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On Compassion and Screaming Children

I had an interesting experience the other day.

While sitting in my corner of the (mostly quiet) ER where I work, I watched a family rush by my little cubby towards the nurse’s station, carrying a limp, naked child, face down.

That’s the sort of thing that will get me to stop playing Half-Life 2 immediately and go to work (Saved game be damned!).

It turns out this 18-month old toddler had accidentally tipped over a curious bottle causing a quantity of sulphuric acid to spill down his back and the back of his legs. An angry red topography of burned and twisted skin presented itself on this child’s back with clothing fibers and some of the chemical still visible on the worst of his burns.

At first, my job is to restrain this screaming, frightened child while the nursing staff and my ‘medic partner pour quantities of sterile water over his burns to wash away the acid. We find we don’t have enough bottles of sterile water on hand to do the job properly and the decision is made to move the child to a decontamination shower. I already have the most control over the squirming, screaming kid so I gather him up, careful not to touch his burns, and carry him to the shower.

On the way he gets a jab of morphine into his leg muscle. Probably a combination of that and the warmer water of the shower calms him down a bit. Up to this point he is such a whirlwind of pain and fear-induced screaming that his mother and father have fled the treatment area and the rest of the Emergency Department has fallen into an awed silence.

My entire attention has been taken up with restraining this child without breaking anything. This is not an easy task as he is a strong little Arab boy and I can feel the softness of his joints and bend of his long bones as he violently tries to escape this torture we’re inflicting upon him. A few times, despite my best efforts, I feel a wet crackle in his joints and feel his humerus bend beyond what an adult’s ever could.

Here’s the "interesting" bit: I don’t care.

I don’t mean to say that I’m not concerned that this child is injured, that he is in pain and that it’s my job to help alleviate his injury and suffering. I’m making a lot of effort to keep from touching his burns and to move my grip in response to his struggles so he doesn’t dislocate a shoulder or twist his little bones. 

What I mean to say is that the pain and distress that we are causing him as we treat his injury does not bother me. I don’t find myself distressed in the same way I am when I see needless violence, or some stranger abusing a child. The entire time I’m wrangling this kid so he can be subjected to this painful and necessary treatment, I’m murmuring something along the lines of, "Ok, buddy. I know, little man. It hurts, I know. It’s a bad deal, little buddy. Ok, little man." or  something like that. Clearly, some part of my mind recognizes that what we are doing to this child is horrible, frightening and painful. What surprises me is that I’m not upset.

Later, in the shower, I stood for 15 minutes, holding this child under the water as I got soaked and my back became more and more sore with the awkward angle I had to hold him due to his burns. I have to give mad props to my partner, Saggy (he’ll never read this). As soon as I said something about my back, he put both of his hands in exactly the right spot in my lumbar and braced me there with his own body, taking the pressure off my back, for the full 15 minutes. The next person that tells me that all Arabs are lazy is going to get punched in the face.

It was only later, after I had cleaned up, dried off and had a chance to think about that patient that my thoughts turned to how odd my reaction seemed to be. I was not upset. Is this one of the early signs of burnout? I always told myself that as soon as I stop caring, I’m out. I’ll sign on as a forecastleman on a sailing cruiser, change my name and never treat another patient again.

I wrote about this later in my journal:

I never want to hurt a child or scare or distress him. However, I can forcibly hold a toddler spread-eagled while cold water is being poured down the acid burns on his back. While doing that, I don’t feel distressed as he screams and struggles. It is almost as if I’ve become heartless to that distress because this treatment must be performed, no matter how distressing it is now, in order to avoid/reduce greater and longer-lasting pain.

After the incident, when I examine my feelings, I don’t find myself distressed by this any further. Is it because I don’t know the child? Would I feel so nonchalant if the patient was one of my nieces or my nephew? I imagine I’d be upset at their injury but would not hold back on the appropriate treatment to avoid distressing the child or myself. In short: I’d do the same thing. I just might feel a bit more shitty about it.

I know that I often must inflict pain on my patient in order to help her(or him). With adults, there is an understanding. They know a bit of how this works and can bear up in order to get the treatment they need. I can also talk and reason with an adult more than a child. I can warn them and apologize in advance. I can say things like, "This is going to hurt but I have to do it. Do your best to stay still."

Children don’t have that understanding. Communicating and reasoning with them is much more difficult if at all possible, depending on their age. They get scared and distressed even when we are not causing them physical pain. I know a few adults who are very much bothered by this. They can’t bear to upset children and see them in pain. I don’t enjoy pain in others, especially children, but I can see when it is a necessary evil and it seems to have no effect on me.

What am I getting at? I guess I’m afraid that I’m losing what I consider to be the most valuable personal component of my practice as a Paramedic: my compassion.

Then again, when I think about it, there’s a difference between being compassionate and being empathic. I can be empathic with the pain of this child and get upset, feel a small part of his distress inside myself and let it tear me up. On the other hand, if I’m truly compassionate then I put what’s right for my patient ahead of my own overwrought feelings of empathy and do the hard job of pinning down a child so we can effectively torture him for his own good. It may suck now, but the compassionate thing to do is treat his burns the right way and not let that treatment be inhibited by my own threshold of child distress.

I come away from this experience feeling that I’ve passed some sort of compassion test. It’s one thing to be feel what my patient is feeling and to empathize with him or her. If that empathy, if my own upset at their pain and discomfort, gets in the way of effective treatment, then I have taken the coward’s path and allowed my own personal feelings to get in the way of ultimately compassionate care.

Then again: Does it make me a good ‘medic that I’ll torture a child for their own good?

The next day seemed to be "Bring your kid to the Emergency Department" day. I made no less than 8 funny faces from inflated purple nitrile gloves for bright-eyed, barefoot kids running around the place.

Still thinking about it…


  • Hilinda

    One of the things I find most difficult on scene is a patient in severe (and loudly expressed) pain. The medics I admire most are able to do whatever is necessary to help that patient, and not let the level of distress keep them from doing their jobs. It isn’t that they don’t care- and it isn’t that YOU don’t care- it’s the ability to appropriately manage the scene both physically and mentally.
    Sometimes, what we do is painful. It’s not an attempt to cause pain, by any means, but in moving an injured person, sometimes it simply isn’t possible to do so without causing pain. I think that being able to go ahead and do what needs to be done as efficiently as possible serves the patient MUCH better than having to struggle with your own feelings about it at the same time, which can make things more difficult, and make them take more time, prolonging the very thing we want to be reducing. It’s definitely something I still need to work on.

    I’m not worried that you have somehow lost your compassion.
    The moment YOU stop questioning whether you have, THEN I’ll worry.

  • http://twitter.com/lizditz Liz Ditz

    Hi Maddog.  I’ve been in that space with my own children when they’ve been injured (thankfully, nothing as bad as acid burns!).  It’s not “lack of compassion” or even “lack of empathy”. It’s just that still place in space and time where you do what has to be done, calmly and efficiently, while providing reassurance.   

    I think it is the essence of compassion, really.

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