address the well-being of health care workers during COVID-19. Trauma-informed care recognizes the presence of trauma symptoms, common in this current epidemic, and promotes a culture of safety, empowerment, and healing by providing support services in a way that is accessible and appropriate to individuals who may have experienced trauma.37Fischer K.R. Bakes K.M. Corbin T.J. et al.Trauma-informed care for violently injured patients in the emergency department.Ann Emerg Med. 2019; 73: 193-202Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar For example, brief training interventions, such as guided mindfulness exercises, can help us focus awareness on the present moment and include acceptance of internal experiences.38Smith S.A. Mindfulness-based stress reduction: an intervention to enhance the effectiveness of nurses' coping with work-related stress.Int J Nurs Knowl. 2014; 25: 119-130Crossref PubMed Scopus (117) Google Scholar These cognitive interventions have been successful in reducing perceived stress in high-risk populations such as first responders39Joyce S. Shand F. Lal T.J. et al.Resilience@Work mindfulness program: results from a cluster randomized controlled trial with first responders.J Med Internet Res. 2019; 21e12894Crossref PubMed Scopus (51) Google Scholar and resident physicians.40Goldhagen B.E. Kingsolver K. Stinnett S.S. et al.Stress and burnout in residents: impact of mindfulness-based resilience training.Adv Med Educ Pract. 2015; 6: 525-532PubMed Google Scholar,41Minichiello V. Hayer S. Gillespie B. et al.Developing a mindfulness skills-based training program for resident physicians.Fam Med. 2020; 52: 48-52Crossref PubMed Scopus (16) Google Scholar It is essential for our specialty to establish a mechanism by which health care workers have early access to confidential, professional behavioral health resources for further support during this crisis.42Tatebe L.C. Siva N.R. Pekarek S. et al.Heroes in crisis: trauma centers should be screening for and intervening on post-traumatic stress in our emergency responders.J Trauma Acute Care Surg. 2020; https://doi.org/10.1097/TA.0000000000002671Crossref Scopus (13) Google Scholar Digital and technologic platforms are an important adjunct to typical behavioral support, especially given the unique challenges of social distancing. Some mobile applications may provide support in a more informal manner. Although further evidence is still necessary, we highlight the government-developed PTSD Coach (https://mobile.va.gov/app/ptsd-coach), a program based on cognitive behavioral therapy. Principles that has evidence from a randomized controlled study.43Kuhn E. Greene C. Hoffman J. et al.Preliminary evaluation of PTSD Coach, a smartphone app for post-traumatic stress symptoms.Mil Med. 2014; 179: 12-18Crossref PubMed Scopus (190) Google Scholar,44Ruzek J.I. Kuhn E. Jaworski B.K. et al.Mobile mental health interventions following war and disaster.Mhealth. 2016; 2: 37PubMed Google Scholar This application offers PTSD symptom tracking and skills to cope with common distress reactions such as anger, anxiety, hopelessness, and sleep problems, and may be helpful to some of our distressed colleagues. Others may also wish to consider resources such as telepsychiatry, which is feasible and effective for a variety of mental health diseases ranging from depression to anxiety.45Ruskin P.E. Silver-Aylaian M. Kling M.A. et al.Treatment outcomes in depression: comparison of remote treatment through telepsychiatry to in-person treatment.Am J Psychiatry. 2004; 161: 1471-1476Crossref PubMed Scopus (286) Google Scholar Training in mindfulness can easily be found online, and applications such as Headspace are now free to all US health care providers with a National Provider Identification number. We also turn to one of the most well-known psychological theories, Abraham Maslow's hierarchy of needs,46Benson S.G. Dundis S.P. Understanding and motivating health care employees: integrating Maslow's hierarchy of needs, training and technology.J Nurs Manag. 2003; 11: 315-320Crossref PubMed Scopus (122) Google Scholar to illustrate a potential path forward based on established psychological principles (Table). It provides a hierarchic context for how individuals prioritize their needs, starting from the most fundamental (physiologic and safety) and progressing to more abstract and complex needs once more basic ones are met (love and belonging, esteem, and self-actualization). Many clinicians are finding solutions through a purposeful focus on positive and adaptive behaviors that address each of our needs in Maslow's hierarchy. Taking walks outdoors as the weather becomes warmer, maintaining sleep and exercise schedules, and reconnecting with friends and family can help our bodies feel whole. These simple actions also help us overcome feelings of social isolation, restlessness, and loneliness. As more basic needs are adequately met, we may be able to channel some of our frustrations with the pandemic into constructive efforts to combat the outbreak. For example, some of our colleagues are synthesizing up-to-date knowledge about disease management or creating innovative solutions for equipment and clinical work flow.TableAbraham Maslow's hierarchy of needs46Benson S.G. Dundis S.P. Understanding and motivating health care employees: integrating Maslow's hierarchy of needs, training and technology.J Nurs Manag. 