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Keeping On
September 3, 2010  |  by Deborah Rudacille

Sometimes waking life resembles a nightmare. Picture a graduate student walking through a Romanian orphanage that has hundreds of cribs. In each of them are two or three emotionally or physically malnourished infants, many crying or catatonic, with the student slipping from room to room like a ghost. For six hours she just wanders, never encountering another adult, unable to comfort the babies because there are simply too many of them.

Half a world away, another young woman steps into a different kind of bad dream. She is 17 years old and training to be a licensed practical nurse. She doesn’t know how to do much, so in the hospice unit to which she has been assigned she mostly talks to her elderly patients about their lives. The next day she comes back eager to continue the conversations, only to find that the patients have died. One right after the other, over and over again.

Or every Monday, clinic day, a physician sits across his broad desk from two or three new patients and tells them they have amyotrophic lateral sclerosis (ALS) and what that means—they have a terminal neuromuscular disease that within two years will take from them their ability to walk, to speak, and ultimately to breathe. Some immediately begin to cry, or scream uncontrollably. Others take the news stoically, but the physician knows that at some point, an hour from now, two weeks from now, they are going to absorb the news and fall apart.

Such is waking life for many Johns Hopkins health care professionals. These are the doctors, nurses, psychologists, and other caregivers who, day in and day out, treat some of medicine’s most challenging and often tragic cases. They are not unmoved by the pain and grief they encounter in their work, and bearing witness day after day puts them at risk for what psychologists call vicarious traumatization. (Health care workers more likely call it burnout or compassion fatigue.) Research shows that an individual’s susceptibility to vicarious traumatization depends on a host of factors, including personal history, coping strategies, and support network, combined with the type of work they do and

the sort of clients they serve. Those who find their calling in these professions stick it out by adopting—consciously or unconsciously—a variety of protective strategies, and by doing so, manage to maintain an emotional equilibrium.

One strategy is to bear in mind that they have the capacity to make an awful situation better. Laura Murray, now an assistant professor in the Department of International Health at the Bloomberg School of Public Health, was the young graduate student who found herself all but helpless in the Romanian orphanage shortly after the 1989 fall of the Ceausescu regime. She gets through tough times on the job by reminding herself that she has something to offer—and that the traumatized children she encounters in her work will benefit from her involvement in their lives. She works with children around the world who have experienced severe trauma: sexual abuse, sex trafficking, HIV and AIDS, combined with poverty and other stressors common in low-resource countries. She (along with her Applied Mental Health Research team) has also helped set up counseling programs for torture victims in Iraq, women raped in Congo, and Ugandan youths abducted and forced to fight and/or provide sexual services to soldiers. It’s heavy stuff, she admits. When people at parties ask what she does, she thinks, “Hmm, what do I say here? It’s such a buzz kill.”

She says, “Because I’m a clinician, because I’ve treated kids, always in my head is the way you watch kids turn around and improve. We know very effective ways to treat kids who have been through trauma. I’ve seen it and experienced it so much myself that [when I need to] I envision it. That’s one of my real tools when I get into the field or when I’m supervising and I hear these awful stories. I know these people are going to get better if we give them the right treatment.”

In public health, feelings of helplessness can be compounded by the fact that clients are dealing with a host of issues beyond the health care professional’s power. “It’s not just the trauma or the HIV deaths in the family, or the poverty,” says Murray. “It’s everything. We’re going in to fix one thing, but we can’t fix the legal system, we can’t change the poverty or so many other factors.” Even with all of her awareness and experience, there have been times, she says, when working with a child, she’s had to “leave the room for 20 seconds to take some deep breaths, to come back in and be effective. It’s tough. It’s really tough.”

No one makes a moral commitment out of a need to cope with an emotionally exhausting environment. But a sense of moral vocation is another source of resilience. Clare Ferrigno was the 17-year-old encountering the realities of hospice care for the first time. Now a nurse practitioner at Johns Hopkins’ Sidney Kimmel Comprehensive Cancer Center, she recalls those days. “While all my peers were taking care of the same patients for days on end, I was getting a new patient every day or two because I just couldn’t seem to keep mine alive. After about six weeks I said, ‘Can you please get me off of this unit? Because I am killing Baltimore.’” Nevertheless, she has been working with terminally ill patients ever since she began training as an LPN in 1982. “At that time, hospice was just taking root in the United States,” she says. Though it would take some time for her to understand that she had found her calling, she early on assumed a sometimes-controversial role as an advocate for patients. She challenged the visiting policy of institutions where she worked by calling in family members to sit with dying patients in the middle of the night. She criticized the lack of pain management and symptom control and other policies that she felt harmed patients. As a mission she adopted speaking for those unable to speak for themselves, and she’s been doing it ever since as an RN working in chronic care units, hospice, and home health, and in her current job at the Kimmel Cancer Center.

Illustration by Noha Woods


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