Web Exclusive

Amid the Pandemic, Social Workers Play Pivotal Role in the ED
By Claudia Boles, LCSW

A year ago, when the novel coronavirus transitioned to a full-force widespread reality, life suddenly began to feel like a modern-day version of the horrifying aftermath of the Titanic. A sense of helplessness and uncertainty was met with a degree of denial and a general lack of preparedness. Personal protective equipment and ventilators—our pandemic version of lifeboats and life vests—were limited. Some swam for their survival while others sank.

It was a mid-March, weekday evening in 2020 when our inner-city, tertiary care pediatric hospital emergency department (ED) clinical social work crisis team, consisting of around a dozen of us, warily celebrated Social Work Month together—in person—with a generously donated dinner from a neighborhood restaurant. That staple, family-owned eatery that had been in business and had nourished locals and health care professionals alike for decades closed its doors to indoor dining just a few days later and has been partially operating ever since.

That was the last time our team gathered as a group, face to face. Like most professionals, we began holding our monthly team supervisory meetings virtually. However, we hadn’t ceased for a moment with providing direct 24/7, in-person clinical crisis services to our urban hospital’s vulnerable patient population in our ED and Level I pediatric trauma center.

A couple of conflicted colleagues jumped ship early in the pandemic in an attempt to avoid coming into head-on contact with the virus within the walls of our medical institution. Could you blame them? My typically emotionally reserved husband, a pediatric specialty physician himself, working mainly in telemedicine from the safety of our home, was outwardly terrified by the prospect of my bringing home the virus. But he quickly recognized that we were now in a war zone and the idea of stepping up to serve was admirable.

Others in our group, without choice, were temporarily furloughed due to the hospital’s anticipated revenue loss brought on by the intentional slowdown of patient traffic and the halt on elective procedures. That left only a handful of us to hold down the fort.

Working in pairs in a small office just steps away from patients, we bonded through fear and fatigue as well as gratitude and a sense of duty. After all, we were the lucky ones who were spared while others fell into joblessness.

As pediatric ED clinical social workers, we’re accustomed to responding to a high volume of referrals in a fast-paced environment. We see a wide range of traumatic events and crises, ranging from automobile accidents and pint-sized digits demolished by Fourth of July fireworks to toddlers falling out of windows or into swimming pools. In more recent years, much of our focus has shifted to addressing mental health crises—severely anxious, depressed, and even suicidal youth—a foreshadowing of what was to come.

At the beginning of pandemic, we didn’t know what to expect. Families were on lockdown and indications were that children with COVID didn’t get as sick as infected adults. So, what would we be seeing as clinical social workers in the context of a pandemic? Some had a hunch that our child abuse referrals might increase dramatically.

The universal, global experience of the pandemic felt like a unifying one to some extent—like we were all traveling and sinking together on some part of that massive Titanic—as professionals and patients alike. But would those with first-class tickets be spared more than those traveling in steerage? As the weeks went by, the disparities became more apparent.

The remainder of March and April was eerily quiet and relatively slow as patients, for the most part, respectfully and thoughtfully kept away. This was a well-intentioned avoidance on the part of the hospital and community alike, but it didn’t go without consequence.

I recall meeting with a distressed caregiver of an infant who had sustained a skull fracture and an intracranial bleed. The patient had rolled from a sofa onto a hard-surfaced floor. This is a rather typical yet preventable injury for mobile little ones. But what was more unique with this patient visit was that this incident had occurred days prior to the patient’s arrival to the hospital. In a prepandemic world, most of our patients would have been brought through our doors within hours of the incident if symptomatic. I consoled the remorseful relative, who tearfully expressed that he had purposely waited to seek medical attention on behalf of his son for as long as he possibly could because he didn’t want to burden the hospital with what he initially hoped was a minor injury.

After my first few encounters with patients or parents with positive COVID tests (even though I knew that I was almost fully protected thanks to my face shield, N95 mask, and copious amounts of handwashing and hand sanitizer), I went from moments of feeling fortunate for having retained employment to periods of resentment. This was exacerbated when some of my supportive and well-intentioned friends who worked from home texted and chattered about their favorite new streaming series.

By summer, our patient volume and its typical garden variety of social work referrals started to pick up gradually —and then rapidly. By the fall, it felt like we were back in full swing. And, thank goodness, my furloughed friends were invited to return to their posts. Burnout began to set in quickly; many of us became grief-stricken ourselves as we paddled ferocious waters while others drowned.

What became most notable was that we were being called—continuously—to evaluate children and teens who were in a state of total despair, whether this was the primary or secondary reason for their hospital visit. Coping strategies such as socializing with supportive peers, playing sports, and visiting the skate park were temporarily suspended. Food became scarcer and so did the availability of mental health providers.

Some struggled with the fear of becoming ill themselves. Their panic attacks either mimicked or even induced respiratory distress—a primary symptom of the COVID disease.

Some were faced with the anticipation of possibly losing a loved one. Suddenly, my typical reality-testing reassurance interventions, e.g., “Now, what is the likelihood of that really happening?” were no longer relevant.

Others had actually lost loved ones—including their parents. Brief grief and bereavement counseling skills were in demand like there was no tomorrow. For many of these families, there really was no tomorrow.

Some were also distraught by the transition to distance/virtual learning and were struggling to keep up. As a parent of a high schooler whose grades and motivation had plunged, this was a parallel experience. If only I could better take my own advice and practice what I preached. In one patient’s discharge plan, I passionately and despondently typed, “Please advocate for your child’s teachers and counseling staff to modify instructional style and workload to better accommodate this student’s current state of emotional distress.” This was countertransference at its finest.

In prepandemic days, school staff frequently referred their high-risk students who had vocalized suicidal ideation for a safety evaluation, often requiring transfer to inpatient psychiatric care. Now, schools were no longer the primary referral source, as many of these patients had fallen off the radar, with their cameras turned off during instruction time or even bowing out from distance learning completely. These patients were now mostly brought in by paramedics or by parents in complete and total desperation as their children were contemplating dying by suicide or who had already made their suicide attempts. The volume of these types of patient situations skyrocketed while availability of community psychiatric hospital inpatient beds plummeted.

Because their moods dropped dramatically or they were so sedentary that they hardly expended any energy, some patients arrived with decreased appetite and significant weight loss. After all, meal preparation required motivation. Others micromanaged their caloric intake because this was their only conduit of control in a spiraling situation.

Teens were ingesting recreational substances such as marijuana and alcohol in higher quantities to numb their pain and boredom. Toddlers were accidentally ingesting their overextended caregivers’ medications.

And young parents—really young parents—began bringing their sick newborns and infants in for medical care. I hadn’t seen this many teen parents since my first experience in the social work profession back in the 1990s. Statistically, I’m not sure whether there has been an actual increase in infants born to teen parents during the pandemic, but it certainly seems like it.

So, what did the rescue ship bring to our sinking crew members? It brought us safe and effective vaccines as soon as they became available. It brought us revitalized clinical skills and an increased capacity for empathy. It brought us an unparalleled life experience.

Now March is upon us once again. This year, we’ll undoubtedly celebrate most of Social Work Month virtually. The theme? Social Workers Are Essential.

— Claudia Boles, LCSW, resides in the Los Angeles area with her husband—a medical geneticist—and their three children. She works as a crisis medical social worker in a pediatric emergency department as well as maintains a modest teletherapy private practice. Boles spends her downtime taking mindfulness walks and enjoying aromatic experiences (scented candles, perfume, and aromatherapy).