An Interview with Dr. Angela Riccobono
Unmasking Rehab Medicine During COVID - Narratives & Portraits
Dr. Angela Riccobono is a psychologist in New York City, and works at Mount Sinai, treating patients with spinal cord injury (SCI) and more recently post-COVID patients. “The post-COVID patients on rehab, they’re doing much better thank god, but they’re also starting to have a lot of emotional issues,” said Dr. Riccobono. She said that similar to her previous patients who’ve been paralyzed from gunshot wounds, “What I’ve been finding is a lot of the same adjustment-related themes are applicable.” “You have people who are so anxious because most of them don’t remember a good portion of their ICU stay, and part of that’s because they were placed under sedation. So they’ve literally woken up on rehab and have no idea what happened to them. They’re 70 or 80 pounds lighter, their memories aren’t clear, some of them have delirium or are hallucinating, and they’re terrified. They don’t understand how their self-image changed so much. They ask their one visitor to show me pictures of themselves on their phones, and honestly they’re [physically] so different. Some people who are in their fifties look like they’re in their seventies. And they have so much anxiety about the future, the uncertainty of ‘not knowing if I’ll ever be how I was,’ and no one really knows.”
Dr. Riccobono said it’s especially difficult, because with her patients who have had COVID, unlike those with SCI, she can’t predict their course or prognosis. “I don’t have an answer, and consequently it’s just about living in the here and now with what you have, and looking for silver linings along the way.” Dr. Riccobono said that many of the patients she’s seen can’t stand up by themselves or walk. “It’s like they’re waking up into a surreal world, and no one can get them a lot of reassurance about direction.” Regarding the family members, Dr. Riccobono said, “They’re almost as traumatized as the patients because they felt so helpless.” The theme of helplessness also continued when she had her individual check-in sessions with doctors. Dr. Riccobono heard how in some cases, residents would tell the patients they needed to be intubated, but they had a low chance of being able to come off ventilation. If the patient decided they didn’t want to be intubated, the resident would help the patient call their family, and then the patient would say goodbye. Dr. Riccobono noted that these types of end of life care decisions are incredibly difficult for everyone involved. “None of us really know how to manage the future and uncertainty is part of life now for everyone, including the hospital staff” said Dr. Riccobono.
At the start of the pandemic, Dr. Riccobono said, “Everything happened so fast in New York.” Within a weeks notice they had to discharge all of their rehab patients to convert the rehab floors to COVID floors. Dr. Riccobono explained how difficult it was to discharge patients with spinal cord injury in a physically inaccessible place like NYC. They also couldn’t send their patients to nursing homes because of the risk of COVID there. Eventually they were able to discharge everyone, and started admitting patients with COVID.
She said how personally it was a stressful time because of the lack of knowledge about the virus and its transmission, and not knowing if they’d ever get the rehab unit back. She remembered being told to clear everything out of her office, and the day she left she had a shopping bag carrying her diploma. “And that was scary, on a personal level, like will I have a job at the hospital, will I be sick myself? I told myself what I tell my patients - take it one day at a time.” Dr. Riccobono said that their rehab residents had to pivot from rehab medicine to critical medicine practically overnight. At that point, it was clear that she needed to find a way to support the rehab residents, fellows, and attendings, but she said it was challenging to figure out how she could effectively help such a large and heterogeneous group. So she started by sending out a brief survey to figure out what people needed. Dr. Riccobono recalled how the PGY2s had a lot of anxiety and the PGY4s, who were about to graduate, had a lot of frustration, understandably. “Everyone was very overworked, working these very long shifts, and emotionally very overwhelmed. They were seeing like seven deaths in five days, 3-4 codes a day, and that’s not rehab, that’s not something they were used to seeing. So I didn’t want to overburden them with something else.”
When the survey came back with only a handful of respondents, Dr. Riccobono tried a different approach, discussing an article about talk therapy and COVID with the doctors during their regularly scheduled journal club. Initially she said, nobody wanted to talk and it wasn’t working. “Talking about it is like reliving it” one doctor told her. Dr. Riccobono said, “The feeling I got was that to do anything, to set up anything was a burden to them, and what they really needed, and I felt this in my heart, was that they needed to be nurtured and restored. They needed not to give anything.”
