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Standing AFFIRM

Standing AFFIRM

Acting on Compassion Builds Our Own Resilience

Barsotti, Christopher MD

doi: 10.1097/01.EEM.0000804964.50087.1f
    EP life, trauma, COVID-19

    I had the pleasure of taking care of an Army veteran on the day the United States withdrew from Afghanistan in August. Unfortunately, he was suffering from another long-term complication from an injury sustained during his second deployment there.

    He needed specialized care that my hospital couldn't provide, and his situation was further complicated by his insurance, which required us to coordinate his care with a Veterans Affairs hospital nearly three hours away.

    As we struggled with the care plan, insurance, and disposition—and wondered aloud why it's so hard to get care for veterans—we watched the chaos unfold in Afghanistan on the television at the foot of his bed. This irony was not lost on him, and he remarked, “Why on Earth did I go there and get this injury?”

    The U.S. surrender of Afghanistan was a psychological blow to many veterans, and it was painful to watch it sink in for this patient who was already compromised by a health condition. But as I started to consider adding a crisis evaluation to his ED visit, he turned the tide. Despite his current condition, he had a willingness to continue to serve, and he said, “I can't just sit here and watch this happen. I've got to help get those people out.” As impossible as the task appeared, he clearly had a plan in mind. I expedited his disposition and discharged him to follow up at a faraway hospital, but I was certain that there was something else he was going to do first.

    Now I know what raw resilience looks like.

    EPs Traumatized

    Like the military recruits who enlisted after 9/11 because they felt a desire to serve and protect our country, many of us joined emergency medicine. We want to be part of something larger than ourselves and serve society, and we try to alleviate the suffering that happens every day in our communities.

    Like many recruits, we didn't fully realize the trauma that awaited us in service to our work or the many different ways we could be physically, emotionally, and psychologically traumatized when caring for patients and families in distress. We also didn't know how, over time, even minor insults could degrade our resilience in unpredictable ways.

    Trauma is part of the package of emergency medicine, and the ED workforce is traumatized. Physician burnout, reflecting a large-scale loss of resilience, has been a growing concern in our profession and society for many years. It grew more acute during the COVID pandemic, which created a series of new and deeply personal opportunities for trauma. Our lack of knowledge about the virus and its pathophysiology compounded our fears of exposure, illness, death, and worse: bringing the virus home to infect our loved ones. The PPE shortage augmented these fears, and our impact as healers was hampered by our limited knowledge and resources in the early days of the pandemic. We suffered alongside families as we put their loved ones on ventilators and watched them die alone.

    The myriad traumas we experienced were at first buffered by an outpouring of support from our patients and society at large through the many thoughtful cards we received and a steady stream of donated meals from restaurants that were struggling and on the brink of closure. These kind acts cultivated our relationships with our communities and reinforced our broader mission as caregivers, helping to preserve our resilience.

    Now we trudge through the later phases of the pandemic, and our relationship with patients and society has become challenged in many ways. The primary tool we all use to serve our patients—science—is being questioned, if not denied, by large sections of society. As practitioners of science and advocates for public health, health care professionals are victimized by the very people we serve.

    The violence against caregivers in some places has created a need for staff to wear panic buttons. (The Washington Post. Sept. 30, 2021; Our social fabric is eroding, and we observe firsthand the epidemic trends of violence, suicide, substance abuse, and behavioral disorders play out among our patients, their families, our communities.

    Where do we go from here?

    Finding Agency

    The fabric of our health care safety net is stretched thin even in the best of times, but that fabric can be patched and reinforced by compassionate relationships, as we saw in the first phases of the pandemic. Last month in EMN, Stephen Trzeciak, MD, MPH, and Anthony Mazzarelli, MD, JD, MBE, clarified the difference between empathy and compassion. ( Empathy is detecting, feeling, and understanding another's pain and suffering, while compassion is taking responsive action to decrease the suffering of others, hence the equation: empathy + action = compassion.

    I observed this evolution from empathy to compassion in my veteran patient, but he revealed one more variable that made his resilience clear: agency over a problem. So I propose a derivation on Drs. Trzeciak and Mazzarelli's equation: compassion + agency = resilience.

    As the need in society continues to grow, abundant opportunities exist for action, and we can each find our way to grow and share our resiliency. We've seen some outstanding examples through the pandemic, including #GetUsPPE, a viral social movement led by a coalition of volunteer physicians, engineers, medical students, and others to help solve the PPE shortage for frontline workers. ( Almost daily now, ED staff resiliency grows when physicians and nurses individually address the pandemic and succeed in convincing appropriately selected ED patients to receive the vaccine.

    We can begin rebuilding and reinforcing the fabric of our safety net and the resilience of those of us who maintain it by individual actors finding agency and working to solve enormous problems one step at a time, for ourselves, our colleagues, our profession, and the communities we serve.

    Dr. Barsottiis the program director of AFFIRM at the Aspen Institute, a program dedicated to reducing firearm injuries in the United States through health-based, nonpartisan approaches. He is also a community practice emergency physician at Berkshire Medical Center in Pittsfield, MA, and a certified 4-H youth rifle safety instructor. Read his past columns at, find more information about AFFIRM at, and follow the foundation on Twitter@ResearchAffirm.

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