Emergency medicine is stressful. There are charged moments of powerful highs and  lows. In one shift, you may achieve return of spontaneous circulation in a college student with a massive pulmonary embolism, who will survive neurologically intact. The next shift you may feel inadequate as you realize the antibiotics you prescribe will never be picked up by your patient. You may alleviate pain and anxiety for a dying great-grandfather and his family or listen to an underserved veteran recount their service and struggles. You may ponder your life decisions and over a decade of specialized education, while a patient calls you slurs and hurls a turkey sandwich at your face.

The emotions and thoughts associated with our work are one of the reasons that burnout rates and levels of mental illness are high in emergency medicine.^1-3 Also, on shift, time is short. Emergency physicians spend only 5 to 10 percent of their time for personal activities on shift.^4-5 That amounts to as little as 24 minutes on an eight-hour shift to include going to the bathroom and eating. While there has been ample discussion of “the practice of mindfulness” in health care workers that improves mental well-being, when do we have this time?⁶

What’s Your Pre-Shift Ritual?

We can leverage pre-shift rituals that many of us do already to exercise mindfulness. Some of us bike to work or chat with colleagues just before shift. While the activity is different for everyone, these rituals are primed for stress-reducing mindfulness because they are routines we already use to prepare for stressful shifts.

Mindfulness involves being present—experiencing the moment you’re in—and being an accepting observer of those experiences, thoughts, and emotions. For example, my pre-shift ritual is a cup of hot, black coffee that I either buy or brew myself. I am being present as I smell and taste its sour and sweet parts, like an orange. I feel warmth as I drink and often feel content to enjoy the taste of the coffee. I’m observing the moment, accepting whatever feelings or experiences are occurring.

However, it’s natural for our mind to wander from the present or to experience negative emotions. When we do this, we may experience reflective thoughts like, “I must’ve burnt the grounds … again” or future thoughts like, “I should really go to a coffee shop next time.” That’s okay. We should decenter our viewpoint, shifting our perspective from internal to external, to that of a listening friend, observing our own thoughts and emotions. It helps one to realize that many thoughts and emotions, whether good or bad, are only transient. Future worries or past ruminations are natural, but the stress attached to them is fleeting.

If you find yourself meandering from the present too much, you can always refocus to the present pre-ritual activity. It’s another sip of coffee, another pedal on your bike, or intently listening to your colleague’s recollection of their latest vacation.

The Art of Breathing … on Shift

It is non-stop on shift. It feels impossible to fit in a moment to go to the bathroom or take a sip of water. Staff interrupt you while you’re in Room 3 with a patient you’ve placed on BiPAP, “We have an incoming patient with CPR in progress in five minutes,” the nurse says before adding, “Room 4’s family really wants to talk with you again.” And as you power-walk to prepare for the incoming ambulance and tell Room 4 you will be delayed, thoughts interrupt you: “I’m worried about Room 3; if BiPAP doesn’t turn her around, I’ll have to intubate her.” and, “I hope I make it out on time to tuck my kid into bed tonight.”

You may have heard of “mindful breathing” or “tactical breathing,” which is associated with a decrease in acute stress, anxiety, and mental illnesses—and on the flip side, even improving performance.^7-10 But when do we have a moment to—figuratively and literally—just breathe? After patient contact, the 15-20 seconds we take to use alcohol-based sanitizer and/or wash our hands is an opportune time to “habit stack.”^11,12 As James Clear describes in his book, “Atomic Habits,” by linking a new behavior (mindful breathing) to an existing habit (hand washing) you use less cognitive energy and are more likely to successfully adopt this practice.

While there are multiple techniques for mindful breathing, the general concepts include: Focusing on the present process of breathing, and breathing in through your nose and out through your mouth.

To give an example, “box breathing” starts with exhaling for four seconds, inhaling for four seconds, holding the breath for four seconds, and exhaling again for four seconds. As a plus, the breathing technique can even be helpful to coach an anxious patient, a patient in pain, and your patient who doesn’t know how to use a metered-dose inhaler!

During and After Shift: Expressing Gratitude

It may sound counterintuitive to say “thank you” during or after difficult shifts. You may be ruminating on the unsuccessful resuscitation of a cardiac arrest in a young mother, all the notes to be done, or the dread of possibly missing something on the patients you signed out or discharged. However, expressing genuine gratitude for yourself and others is powerful for your mental and physical well-being.^13-15 Even the thought of gratitude can positively influence mental wellness.¹⁵

Remember that turkey sandwich that was flung back in your face? After shift, think of the person who spent their time making hundreds of those sandwiches, which are free of charge, for your patients. It’s amazing that someone provides these comforts—turkey sandwiches, warm blankets—that allow us to do what many of us went into medicine for: care for patients. When you think of that person who made the sandwiches, the comfort some patients receive from these simple gestures, that turkey sandwich may just not seem that contentious anymore.

Think of the team after shift. The senior nurse who was the key lead in a resuscitation when you were occupied with a crash femoral central line. The security personnel who kept you and the team safe during a violent interaction with an intoxicated patient. The environmental-services worker who cleaned the room after a patient with a gastrointestinal bleed hemorrhaged all over the floor. If you’re up to it, say a genuine “thank you” to those individuals. They deserve your gratitude and, on top of that, you might feel better too.

Planning for the Unknowns

Emergency medicine is not, and will never be, an easy job. The unknowns are constant, whether it’s the boarding situation, the future of the Match, or whether your “black cloud” status will come onto your next shift. Every day, we face the challenges and celebrate the successes we see in our patients, our coworkers, and our health care systems. These experiences and thoughts rightfully evoke strong emotions. However, they should not define our wellness.

In “Man’s Search for Meaning,” psychologist Viktor Frankl describes his observations in Nazi death camps: “Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.”¹⁶ While we can’t and shouldn’t prevent the way we feel or experience things, by taking a mindful approach, we can transform our own attitudes towards them. Listening to ourselves and accepting these emotions openly, taking a breath, and showing gratitude are simple and accessible ways to practice mindfulness. In the end, we may just realize the burden we feel is transient, like the ebb and flow of our emergency department census.

Dr. Koo is faculty and an emergency physician at MedStar Washington Hospital Center in Washington, DC and St. Mary’s Hospital in Leonardtown, Maryland. He is an assistant professor of emergency medicine at MedStar Health and Georgetown University Hospital and adjunct assistant professor of military and emergency medicine at the Uniformed Services University of the Health Sciences.

Dr. Goyal is professor of emergency medicine at Georgetown University School of Medicine.

References

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