Saturday, April 10, 2010

compassion fatigue

a while ago i ended up in conversation with a psychologist. she mentioned the danger in her profession of compassion fatigue. the term struck a chord in me. she was referring to people moaning about how tough their lives were when their lives were nothing close to tough. it irritated her and she knew she needed to guard against this. i decided not to even mention to her what my compassion fatigue was like. it might have made her think less of me. i know i did.

he was no more than a common criminal of the south african variety. on that fateful day he decided to rob a small rural supermarket. i suppose he had gotten his hands on a gun and it seemed like the natural thing to do. anyway he entered the store with gun at the ready. he entered the outer door and was in the tiny area of about two meters between the inner and outer doors. just at this moment the owner of the shop was exiting the store and the two found themselves together in this rather cramped space. the owner immediately realised there was something amiss. this might have been due to the fact that he was staring straight down the barrel of a gun. then all hell broke loose.

the criminal didn't say a word. he started blazing away, spraying that tiny space with a hail of deadly lead. the owner dropped instinctively to the ground, drew his own weapon and fired one single shot. when all was tallied at the end, the shopkeeper had come off better. he had been hit in the arm but the damage was minimal. his shot, however had entered the criminal's head on the side just in front of the temple. it had then passed through both eyes and exited on the contralateral side at about the same place. the guy would be blind for life. i reflected that his terrible aim would now be even worse. it would definitely be a problem with his chosen profession.

the other case i thought of was a car thief i once treated. he got shot in the line of duty. he was innocently driving away at high speed in a car he had just liberated from the rightful owner when the police, who were on his tail, shot him twice. the one bullet took out his femoral artery. the other shattered his knee and tibial plateau of the other leg.

to cut to the chase, we cut his leg with the arterial injury off to save his life, he was that far gone. the orthopods stuck an exfix over the knee on the other side. and then he gradually recovered. at about this time i was transferred to orthopaedics so when he developed a pseudoaneurysm of the popliteal artery of his good leg i just heard about it via the grapevine. i also heard that they were going to give it some time before they operated, hoping that...well i don't know what they were hoping actually. anyway safely tucked up in the orthopaedic hospital it was not my problem.

then i learned that the orthopaedic surgeons were going to try to repair the tibia and i was going to be involved. step one was to get the patient down to the orthopaedic hospital from the main hospital. other than the usual administrative frustrations, he was finally loaded into an ambulance and brought down. it was the loading out that proved to be tricky.

as the ambulance drove into the parking area of the orthopaedic hospital the aneurysm burst through the skin and the patient started bleeding all over the place. he was rushed straight into theater and yet still by the time he got there once again he was flirting with death. the vascular surgeons were called and they arrived amazingly quickly. they then sort of looked at the leg for a while. after a few minutes of inaction they pointed out that the muscles of the leg were dead. it seemed that the pseudoaneurysm had gradually decreased the blood supply to the leg and by the time the thing had burst in the parking lot, the leg was already in a bad way. they then instructed us to remove it and left. the orthopaedic surgeon in turn instructed me to remove the leg and then he too left.

as i lopped off the limb i reflected on this twenty something year old who now had to face the challenges of life without a leg to stand on. it seemed sad. but then i realised my own car had been stolen only about a month before and it was not completely impossible that this person could be the very person who had stolen my car. it was the life he had chosen and the risks were part of that life. i struggled to feel sorry for him. besides, i reflected, he would no longer be so fast when running away from cops in the future.

the first time i realised i had compassion fatigue was around intermediates (roughly half way through specialising). i was warn down from cases like the two mentioned above. but there also seemed to be a run of gunshot wounds of criminals that i ended up trying to keep alive at unearthly hours with exams looming. in the end i just seemed to get sick of them and overly sceptical.

then one day i was required to go to some or other awkward social function. at that time my work was so all encompassing i didn't get out much and it showed. i ended us standing away from the normal people and whenever i was forced to speak to one of them, when i looked at them my mind kept on repeating one phrase over and over again.

"fresh meat."

i needed a holiday.


boz said...

That is all.

anne said...

What I am always curious about when I read stories like this, is what it's like later on the ward. The surgery lasts a few hours of what will be a long stay at the hospital. You have to talk to them at least once a day during rounds. Are these normal patients? Do that have families who visit them? Do they ever express remorse (or anything else for that matter) about their actions? Are they ever grateful to be alive? Do they feel sorry for themselves? Do they have any empathy with those around them? I know I am asking a lot of questions, but his degree of violence seems incredible to me. We have prisoners sometimes on the ward here, but they seem to be surprisingly ordinary. I can't say I've ever met an armed robber though.
You did write a post once about an intubated ICU patient who made a run for it... anyway, any thoughts you have about this--that is, the normality or abnormality of criminals-- are welcome.

Jabulani said...

