Diagnosis: Compassion Fatigue

Last Wednesday morning was a particularly busy morning. By the time 0900 rolled around, I had already seen 9 patients, rounded on them with the rest of the staff, and then discharged five of them. Of course, there was a lot of drama involved. One of the patients was a two star general in the Afghan National Army (ANA). His staff was anxious for him to leave and they seemed to think that the discharge process occurs with the snap of a finger. I wish that was the case. Two of my discharges that morning were American contractors that basically should never have entered a war zone. One was 78 years old on 14 medications who presented with chest pain. I am sorry my friend, but this is not the VA! The other one was 62 admitted to the hospital for a possible seizure or mini-stroke. Neither of these patients wanted to leave Afghanistan to obtain medical treatment consistent with the standard of care in the western world. After all, they make a small fortune here off the US government. I have seen this scenario play out several times before. I have learned to simply ask the patient straight out if they want to go to Germany for further treatment or not. The 78 year old reluctantly agreed. The 62 year decided that money was more important than his health. He signed a letter written by me stating that he understood fully that he could have a stroke and die in Afghanistan. Thi is called leaving "against medical advice" or AMA. It does not bother me too much anymore when patients do not follow our recommendations. After all, it is their body and it is their life.

Nevertheless, these interactions all put together left me exasperated. I went to the gym that afternoon to work out some of my aggression. 18 plus weeks working every single day was wearing me down for sure. Maybe I just needed to throw some weights around for a while. So, THERE I WAS on the bench press when it hit me. I realized what was really going on with me which is a very real phenomenon in medicine known as compassion fatigue. Simply stated, this is when a healthcare provider temporarily has lost much of his or her ability to provide compassionate care. The cause is usually an overwhelming workload or prolonged exposure to difficult situations. Here at Bagram we have both of these on a regular basis. As I continued to tone my pectorals via the butterfly curl, the thought occured to me that most of our staff probably carries the diagnosis of compassion fatigue as well. Let me give you an example of how this occurs.


Several months ago an Afghan patient whom I'll refer to as Ralph (not his real name but close enough) was transferred to the ward from the Intensive Care Unit. He was under my care for the next 8 weeks. Ralph had been hit by a car sustaining muliple facial fractures, a broken arm, and a broken leg. His jaw was wired shut and an artificial breathing tube was placed into his neck called a tracheostomy. Thus, he could not talk and he could not eat. It was a difficult situation to say the least. In addition, Ralph had a VERY low pain tolerace. He called out for pain medication constantly. He would wave his hand in the this distinctive limp wristed motion and then cry out in his high pitched voice. It did not take long for us to realize that Ralph could handle quantities of morphine that would permanently disable the respirations of an average human being. The problem was that Ralph had many reasons to have pain. After all, he was in the category of "All Blowsed Up" as our orthopedists like to say. In addition, he had parasites in his guts which we realized when he passed a foot long worm in his diarrhea one day. (I am NOT making this up) Ralph would become hysterical after surgery. One day our anesthesiologist was tired of it all. He gave Ralph massive quantities of pain medications, barbiturates, and sedatives. Ralph was not heard from for about 2 days, but then he was back with a vengeance. The calling out was incessant and unstoppable. It got to the point where there was almost no way to tell if the man really had a problem or not. This continued for weeks. We gave him a pain pump called Patient Controlled Analgesia (PCA) which usually does the trick for just about anyone. Not Ralph. I mentioned that Ralph had his jaw wired shut due to a broken mandible. It was supposed to be in place for 6 weeks. In the event of profuse vomiting which could cause him to choke to death, wire cutters were left at his bedside to cut the jaw wires. They were only to be used in an emergency. Well, one afternoon Ralph cut his own wires and then he tried to tell us that it was an accident. Ridiculous! In addition to his pain issues, Ralph also had several serious complications as he recovered from getting hit by a car. I'll spare you the details of all that. Several weeks ago the day finally came when Ralph was discharged. Fittingly, he asked for morphine as he was wheeled out the door!

To be completely honest, Ralph sucked the life out of me. He did the same thing to several of our nurses. These are good people who would react with justified anger because his wants and desires were just so out of proportion to what is realistic. When you have a patient like this in addition to all the stressors of dealing with blown up Americans and foreign patients with major communication barriers, it simply becomes overwhelming. We are all doing the best we can at this point. Everyone has their own coping mechanism. My colleague Dr. Mike Greene keeps his head down and ignores people. My style is a bit more flamboyant. In the end, we all need to dig very deep to make it through this. I do not think there is a a perfect solution to any of this other than taking it one day at a time.