Act III: Paging Nurse Empathy

This series was started by an odd confluence of events: I saw the performance of Dr. Horrible, and shortly thereafter I ended up on one of those random Web-walks exploring doctors’ and nurses’ blogs. It started with ER humor, but I found myself drawn into blogs by regular floor nurses, like my mother.

Medical humor is often black humor, grisly humor created by people faced with a Sisyphean task (people do keep getting sick, after all) that all too often leads to compassion fatigue. What do you do, after all, with the third person this week with an iPod in a body cavity? (Have the Nanos made that any less of a problem, I wonder?) Or the thousandth person who comes to urgent care for antibiotics for their cold? Or the ten thousandth? And nurses get the worst of it: they are the front line of care for patients and families (nurses care for whole families, not just the person in the bed – just ask), which puts them at the interface between the medical system – usually doctors – and the people who are actually in pain, or dying, or depressed, or confused and combative, or throwing up, or all of the above. All too often, doctors shove the results of their compassion fatigue down onto nurses, and families who are in unfamiliar settings with scary things happening to loved ones amplify their anxiety up, sometimes in the form of defensive anger. Nurses get the brunt. And who else gets a college degree to spend most of their days wiping butts?

One strain of the anger and frustration that I saw on some blogs really started to bother me. It’s often hard for nurses to deal with people with major health issues that are caused or exacerbated by the person’s behaviors. Noncompliant diabetics who are obese, and going blind, and having amputations, sometimes in their 30s, are some of the most vivid examples. Diabetes is a terrible disease, but it is largely controllable – if. If the person will make the changes. If the person can make the changes. If the person isn’t trapped by the culture of the Diabetes Belt combined with, and including, her own personal circumstances.

The point when attitudes go beyond black humor, beyond compassion fatigue, is often marked by one signature phrase: “My tax dollars at work.”

It’s absolutely true that a lot of the people who need repeated health care for major medical problems are on public assistance, whether that’s disability, welfare, Medicaid, or combinations thereof. And so, yes, when a nurse is frustrated beyond words with a patient who is drinking herself into an early grave with sugared sodas, and as a result is so sick that she’s on disability and Medicaid for the repeated procedures that won’t halt the course of the disease and may not even delay it much, it’s true, the nurse’s tax dollars are paying for that person’s living allowance and medical care.

But the subtext is more than that. The subtext is usually: “I wish I wasn’t paying for that person.” Sometimes there are varying degrees of anger wrapped up in this, or greed (“My taxes wouldn’t be so high if…” If what? We just let them die?) or other unexpressed factors, but a lot of it is compassion fatigue, especially when there are degrees of personal responsibility involved. It’s exhausting to see people contributing to hurting themselves, especially when you know (but they may not) that there are alternatives, there are other choices they could be making. From your point of view, those choices may even look simple, or easy, or at least the only rational path to take.

And the nurses, especially, are tired of being the superheroes trying to swoop in and save people from the trap of the Diabetes Belt. They’re being superheroes from 7a-3p, 3p-11p, and 11p-7a, day in, day out, sometimes with the same patients, over and over again, up to their elbows in crap and paperwork and staffing cuts. They wish that some of their patients would stand up for themselves, and not be falling into the superheroes’ waiting arms over and over again. Their arms, and their hearts, are getting tired.

But the existence of the Diabetes Belt shows that this is about culture, not just about personal choice. If we want to change this, we’re going to have to change the culture. What kinds of food are available? Affordable? Accessible? What do families teach their children to eat? To cook? To enjoy?

It’s not that individuals don’t have responsibility, it’s that individuals don’t bear their responsibilities alone. We have to change the context and create opportunities for different kinds of responsibility from the top down, as well as demanding it from the bottom up. Because really, the “top” and “bottom” are parts of the same social, economic, and cultural web of interactions, and no one person can change the web alone. Even a superhero.

Even a villain. When he was trying to become a villain, Dr. Horrible believed he could make a difference. He believed that what he worked for would have the results he intended. He was horrified to discover otherwise: “You think your world’s benign, and justice has a voice, and we all have a choice…” When confronted by that horror, he realized that he had forced himself into a heartless position, and he allowed it to empty him out, he accepted that he had become what he hated. He only truly became a villain when he put on his nemesis’ gloves.

We are confronted with similar tragedies every day in the Diabetes Belt. What will we do in response? Will we embrace the role of villain, willingly becoming part of the problem, withdrawing and becoming heartless? When black humor crosses the line into suggesting, even implicitly, that we should withdraw public assistance from people, that we don’t want helping those people to be “our tax dollars at work,” that advocates one course of action. That’s Dr. Horrible’s course. That’s picking up the black gloves.