Compassion fatigue is not limited to only the medical profession. So I have discovered...

Jayne said...

In our country today, several people will be murdered, raped or assaulted with the intent of murder. Joe Public soesn't understand the stress that the stabbings & I would think especially the child rapes, put on our doctors. During your years of study, you, like 99% of other docs, learned to 'switch off', which in itself can be a good or bad thing. I don't know how you cope sometimes, with the horrific things you have to deal with.
I applaud you sir.
Now have a dop & voetsak off on holiday! :-D

Bongi said...

anne mostly i don't speak to them too much. there are three posts i still vaguely remember that talk a bit about the days that follow.

basically put you get all sorts but in general once a psychopath, always a psychopath.

jayne, thanks. will do.

Compassion Fatigue Solutions said...

I'm a CF specialist who works with physicians and nurses in Canada. Different challenges, very similar challenges in some ways. I've compiled a ton of free resources on CF for people in health care, if you are ever interested in reading some more about it visit my site and blog:

Also some other good websites on the topic with free resources:

Anonymous said...

Thanks Fran├žoise, I am aware of these things, but often don't have the mental energy left to decide what to do to relax (LOL ?!?!), so I printed your "list" :o)


Smybinn said...

I guess many SA doctors and those abroad, both alike, face compassion fatigue at times. But in light of it all, sometimes I think this is a way of getting the vital job done at the end of the day... well that's purely opinion.

Hope you find some peaceful quiet time to rejuvenate compassion for the great work you do :)

Cockroach Catcher said...

Interesting post. Thanks.The Cockroach Catcher

Lockup Doc said...

Thanks for sharing this.

Trying to remain compassionate while providing criminals and psychopaths with good health care really is stressful and can wear a person down. And it's hard to discuss this issue with a lot of people because many of them either cannot relate to the situation, or they, themselves would rather see the criminals not receive any medical treatment.

Keep up the great work. I enjoy reading your stories.

VIVA TIVA said...

@ anne: they are abnormal patients, and never express remorse. I once had a guy who had raped and killed two little girls. Also with gunshot femur administered by the police. He was in theatre with shackles around his legs. Althoug I explained his options to him I was not overtly friendly, but certainly not rude either. He had the audacity to look me straight in the eye and tell me he didn't like my attitude towards him.

Albinoblackbear said...

I always struggle with compassion fatigue, as well as where the lines are compassion ought to be drawn.

Granted, I realize that I come from a country that isn't inundated with the same degree of violence as SA and the heartache that comes with it.

When I used to work acute psyche (before going to the darkside of emergency) we had the forensic assessment unit. Many criminals had to come through our unit until their acute psychosis settled and they could be moved to a proper institution.

While in the acute unit we often had time to actually go through people's old charts and see a fairly clear picture of their lives up to that point. So many of them had been abused terribly (tortured would probably be a better word for many) and of course came out the other side of it hardened criminals living in poverty with addiction or two.

I know I am a bleeding heart (which probably discounts my opinion on the matter almost entirely) but I think maybe just a hair of compassion ought to be considered for those that cause the harm as well. I am sure that many of them equate violence to survival, and it's all they've ever known. I think if you're choosing to be a criminal you've got no choices in life at all.

I am sure if I spent a week with you in your service Bongi I'd be burnt and jaded...I commend the challenges that you and your colleagues face on a daily basis.

(My apologies for the rambling comment.)

Bongi said...

albino, please never feel the need to apologise for rambling or any other form of comment here. your comments are always welcome.

i think there is a difference between the psyche criminal and the common of garden variety. if there is genuine psyche pathology then one needs to understand that a bit.

my sympathy for criminals that get it is two fold. firstly if he ends up being my patient i do all that i can for him. my treatment is as good as it woulf be if it was a normal law abiding citizen. however i do not shed tears for those living by the sword who die by the sword. if they chose that lifestlye and they cop it, so be it. it is good for the country for them to be eliminated and i feel nothing for them. whatever the circumstances when you take up a gun against your fellow man, what you are actually saying is that you value your own circumstances above the lives of your fellow humans. this is sociopathic behaviour and we all know the only cure for a sociopath is an acute dose of lead to the cranium. if the police administer this dose, that's fine by me. if they miss and wing the guy and he comes to me, i'll do my job to the best of my ability.

let me warn you that being soutyh african causes me to be jaded the other way, so please don't be too offended if my sentiments sound a bit harsh.

Albinoblackbear said...

Bonji--I wasn't offended at of the things I find amazing about your posts is the amount of compassion that still exists in you despite the things you see day in and day out.

And yes I suppose I agree that there are different realms and motivations for criminal behavior~psyche being its own animal.

I think compassion fatigue (or vicarious traumatization) is one of those ugly realities that people in healthcare like to pretend doesn't exist. I am really glad you chose to write about it.