If You Listen Closely

If you listen closely, amid the roar of the emergency department, you can hear it. It’s there in the delivery of coffee for the team, the name of a pet, a shared chuckle between nurse & patient. If you look closely, you can see it. A moment of pause after the diagnosis, a warm blanket, a tea. Should you ask them afterwards, they’d say, ‘It’s just what we do.’ But it’s never ‘just.’ Like sparks of light in a dark night, these moments of compassion permeate the grief, trauma and heartbreak that exists in any place where people find themselves on the worst day of their lives. These things may look small, but in fact, they are everything.

If you have found yourself in this profession, chances are you’re compassionate by nature. But in a system where there never seems to be enough staff, equipment, or time, making a meaningful difference can feel like trying to light a candle in a downpour. If you’ve ever wondered how much you can give to those around you before the tank runs dry, you are not alone. We pull back in the name of self-preservation. Say things like ‘I just have nothing left to give today.’ Those days are hard. Feeling like another cog in this inequitable health system is hard. When will we get to make the difference that we dreamed of?

‘How do you do it?’ I once asked my boss, who is always calm, kind and on top of things no matter how wild the department is. When I think about the kind of consultant I want to be, it’s her. She paused and smiled at me, like she had all the answers but was deciding if I was ready to hear them. I waited, unmoving. Her advice came out in stories (do you see why I like her?). Stories about being thrown in the deep end, about lifeless children and generations of trauma. Stories about empty medication cupboards, about school bus rollovers and watching colleagues becoming numb to the horror of another life gone too soon. ‘You have to remember’ she said, ‘that you didn’t create any of this. It was all here before you and will continue to exist whether you are here or not.’ She told me about a time the hospital power had failed on a busy nightshift, when her team had already run out of cannulas. With nothing left to give, she’d handed out warmed bags of fluid to patients as makeshift hot water bottles. ‘You just help as best you can, using whatever resources you have.’

We meet people on their worst day, at their most anxious and terrified. In Australia, there are often lots of things we can do for people, but the way we do these things matters. Did you know that patients get fewer PTSD symptoms after life threatening emergencies if they feel their resuscitation team genuinely cares?¹ Does our team genuinely care? Of course we do. I see it all the time. It’s in the way you get down to eye-level with a patient when you take their story. It’s the extra packet of biscuits for their wife at the bedside. I hear it too, in the softness of your voice when you call a family member to say they should come in, tonight. In your gentle encouragement of an uncertain intern. It flows so easily when we have the time, but as we are squeezed tighter and tighter by four-hour rules, ramping and KPIs, caring can start to feel like a luxury we don’t have room for in the budget.

We hear so much about incivility in medicine. Its impacts, its ability to cripple the learning experience and lead to patient harm.² But for how many years does an act of compassion reverberate? How far does one kind action go? In my first rotation through ED as an intern, a consultant took 15 minutes to coach me through a fascia iliaca nerve block. It’s a procedure done to prevent pain in people with a fractured hip. She could have asked a registrar to do it, but she set aside that moment for me. It was the best thing of the entire term. I felt seen and supported, finally more than just a line on the roster. In the years that have followed, I’ve relieved the pain of many patients through this procedure. When the time came for me to help one of my juniors learn it, I was so excited for their sense of accomplishment that I was unprepared for the realisation when it hit me – it felt even better to teach it.

Quite recently, I’ve realised that I’ve had the equation wrong the whole time. I was somehow led to believe that caring depletes us, that anything we ‘give’ to our patients and colleagues must be at the expense of our own wellbeing. But the devil is in the details or, in this case, the definition. In one study³, researchers scanned the brains of people they’d trained in empathy—the feeling and understanding of another person’s emotions – and found that the pattern of activation overlapped with the experience of pain. However, when they trained them in compassion—which involves actively taking steps to alleviate another’s suffering— the areas of the brain activated were those associated with positive affect and reward. It makes so much sense. It’s that feeling you get when you’re able to reassure new parents that the rash on their baby is completely normal. Or when you can finally explain the diagnosis to a patient in a way they understand. It’s why so many emergency docs love reducing shoulders, or pulled elbows. We get to help, and it feels fantastic. The evidence suggests that these things help us, too. The simple act of doing something to help others, rather than just feeling their pain, boosts our sense of purpose and counters the effect of stress on our emotional wellbeing.⁴

What we absolutely don’t need is another lecture on how to care. Caring is the reason most of us ended up here, propping up a broken system, taking stories and weaving them into diagnoses and treatments. Taking stories and holding them. Taking stories and trying to re-write them. What we need is permission – from the system, but also from ourselves—to spend that extra 40 seconds at the bedside⁵ or take five minutes for some teaching. To let ourselves share a joke with a colleague without feeling guilty for slacking off. These things aren’t extra, they’re the base on which everything else in built.

So let this be your permission, the start of your evidence-base for compassion. That thing that protects us just as much as it benefits our patients and colleagues. It’s already there in your department. You’ll hear it if you listen closely. Seek it out, amplify it, don’t let the system squeeze it out of you. To all those leading the way, keep going. You are making more of a difference than you can possibly imagine.

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1. Moss J, Roberts MB, Shea L, et al. Healthcare provider compassion is associated with lower PTSD symptoms among patients with life-threatening medical emergencies: a prospective cohort study. Intensive Care Med. 2019;45(6):815-822.
   
   
2. Youngson GG, Flin R. Patient safety in surgery: non-technical aspects of safe surgical performance. Patient Saf Surg [Internet]. 2010 Mar [cited 2021 Oct];4(4). Available from: https://doi.org/10.1186/1754-9493-4-4
   
   
3. Klimecki OM, Leiberg S, Ricard M, Singer T. Differential pattern of functional brain plasticity after compassion and empathy training. Soc Cogn Affect Neurosci. 2014;9(6):873-879. doi:10.1093/scan/nst060
   
   
4. Raposa EB, Laws HB, Ansell EB. Prosocial behavior mitigates the negative effects of stress in everyday life. Clin Psychol Sci. 2016;4(4):691-698.
   
   
5. Fogarty LA, Curbow BA, Wingard JR, et al. Can 40 seconds of compassion reduce patient anxiety? J Clin Oncol. 1999;17(1):371-379.

Photo by Cristian Escobar on Unsplash