Table 2. Themes and Example Participant Quotations.
| Participant’s work context | Quotation |
|---|---|
| Theme 1: isolation | |
| Differing definitions of crisis | |
| Minnesota community institution | Almost nobody has been in [an official] crisis, but we’ve been in crisis. And you don’t declare formal crisis in one sort of system of measurement, and yet you’re not well. You’re sending a very, to me, a bad message, and inconsistent message. |
| California academic institution | They were creating a bunch of beds that have ICU capacity. But they weren’t really getting enough input from the frontline providers that would be able to tell you things like…this particular room will be a problem…because there’s all of these windows such that we can’t see any of the monitors…but this room over here actually is perfect. |
| Idaho community institution | All the intensivists felt [a crisis declaration] probably ought to happen statewide based on what we were experiencing on the ground. But…the administrators from our institutions did not feel we were in crisis standards.…The disconnect between what is said from administrative people and what is the experience on the ground.…At best, it feels like I’m being dismissed for my experience…at worst, I’m being gaslit with how they’re rewriting it. |
| Limited view | |
| California private institution | You get these pages.…“There’s 9 ICU patients waiting for an ICU bed.”…You wonder who else is going to be waiting if you move [your patient] to the ICU room.…I don’t know that situation, I can only advocate for the patients I’m taking care of. |
| California academic institution | We said, once we’re off service, we’ll come back just to set up the cyclers, because that support is needed.…But then other [physicians] were like, “Why can’t the nurses do it?”…It was just that complete lack of frame of reference. |
| California academic institution | Normally…I would say, “Hey…I think this patient needs CRRT.”…Now, I just go to the nephrology staff and, “Hey, I think this patient needs volume off. How can you get me volume off?”…Because I don’t understand the resource limitations that they’re seeing from their nursing and machines.…I don’t always understand their limitations. |
| California academic institution | [Fatigued clinicians are asking] “Are the other services in the hospital, how are they going to help me out?”…Not all of the problems in the hospital are visible to you, we tend to be a little bit myopic. |
| Responsibility without power | |
| Idaho community institution | The triage piece that was supposed to be in place never materialized.…We wrote the [crisis standards of care] guidelines in such a way that that distress was supposed to be distributed…[but] it fell pretty squarely on the point-of-care providers.…It was always the frontline person who was triaging, and quite frankly rationing…I had to do all of this by myself [and] I feel psychically distressed by it. |
| California academic institution | I got the sense that nobody was in charge.…I had to remind myself numerous times a day, ok, nobody is coming to our rescue. If we don’t do this right now, it’s just not going to happen.…It was the anxiety over the sort of vacuum of leadership. |
| Idaho community institution | [Patients] get stuck out in the rural hospitals.…[I say to the transfer center] “Find a way to get this patient here. Put him in the hall. I don’t care, we can find a way to dialyze him.”…And the transfer center people [say] “Let me talk to my supervisor.” Two hours later: “Supervisor says no.” So, you know, I’m pretty sure patients are dying out there. |
| Theme 2: in-the-moment decisions | |
| Official crisis declaration could be dissociated from clinical experience | |
| Idaho community institution | Everybody who wanted to be full code got at least a run of CPR. Regardless of their prognosis, even though we’re in crisis standards, even though epinephrine was on shortage.…We didn’t get any guidance from our office, so we were having to make these decisions on our own, which we weren’t supposed to. |
| Idaho community institution | I don’t believe that the crisis standards carry…a lot of weight from a liability standpoint. You know, I think that would be worked out in a court and…I’d rather not have that experience. |
| Idaho community institution | We never activated our triage committee to look at all the patients that might need resources and where they should stack in any sort of framework. It ended up coming, becoming either first-come, first-served or who was just lucky enough to get that first phone call in when a bed came open. |
| Clinical judgment applied to resource allocation | |
| California academic institution | Usually you might be more willing to try CRRT for 1 or 2 days before we say no. But here I was much more willing to be like, we won’t even try.…If this is all futile and also delays somebody else’s treatment by 4 hours, I’m like, this just doesn’t make sense. |
| Minnesota other type of institution | I had 2 patients who were on trachs, both waiting for LTAC, an LTAC bed opened up, I picked the one who was like 50, and I sent the 80-year-old to the floor. And that was me, in that moment, deciding I pick you.…There wasn’t a ton of thought. I mean, the younger patient clearly had better rehab potential than the older one. |
