The introduction of vaccines last winter provided a glimmer of hope for health care workers otherwise exhausted by caring for critically ill COVID-19 patients. After months of uncertainty, doctors and nurses finally saw a path for how they might end the public health crisis.

But now, some nine months later, caregivers are confronting the stress of responding to yet another COVID-19 surge with deeply conflicting emotions — their compassion for the sick at the bedside is accompanied by private moments of frustration over the suffering that might have been avoided had more patients opted for immunizations.

It's all been a recipe for what doctors and nurses are calling "compassion fatigue," and it's left many wondering whether they can continue managing burnout while responding to the call of duty.

"By and large our patients are unvaccinated, and so much of the suffering … feels preventable," said Dr. Jacob Lyons, a critical care specialist at CentraCare in St. Cloud. "That's where the heartbreak comes from …"This didn't have to happen. It doesn't have to keep happening. And it looks like it will get worse."

It's hard to know just how much burnout has contributed to staffing problems at Minnesota hospitals in recent weeks. Even though the health care industry sees it as a growing problem, state officials say burnout hasn't been the primary driver for hiring in the past.

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But after more than a year of treating pandemic patients, many health care workers are talking about leaving the field altogether and some are retiring early. This summer, caregivers have tried to reduce hours or take needed leaves and vacations. Some have transferred out of intensive care and other critical units, searching for less stressful work.

"I'm not going to lie, it takes a lot of hours of the day to try and fill those shifts," said Chris Boese, the chief nursing officer at Regions Hospital in St. Paul.

Hospitals are meeting the challenge and providing good care, Boese said, but the latest surge means patients again are lining up in the ER, awaiting beds upstairs. Health care providers are wired to help patients, she said, but many are disappointed because they "feel like we're battling in a war and there's no end in sight — and patients could have done something about this."

Frustration and sadness

Jessica White worked as an ICU nurse during Minnesota's first three COVID waves. In June, when her unit at North Memorial Health Hospital finally got quiet, White was able to reflect on the experience and opted to make a change.

"I just decided I did not want to go through another wave of COVID, dealing with all that loss and sickness," said White, 45, of Plymouth. "I'm not a crier, but I would cry all the time."

White now works in a hospital unit that cares for patients before and after surgery. It's better for her mental health, she said, and sense of well-being. Even so, every now and then White pulls a shift back in the intensive care unit.

The scenes she's witnessed recently of COVID patients struggling to survive are a painful contrast to her joyful memories of the spring, when she volunteered giving shots at mass immunization events in Minneapolis. Having watched the pandemic arrive in the ICU, White believed her work in the vaccine clinic was helping bring about its end.

"Now it feels like it's not hopeful — like this is never going to end because people are choosing to not get vaccinated," she said. "We've got people there who are so sick with COVID … and they're intubated and sedated and their family members still don't want to get vaccinated. For me, it's frustration and it's sadness."

Working in health care means caring for patients who smoke or eat unhealthy foods, or who are sedentary or miss doctor visits — all of which can contribute to illness. Doctors and nurses are practiced at setting aside judgment so they can do everything possible to help the sick no matter the cause, said Dr. Bryan Williams, a pulmonary critical care specialist at M Health Fairview.

Health care providers are doing everything they can to help COVID patients who are unvaccinated, too, Williams said, yet they find it hard to understand the decision to not get immunized with a vaccine that's been shown to be safe and effective.

"It's something easy that can be done," he said. "Stopping smoking is not easy. Avoiding some of the social determinants of health — not everybody has access to health care.. But this is something we've worked really hard to make universally available," he said. "While some people still struggle to have the means to find it and get it and understand it, we also know that a number of people have made the choice not to."

Williams, who is the chief well-being officer at M Health Fairview, added: "It's not personal when they come in — it's just frustrating, in general. And it's a real blow to our compassion, as it were. It's hard to keep going."'

Struggling for hope

As case counts rise and patients with COVID and other health problems fill her ICU, nurse Ericka Larson Helling has felt torn by the text messages she regularly receives as the hospital looks to fill nursing shifts. She doesn't want to strand colleagues at work who need help, but recognizes the need for time away, too.

Larson Helling says she has some understanding for people who opt against vaccination. Even some nurses, she points out, believe they're adequately protected because of previous infection. But if people aren't going to get immunized, they must be vigilant about stopping the spread in other ways, she said, like wearing masks and avoiding crowds. Yet many seem to deny COVID-19 is real.

"I didn't sign up to have people disbelieve the health care professionals — that we do have biology and science backgrounds and an understanding of vaccine," Larson Helling said. "For those folks who are kind of Google MDs — I don't mean to insult the public in any way, but I wish you could see what I see."

Amy Forkner is retiring later this year at 55 — much earlier than she ever expected. A nurse at St. John's Hospital in Maplewood, she works in the operating room where patients are intubated, a procedure that she says brings the chance of aerosolizing SARS-CoV-2. The experience with personal protective equipment has shown that health care workers can work without getting sick, but it weighs on you, Forkner said. Of the delta variant that's driving the current COVID-19 surge, she said: "It's scary. You just don't know. It's so unknown. It's like we're starting the beginning of the pandemic all over again."

Through it all, there is still compassion for those sick with COVID-19, said Lyons, the CentraCare physician. There's also sympathy, he said, for what doctors view as misunderstandings about the risks of the vaccine or alternative treatments pushed by some.

"We will still take care of anyone that comes to us," he said. "We're just really hoping not to have to."

At the same time, the profession is struggling. Burnout, mental health concerns and fatigue have driven nurses from intensive care units. Some nurses and doctors have entered counseling, Lyons said, for what is, effectively, ongoing post-traumatic stress disorder.

After summer's hopeful start, the jump in COVID-19 patients during August was a terrible shock, he said. Caregivers now are fearful about what coming months will bring, particularly with large gatherings like the State Fair and the reopening of schools.

"I think the reality is that we're struggling for hope," Lyons said. "We have never been more joyful than when the vaccine got rolled out. The thought was that … it's not over, but we've got a way to win. And the fact that that hasn't happened is the most defeating part of this last wave …"We are, today, at an unexpected nadir of hope."

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