I took July off. I had finally had enough. I had a bone-deep weariness that no weekend off could shake. I cared little for my patients. I was short tempered with my family. I felt breathless. I slept badly. Old memories were haunting me.
I work frontline for the ambulance service in England. It’s been six years, including a one and a half year stint in London (the world’s busiest ambulance service). I’ve never been off work for stress.
I also trained in Cape Town, unfazed by it’s dubious auspice as the world’s murder capital. We went into townships to pick up casualties whilst wearing bulletproof vests. The lead clinician carried a gun.
The Coronavirus pandemic presented it’s own set of challenges within healthcare – beyond simply the direct results of the infection. At it’s peak, we simply didn’t have the resources to prolong already frail lives for another week or two. Instead we had to make ‘end-of-life care plans’ that would simply ease their passing at home. When we did take such patients in, a quick x-ray would reveal a hazy grey pleural mass and a terminal diagnosis.
Gone too were the stabilisers of work and education that keep so many depressive people buoyant. My first Coronavirus casualty was a teenage boy who had hung himself on the landing of the family home.
We worked on him for twenty five minutes with the family stood in bedroom doorways sobbing and hoping.
Me and the other two medics exchanged knowing glances; it was clear from the prominent lividity that he had died some time ago. Of course the family still held out some hope that he might pull through. It was a twenty five minute countdown to their extreme grief. I’ll never forget the sight of his burly father shaking him and shouting his name once we had stopped.
The week prior his school had shut and his mental health team had switched to ineffective phone counselling.
These difficult memories began to accrue. The ongoing cost of long, busy shifts and desolate circumstances became too high. I noticed my self caring less about my patients and even less about my own job security.
Post Traumatic Stress Disorder and Burnout are two situations when we have borrowed from our future mental health and the loan is recalled.
Towards the end of June I was afflicted by both.
Burnout has clinically defined symptoms:
- Feelings of exhaustion
- Poorer performance at work
- Mental detachment from one’s job
Tellingly, burnout syndrome was first diagnosed, coined and defined in a care setting. In 1970s New York, psychologist Freudenberger saw volunteers who worked with drug addicts become progressively jaded and fatigued. And there’s a key link here. We do indeed run out of care from time to time as compassion fatigue creeps in and saps much of our zest for life, our conscientiousness, that part of ourselves of which we often proudest.
In June I realised I felt little compassion for my patients and almost wanted to be fired. Odder still was being aware of this but not much caring about it. That’s what was scariest. It was like being drunk in a risky situation and being scared by how not scared you are.
I would argue that at the extreme end of compassion fatigue is PTSD. At its simplest it is when harrowing events cause us psychological and physical problems after the fact. It is now a familiar concept, thankfully, in culture and therapy and was recently written about in an insightful article on Quillette.com in relation to the pandemic. https://quillette.com/2020/04/14/moral-injury-and-the-battle-against-covid-19/
Here James Jeffrey argues that ‘moral injury’ is a useful term and way of understanding PTSD and I strongly recommend a read.
I think it’s a helpful phrase. As with using ‘compassion fatigue’ rather than ‘burnout’, it alludes to the ethical outrage sparked by extreme or persistent trauma. It engages with our complex, humane response to situations which go beyond clinical cause and effect and into our less tangible but equally influential paradigms of how the world should function. The tragedies which trigger PTSD and Burnout are an affront to the justice and dignity which we inherently presume of the world.
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