My tour of duty in Afghanistan introduced me to the Stoic Philosophers, and a new way to see our specialty.
Keep yourself simple, good, pure, serious, unpretentious, a friend of justice, god-fearing, kind, full of affection, strong for your proper work. Strive hard to remain the same man that philosophy wished to make you. Revere the gods, look after men. Life is short. The one harvest of existence on earth is a godly habit of mind and social action.
– Seneca The Younger
Three mortally wounded men lay motionless in my sight, their blood emptying as quickly as we tried to stop it. It was early June, and “the fighting season” had begun. Our readiness was palpable. We worked persistently on these men inside an emergency department that was constructed of just the right amount of plywood and sheet metal. This particular resuscitation galvanized my understanding of the phrase “anyone, anything, anytime.”
In May of 2014, I deployed with the 31st Combat Support Hospital to Ghazni, Afghanistan. I was tasked with two General Surgeons, an Orthopedic Surgeon, and an Anesthesiologist to replace physicians from an existing Forward Surgical Team.
As our Chinook helicopter split through the mountains of eastern Afghanistan, I watched in awe as fields of green valleys repeatedly gave way to rugged snow-capped mountains. We landed uneventfully – my first of many prayers answered – and we began to familiarize ourselves with the base and the emergency department. Suddenly the radio let loose a high-pitched, unambiguous tone. The alarm indicated that we had three inbound casualties, all with multiple gunshot wounds. These were the good guys. They had been ambushed while clearing mines from a nearby field.
My mind raced as the flight medics carried the soldiers in. Was I ready? Was I capable of caring for this severity of trauma? Did I have the emotional capacity to handle the stress of treating soldier after soldier in a mass casualty event? I had just graduated from residency within the last year. What would I do without an attending or a fellow colleague to help if I needed it? How would I deal with the uncertain fate of constant mortar fire? How should I get comfortable with the possibility of my own death?
These internal fears waxed and waned throughout my deployment – to my great frustration – and eventually led me to dive into the ancient writings of Seneca the Younger and Marcus Aurelius. These Roman philosophers of the 1st Century devoted their lives to the constant refinement of character, judgment, and morality. Aurelius was once Emperor of Rome and Seneca was an advisor to Nero, also a former Emperor of Rome.
These men preached a philosophy we refer to as Stoicism. Stoicism’s central theme is recognizing the things that you can control and the things you cannot. Be happy with what you are given in life. Do not be controlled by the desire for pleasure or the fear of pain. Marcus Aurelius stated, “all you need are these: certainty of judgment in the present moment; action for the common good in the present moment; and an attitude of gratitude in the present moment for anything that comes your way.” His words were aimed to help the reader live a life that minimizes anxiety and leads to clear action.
The three soldiers who lay at my feet an hour after my arrival on base were tachycardic, hypotensive, and now quiet. In reflection it was impossible and untimely for me to address the question of my preparedness. Aurelius however, would answer the question with another question: “What is there in this work which I cannot endure or support? You will be ashamed to make any such confession.” The last three years of repetition on cadavers, mannequins, and real-life trauma patients had absolutely prepared me. The moment, however, felt bigger than I could have imagined, and it was in such a different atmosphere. Looking back, my perception at that time was not reality. I was mistakenly creating a fearful situation in my mind. Residency was nothing else if not the practice of supporting one’s fatal pathology. I was prepared for this moment. All I needed to do was “give vigorous attention to the performance of the task in hand with precise analysis, with unaffected dignity, with human sympathy, with dispassionate justice – and to vacating the mind of all other thoughts”.
I went to Afghanistan with the hope of being an emergency medicine physician who would have the opportunity to save the lives of soldiers and citizens. The Stoic perspective says that fear keeps pace with hope. Keeping my mind occupied with the “hope” of how I wanted to perform in a certain situation or how many people I might help recover from the tragedies of this war fueled an anxiety I had no control over. In one of Seneca’s letters to his student Lucilius, he writes, “If you cease to hope, you will cease to fear”. Seneca is not using hope in a God-centered sense but with reference to controlling emotion.
Aurelius’ guidance, given over 2000 years ago, seems to fit perfectly in this moment. He advocated for “no more jerking to the strings of selfish impulse, no more disquiet at your present or suspicion of your future fate.” It is of little use to be mentally manipulated by things that have yet to occur or moments I have no current control over. There would be multiple times when I needed help from my team, but that moment was not as troubling or fearful as I had worried. In fact, I learned and practiced medicine in ways I had never considered because of others’ willingness to help me in situations I had never before encountered.
The Stoics, by definition, are very comfortable with their mortality. They proclaim, “do not despise death: welcome it. Death is just one more of life’s seasons, so accept it and welcome it as you would any other”. All the Stoics discuss it at length, with the humble goal of maintaining an attitude of composure in a moment when most would become overwhelmed with despair. Equally as refreshing is the subtle humor used in Stoicism. If you have concern for things you will miss, consider the things you won’t miss, because “you will find it quite easy to face death if you stop to consider the business you will be leaving and the sort of characters which will no longer contaminate your soul”.
The lessons I learned over 8000 miles away came full circle in my local community emergency department. I was caring for an 87-year-old gentleman who was hypoxic and in the midst of an exacerbation of his chronic congestive heart failure. He was slightly dyspneic, slightly tachycardic, and completely lucid. I repeatedly attempted to admit this gentleman with a room air oxygen saturation of 85% and fluid filling his lungs, but he would not allow it. He refused all care to include oxygen, Lasix, and antibiotics for what also appeared to be pneumonia. We all discussed with him that this decision could cost him his life in the long run. He was adamant that he was tired of being admitted, tired of receiving medicine, and stated without hesitation, “I want to go home and I am OK if I die.” His apparent lack of fear was startling, his actions counter-cultural. But I discharged him home, and thought again of the stoic philosophers. This man, a hard working farmer, had led a full life. He was mentally sound and wanted to live out the next season on his own terms. I admired that.
Our lives are judged by the actions we take in the midst of adversity or advantage. There is no doubt that my time serving in Afghanistan, and my later understanding of the Stoics, put meaning and substance behind those decisions and perspectives. Will we take rightful, just, and honorable actions? Or will we succumb to the easy way out, which is to let our anxieties and impulsive behaviors reign? Applying some of the concepts that have been bandied about for over 2000 years might just be a novel idea.
Edited by Greg Henry, MD
Thank you for this article. I don’t usually feel like the articles I read relate to me but this one did. My son is a US Army combat medic currently training for Flight Medic. I’ve forwarded this to him to read as it just reinforces what I’ve taught him- BE WHERE YOU ARE and DO THE BEST YOU CAN. I’m an ER Physician Assistant and am often asked “how do you stay so calm?” I think most ER providers are Stoic but the general population would see it as cold hearted in a way. It does no one any good if we get excited about someone else’s emergency.
I just wanted to express my appreciation for allowing me to feel normal with my stoicism.