2003; 11: 315-320Crossref PubMed Scopus (122) Google Scholar for frontline clinician stressors and potential solutions in the COVID-19 era.Maslow's Level of NeedExamplesCOVID-19 ConcernsRecommended StrategiesLevel 1: physiologicFood, sleep, physical and mental healthExtra workload demands around COVID-19 preparation and treatmentPhysical strain of protective equipment (dehydration, heat, exhaustion)Housing needs during isolation/quarantine periodsInadequate or disrupted sleep patternsPhysical symptoms of COVID-19 disease for health care workers who contract the virusIndividualTime for basic bodily care and refreshment/relaxation and stress-management breaksAvoid maladaptive behaviors with negative physiologic effects (eg, excessive alcohol, prescription drugs)Physical health and fitness (exercise programs, walking outside, mobile applications)Online mental health technologies (telepsychiatry, mobile applications, PTSD Coach)AdministrativeProvision of respite for staff members requiring isolation (eg, housing, child care)Supplementation of readily available water and nutritious food while on clinical dutyCareful attention to individual work schedules to maximize rest and sleep between shiftsFacilitation of testing and treatment for individuals who develop symptoms or become illVirtual wellness and information town hallsEarly and confidential recognition, detection, and referral for treatment of psychiatric symptoms (eg, cognitive-behavioral therapy)Level 2: safetyPersonal security, financial security, resourcesFears of personal safety around infection and lack of adequate personal protective equipmentLack of clarity around viral transmissibility (airborne versus droplet)Concerns for job security and potential debt, especially if an individual becomes infected with COVID-19Feelings of being undersupported and underequipped to provide safe careIndividualPeer consultation and supervision of PPE donning/doffingAdministrativeAlternative strategies to produce/distribute PPE (local manufacturers, donations, recycling)Clear and consistent messaging and shared decisionmaking with health care workers regarding infection rates, risk, and strategies to minimize riskContingency plans for health care workers who cannot work during quarantine period or if they fall ill after contracting COVID-19 to provide job and financial security without negative consequencesLevel 3: love and belongingFriendship, family, social connectednessPossible separation from family membersRisk of exposure to loved ones, especially those who are at high riskPhysical isolation from friends, colleaguesIndividualIncrease peer social support with regular contact with colleagues, family, and friendsSeek out and share social support virtuallyAdministrativeAcknowledgment and affirmation of health care worker stressors and concernsCreation of specialized collaborative partnerships or teams focusing on COVID-19Online-based group support networks and mental health checksResources for significant others and family members of health care workers to support their loved ones during epidemicLevel 4: esteemRespect, status, self-determination/control, fairnessPressure to serve as source of definitive information for nonmedical family and friendsConstant pressure to maintain clinical acumen with increasing volume and acuityEthical challenges in triaging resources (ventilators, staffing, bed capacity)IndividualLimit worries to actual (rather than anticipatory) threatsFoster a spirit of patience, fortitude, tolerance, and hopeChannel concerns through productive output (scholarly efforts, peer coaching, teaching, educational materials on COVID-19)AdministrativeCreate specialized ethics teams/protocols for information and mentorship in decisionmakingUse patient-centered resources for difficult decisionsHighlight exemplary behavior and celebrate individual contributions and effortsCreate clear, transparent, fair, equitable, and accessible policiesLevel 5: self-actualizationDesire for higher achievementTension between public health priorities and individual patient careAdvocacy for larger systems changes to minimize effects of the epidemicIndividualFocus on efforts within one's individual controlAccept situations one cannot changeContribute to productive efforts for changeAdministrativeSharing of information across institutions/systemsPeer mentorship for clinical, administrative, and academic duties related to COVID-19Creation of volunteering, innovation, and service opportunities to support response efforts (eg, creation of new devices/tools, clinical strategies)PPE, Personal protective equipment. Open table in a new tab PPE, Personal protective equipment. We also suggest established strategies that our clinical leaders may be able to use to help health care workers reduce distress.47Hobfoll S.E. Watson P. Bell C.C. et al.Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence.Psychiatry. 2007; 70 (discussion 6-69): 283-315Crossref PubMed Scopus (961) Google Scholar Top among these is listening and validating our legitimate anxiety and fears, giving us an opportunity for direct input and shared decisionmaking regarding policy changes that affect our level of risk and workload at the bedside. We encourage our leaders to develop strategies that can serve as a foundation for us to improve needs higher in Maslow's hierarchy. For example, careful attention to health care workers' work schedules will not only address physiologic needs but also allow for sufficient rest, thereby strengthening our meaningful work, our esteem, and our sense of self-actualization. Ultimately, these interventions require that we unite as a community to build broad and structured approaches that support all emergency personnel during this critical time of need. Emergency medicine is society's safety net, serving patients irrespective of socioeconomic background, medical complexity, or disease severity. As emergency personnel and frontline health care workers, we have become vulnerable to the behavioral and mental health fallout resulting from this global crisis while straining to maintain this safety net and serve our patients. Efforts to reduce or prevent our acute and chronic stress while promoting positive, adaptive ways to face our ongoing challenges may seem impossible, but experiences in previous epidemics suggest that we can successfully enhance our resilience.