She did get interest in a weekly meditation and breathing group, and so she set up 8 pm sessions with a yoga and meditation instructor she previously used for her patients with spinal cord injury. “It turned out to be one of the most beautiful interventions that I could have imagined,” said Dr. Riccobono. In the beginning of the Zoom sessions, few people had their video on, but over time, as individuals became more comfortable, they turned their cameras on. “It was beautifully guided... [the instructor] does one on self-compassion, and things that residents really needed because they were so hard on themselves, they felt that they should be doing more to help people, but it was impossible. So to be able to do these self-compassion meditations and imagery, as well as really concrete breathing exercises that were amazing to calm your parasympathetic nervous system... There were skills they took away as well as a good nights sleep.”
Not only did the meditation help with stress relief, but it also served as a form of group support and bonding. After work, Dr. Riccobono said how “Everything was locked down, all of the things they did to have outlets were cut off, so they were bored, they were lonely, they were feeling helpless, and several of them got sick with COVID.” After the last session, she got feedback from the group that they wanted the meditation sessions to become a regular part of the residency program, even after COVID. Thinking about the residents, Dr. Riccobono said, “They’re my daughter’s age, they were fearless, they did something incredible and if I could have helped them in that little way then that was great.”
In addition to her work with the residents, Dr. Riccobono also treated patients with COVID on their converted rehab floors. Dr. Riccobono was able to do therapy sessions over the phone with patients who weren’t intubated, and she recalled some emotional conversations: “In one room was a mother and a daughter and they both had COVID, and the mother ended up passing away in the room. And the daughter was obviously overwhelmed. Through the conversations we had she would say ‘At least I got to be with my mother, if I wasn’t here I wouldn’t have been able to say goodbye.’ That was so hard.” Dr. Riccobono also worked with social work to support family members. She would look up patient charts and call their families to see how they were holding up, and she said how many of them were grateful to be able to talk to someone who knew something about their loved one.
“There was one case where, this was really touching to me, there was this sister who was the family member, and her brother had Down-Syndrome and he had COVID. He was pulling out his nasal cannula, he was very anxious and agitated, and when I talked to the sister she was like ‘Of course he is, he doesn’t have his red bag and his record player, his music’ and all of these little things.” She was able to arrange for the sister to bring these items to the hospital, have them disinfected, and brought to the brother’s room, and this really helped him. Dr. Riccobono later saw a staff update that patients with cognitive impairments were able to have one visitor, and after coordinating with the family and the nurse manager, the sister visited her brother. Having them together, Dr. Riccobono said, “Changed everything and he was a much better patient. He was refusing to eat and then when she would [visit] he would eat everything.”
When she wasn’t working with patients on the COVID unit or supporting residents, Dr. Riccobono also continued to treat her patients with spinal cord injuries, whom she discharged at the start of the pandemic. Through virtual programming, her patients with SCI had sessions every day: “they had their meditation on Monday, they had a fitness class on Tuesday, a seated exercise called ‘sitness’ with an Olympic trainer that volunteered his time, on Wednesday they had my regular support group, on Thursday they had a cardio workout with another trainer, and on Friday they had a peer support. By setting up a virtual class every day, it anchored them and gave them an exercise outlet. So that’s what I did on the other days.”
Now, with their rehab units re-opened, her patients with spinal cord injury can return for in-person rehab sessions. She said they filled up their units very quickly, with 50 admissions in one week. “It’s a new normal for sure, to see everybody in eye protective gear and masks. That’s been a whole other challenge connecting with patients. So it’s just been a bit of a different world. As a psychologist, I feel like you get so much information from a person’s face, from a smile... they can’t see me, they just see my eyes barely now.” But Dr. Riccobono also said, “In the healing of people, it’s whether they think you care, and even if you’re wearing a mask they can still sense [that].” Dr. Riccobono reflected, “As helpless as other people felt, I had the opportunity to be helpful, and that was a gift to be able to give to other people during this time. I felt so honored.”
R. Mayeda is a second year MD candidate at the Lewis Katz School of Medicine at Temple University in Philadelphia, Pennsylvania.