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Medically Clear: Find Your Zen in the Chaotic ED

Ballard, Dustin MD

doi: 10.1097/01.EEM.0000483940.05039.08
Medically Clear

Dr. Ballardis an emergency physician at San Rafael Kaiser and the medical director for Marin County Emergency Medical Services in San Rafael, CA.





It's my favorite time of year. The NBA playoffs. For basketball fans, this is ball-pounding, rim-rattling, high-lobbing bliss. Just stand near a television long enough, and you'll likely hear exultations of awe and admiration.

“Stephen Curry from waaaaay downtown ... a clutch three!”

“LeBron stepping up to the line to calmly sink two huuuge free throws.”

Of course, it is not just basketball players who must compose themselves when dumped in the metaphorical pressure cooker; we all have to do it in our professional and personal lives. How should we best prepare? If you are like me, you get ready for your ED shift with a decent night's sleep and a strong cup of coffee. Of course, I've done this job for more than 10 years and much of it is rote. Many of my patients, however, are finding themselves in unfamiliar territory. The pressure is on and not too many know how to handle it. Of course, I can't blame them, but I would like to help them and not just in a medical sense.

So, at the suggestion of and with the assistance of my neighborhood Zennie (Myoun), I drafted some Buddhist wisdom to assist those in unforeseen and unpleasant situations, such as trips to the emergency department. This advice is patient-centric, but the principles can be useful across various settings and roles. And, really, we are all likely to be a patient at some point, right?

  • “Resistance to the unpleasant situation is the root of suffering.” — Ram Dass

We are constantly judging our experiences as good or bad, and if we deem something bad, we want to get rid of it immediately. But in an emergency, we need to accept what has happened and recognize that judging it as good or bad does not much matter. Recent work out of Carnegie Mellon suggests that the act of mindfulness — in particular, the nonjudgmental acknowledgment of pain, suffering, and stress, may actually decrease stress hormone levels for up to four months afterwards. (Biol Psychiatry 2016 Jan 29 [Epub Ahead of Print].) Becoming an ED patient may not be the ideal time to launch into one's first mindfulness exercise, but it would be a perfect time to deploy it if you already have some training or experience in the practice. I have resolved to work this into my ED shift by attempting to recognize and defuse those situations where high-maintenance patients and persnickety consultants have my cortisol levels on high.

  • “Flow with whatever may happen and let your mind be free – stay centered by whatever you are doing.” — Chuang

In any stressful situation, take some really deep breaths and calm down. You are having a unique experience — your own safari. A safari is not just a chance to photograph (or be attacked by) large mammals. It is an adventure with an unknown outcome. This may not have been the journey you planned, but it presents unique opportunities for growth. Maybe the challenge ahead can help you bring family and friends together, channel empathy for others who may be in a similar situation, or commit to healthy lifestyle choices for the future (like quitting smoking for good). Perhaps there is even an opportunity to find a nugget of joy in the situation, like the fact your department's warm blankets really are comforting to patients and staff alike. Acknowledging a simple comforting fact like this this can help down-regulate the stress response going on in your brain.

  • “Zen is simple. Stop choosing.” — Buddhist quote

It is our job to make choices. Patients have to make choices, too, like whether to receive pain medication, undergo further testing, or go home. The days of paternal medicine are long gone, and we now recognize that patient choice is vitally important. But a fixed model of it may not always be helpful. Choices should be dynamic and affected by additional information and change in clinical status. Here, the Buddhists would caution patients from making decisions about their care before having all of the relevant information. By processing and accepting each choice as it comes, you will be in the best place to make the right decision. Remind patients not to be afraid to ask the ED staff to give them and their family a few minutes to discuss options before making an important decision about medical care. I try to remember to slow down and offer patients (and myself) a cognitive timeout when we are struggling to reach consensus regarding the proper care plan.

Some basketball greats believe in visualization as a tool for success. Others, like Myoun, believe that one can improve shooting through mental imagery alone. I am skeptical of this particular claim and a big believer in practicing skills, but I also believe that how we prepare and train our minds can help us immensely when stress and anxiety cross paths with the unexpected. If we keep this in mind at work, we can help our patients (and ourselves) retain a semblance of equanimity.

Learn more about this topic by listening to the Medically Clear podcast on iTunes or on Dr. Ballard's website,

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