Alleviating Panic Symptoms When Wearing Protective Equipment: Lessons from the Military Frontlines

Women in a mask and protective covering
Photo by Marine Corps 1st Lt. Tori Sharp
By Tim Hoyt, Ph.D.
April 17, 2020

Among the iconic images from the heroic response to the coronavirus pandemic are the faces of medical professionals bruised by personal protective equipment during long hospital shifts. As anyone in the military who has done field training exercises in MOPP4 gear knows, this equipment can be extremely uncomfortable. In some cases, breathing through personal protective equipment can lead to panic attacks and other claustrophobic symptoms. Acute symptoms of this kind can lead to noncompliance with guidelines for wearing personal protective equipment, or could result in a member of the medical team being temporarily unable to provide medical services to those in need.

As discussed in an earlier blog, researchers at the Walter Reed Army Institute of Research (WRAIR) have recently developed an intervention to address these kinds of overwhelming symptoms on the front lines. The iCOVER protocol is a 6-step, peer-based intervention that takes about a minute to complete. The protocol helps return soldiers to baseline when a combat stress reaction causes them to freeze.

The six steps follow the acronym iCOVER:

  • Identify the individual experiencing an acute stress reaction.
  • Connect with the individual by speaking their name, making eye contact, and holding their arm.
  • Offer commitment by letting them know they are not alone.
  • Verify facts with two to three simple questions to get their thinking kickstarted (e.g., “What hospital is this?” and “What section of the hospital are you in?”)
  • Establish an order of events to ground them in the present moment by stating what happened, what is happening, and what needs to happen in three simple sentences. (e.g., “You donned your PPE. You are checking the seal. We are about to check on a patient.”)
  • Request action of the individual to restore them to purposeful behavior (e.g., “Double check the oxygen saturation on that patient and report back.”)

Although the iCOVER protocol originally was developed for operational units, WRAIR and PHCoE have learned it is relevant for providers on the front lines of the COVID-19 pandemic as well. Recently, several providers from hotspots across the nation have asked about using the iCOVER protocol with hospital staff who begin to feel panic symptoms due to trouble breathing in personal protective equipment, or become acutely overwhelmed for any reason. These experiences from the field suggest that iCOVER may be a rapid, effective way to help medical teams keep their teammates in the fight. This is a great example of how techniques developed for Combat and Operational Stress Control can play a role in the current fight against the coronavirus pandemic.

The iCOVER training video is available on WRAIR’s YouTube channel, and the complete training module with detailed trainer notes is available on request from the Psychological Health Center of Excellence. WRAIR is developing a specific version of iCOVER training for medical staff and you can learn more in this COVID-19 iCOVER-Med fact sheet. Also, check out the WRAIR COVID19 Leadership Checklist for Mitigating Team Stress.

Dr. Hoyt is a former Army psychologist who is chief of Psychological Health Promotion and supervisor of the Combat and Operational Stress Control mission at the Psychological Health Center of Excellence.


The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.


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