| Idaho community institution | We have put ICU patients in the PACU in addition to non-ICU areas that have been retrofitted with monitors, [but] we have not cared for any ICU patients without adequate monitoring.…We did not want to walk in on anyone who was dead. There are certain minimal standards. |
| Minnesota academic institution | We talked about what our contingency plans might be, like 12 hours on, 12 hours off [of continuous dialysis].…Well, it is rationing. Well, no, that really wouldn’t be rationing if we needed to spread it out to try to provide care to more people than we had machines. |
| California academic institution | I can’t really point to any example where I could have an identifiable [patient] outcome difference…[but] you kind of wonder, if a patient was, instead of being in a converted stepdown unit, or in a converted ED bay, and they were back up in my ICU…would their care be a little bit different? |
| Moral ambiguity | |
| Idaho community institution | That triage piece…trying to save the most lives…we certainly didn’t have a scoring system that would take into account all of these variables…[for example] a less-ill patient who was 4 hours away in a critical access hospital was in bigger trouble than a more sick person who was already with me.…That was tough to figure out the calculus, the formula for what was right. |
| Minnesota community institution | I called it ‘fuscarcity’…to send you to ICU with your end-stage cancer with comorbidities, it feels like it may be futile, it always kind of does. But now you have…this added pressure of scarcity to our existing ethical and moral dilemmas. |
| Theme 3: waning motivation | |
| Selflessness wearing thin | |
| California private institution | They feel like they’re getting taken advantage of.…You throw them in a pandemic where everybody feels morally obligated to work more, and to do more with less, you see people with the best intentions who want to do good work get really depressed and hopeless. |
| Minnesota community institution | It’s maybe the valorization or the calling. We’re here to protect our community, we’re here to serve, and to keep people from harm, to keep people from dying. That culture, it’s a good culture, [but] it’s just circumstances we never faced before. |
| Idaho community institution | I don’t think that in any foreseeable future would I take even 2 weeks [off] because of the burden that I would leave for the rest of my group. |
| Idaho community institution | Most of us go [to medical school] because of a sense of trying to do good in the world. So, to add on this distrust and disappointment, antagonism [among patients]. When you’re having to worry about if somebody’s going to come in and beat you up and try to shoot you because you’re not doing what they think is appropriate therapy. |
| Narrowing clinical roles | |
| California academic institution | To maximize physician resources…[it works to take an] assembly-line approach to patient care, where you maximize what people are really good at.…[But], in becoming that efficient, for me anyway, it removes a lot of the joy.…If you’re not able to keep what you’re doing somewhat light and sort of remind yourselves that this is anchored to being a human being, this becomes an intolerable job after a while. |
| California academic institution | [The trainees] had a very, very high level of burnout.…They were the ones who were writing the notes.…You remove the whole doctoring part where you basically are turned into this glorified administrative assistant.…The sense of feeling helpless was really difficult. |
| California academic institution | Never in my career had I ever thought about physicians in an inpatient setting as a resource.…If you strip away everything, what does this person add to patient care?…It was a little bit dehumanizing. Because it ignored a lot of the emotional side. |
| Staff as a limited resource | |
| Texas community institution | We ran out of oxygen. So they had to come and overnight figure out a way to bring in more tanks…doctors, administration, RNs, everybody we knew, plus people coming in like IT people, our mechanics were coming in working day and night trying to fix our hospital to where we could be able to help these people. |
| Idaho community institution | There’s a limit to how many patients I can see in a day.…It wasn’t physically possible to do, and then there’s rationing of me going on. |
| California academic institution | Bad call nights or long ICU stretches…it’s what we’ve all done.…The hard part is you know that tomorrow, the day after, that break is not really going to be there. And I think that’s where it starts to drag on you emotionally.…You can power through anything for a short period of time.…[but] this is not a sprint, this is a marathon, and I hate long-distance running. |
Abbreviations: CPR, cardiopulmonary resuscitation; CRRT, continuous renal replacement therapy; ED, emergency department; ICU, intensive care unit; IT, information technology; LTAC, long-term acute care facility; PACU, postanesthesia care unit; RN, registered nurse.