Sarah had been a nurse for about 5 years, most of which had been spent in the ER. For the most part, she loved working in this context. Sarah appreciated the opportunity to hone her core clinical skills, especially rapid assessment and trauma response, that would be beneficial for her career long term. She also prided herself on her bedside manner, and her ability to connect with patients and make them feel seen and heard in brief interactions under stressful circumstances. But despite this, she had to admit that the last year had been grueling, and increasingly she felt her patience wearing thin.

At 2:00 AM on a busy Friday night, EMS brought in Arthur. Sarah knew him well. Arthur was a regular in the ER, usually brought in intoxicated and belligerent. He often arrived in a state of severe self-neglect with an EHR (electronic health record) that documented years of untreated alcoholism and failed social work interventions. The staff knew his medical history better than they knew some of their own families', yet every attempt to connect him with long-term care had been unsuccessful. Arthur was non-committal when social workers tried to connect him with support, and it had been coming to light that he had been banned from several local shelters for policy violations.

His typical demeanor was generally respectful, but when intoxicated he had a history of verbally abusing the staff, and tonight was no exception. As Sarah tried to check his vitals, Arthur swatted toward her hand and shouted a slur at her. "Just get me a sandwich and leave me alone," he slurred, turning his back to her.

Sarah felt a wall go up inside her. She checked the monitor—his vitals were stable—and decided that she had had enough of Arthur. She had sick children in the waiting room and a trauma case coming in ten minutes. She moved Arthur’s gurney to the hallway, closest to the nurses' station but out of the way, and flagged his chart as "lowest priority." She told herself she was triaging resources effectively.

Two hours later, a newer resident on duty approached Sarah about the cases so far. When they got to Arthur, he mentioned that he was looking unusually sleepy. Sarah rolled her eyes, thinking he was sleeping off the alcohol and whatever else he may have consumed. "He’s fine," she said. “I see him all the time and he’s always like this. He’s sleeping it off, just like every other night."

However, when the shift change occurred at 7:00 AM, the incoming nurse couldn't wake him. A quick scan revealed Arthur had suffered a subdural hematoma (a brain bleed) from a fall prior to his arrival—an injury Sarah had missed because she assumed his behavior was purely due to intoxication.

Athur survived, but the guilt consumed Sarah. She realized that her "compassion fatigue"—the emotional exhaustion that comes from caring for difficult patients—had morphed into apathy. She had allowed Arthur’s hostility to sever her compassionate connection to him, causing her to view him as a nuisance rather than a patient with a potential medical emergency.