Volume 35

June - 2022

Cover: Felix Felicis

My partner graduated law school in the spring of 2021. Since undergrad, we have had a tradition of sending each other “Felix Felicis” prior to exams in honor of our shared love for the Harry Potter series. This tradition was not maintained due to the rigorous graduate education demands. The second half of my partner’s legal education was remote which took a toll on his academic motivation and productivity. I was experiencing similar disenchantment with remote learning, so I decided, for old times' sake, to cross-stitch a bottle of liquid gold for his last law school finals - a reminder to not lose sight of the whimsical and magical.

Letter from the Editors:

Welcome to Art of Emergency Medicine, an online blog featuring amazing works of art created by your Emergency Medicine colleagues, along with their own stories of wellness and inspiration. Each month we try to focus on a new topic within wellness, and this month we’re discussing managing anxiety.

Anxiety is a normal reaction that emergency medicine providers experience each day. It is not a hindrance or negative aspect, but instead is developed as a method of pre-planning by our brain to prepare for interactions so that we are ready to act and perform complex or daunting tasks when they are asked of us. However, it’s when our response to anxiety prevents us from completing these tasks that it begins to wear on our psyche and hinder progress more than it helps it. 

To begin talking about anxiety, we should first start by differentiating it from stress. Both anxiety and stress result in that classic sympathetic surge triggering our fight and flight response so that we may jump into action. However, stress is a normal reaction to an external stimulus. Think about putting a central line into a crashing hypotensive patient. After the acute stressor, your body returns to its physiologic baseline. Anxiety is a different beast. It is your body’s reaction and triggerent of your fight or flight reflex in response to internal stimuli, whether it is self-judgment, worry, or replays/reenactments of different events. Anxiety, too, has its purpose to prepare us to perform, but it is when we are unable to control our response that it begins to interfere with our professional progress and contribute to a sense of burnout. 

It isn’t that anxiety should be avoided. It can be a valuable tool. In fact, in studies of high-performing individuals (athletes, businessmen, speakers), they experienced similar amounts of anxiety, but it was their ability to manage the anxiety that led to their success. 

So how does one manage anxiety? Unfortunately, it’s not a one-size-shoe-fits-all type of situation and the level of anxiety that becomes detrimental is different for all. There are a number of tricks that you can try to refocus yourself and change your thought process from an amygdala-focused to a forebrain-focused approach. Try your hand at each of them to see which may work best for you:

• Breathing Exercises

  • There are a number of different breathing techniques that are meant to convince your brain that you are calm both through increasing parasympathetic tone and redirecting your attention away from your anxiety. 

  • Some of our favorites are Box Breathing and 4-7-8 Breathing

    • Box Breathing: Draw a square on a piece of paper and trace it with your finger. On the first side, inhale for a count of four. Hold the breath as you trace the second side for a count of four, exhale on the third side, and finally on the fourth side hold the exhale for a count of four. 

    • 4-7-8 Breathing: Similar to when we reviewed sleep, inhale for a count of four, hold it for a count of seven, and exhale slowly for a count of 8. 

• Practice Mindfulness

  • Practicing mindfulness can be done in multiple different ways and again, the best method will be different for everyone. The ultimate goal is to be able to identify your anxiety, your body’s response to it, and then let it pass without judgment. 

  • Meditation:

    • Meditation may look slightly different for everyone and can be done on your own or with the assistance of an app for guided meditation. The ultimate goal is to watch your thoughts and feelings, allowing them to pass without engaging, judging, or reacting. You are creating a separation between your consciousness and the intrinsic response your body is having to anxiety.

    • Need help getting started? Find a quiet, calm room and set a time limit for yourself (often starting with 5-10 minutes is a good place). Focus on your body and your breathing. If your mind starts to wander, do not discipline yourself, but instead refocus and continue your meditation. As time goes on, you will experience less wandering of the mind and be able to meditate for longer periods of time.

  • Somatic Sensing:

    • Is your stress causing a weight in the pit of your stomach? Did your breathing speed up? Can you feel your heartbeat stronger or faster? All of these may be reactions to anxiety. 

    • Somatic sensing is the idea that anxiety results in physical sensations within our body. Identifying your personal reactions is an important first step in preventing a spiral of anxiety with earlier intervention. 

  • Exercise:

    • As with many topics within wellness, exercise provides both a hormonal response and distinct separation from anxiety that allows individuals to recover. 

    • Developing a regular exercise routine (even if just 15-20 minutes a day) can provide daily benefit and improved outlook on life. How are ways to get started? Consider a daily walk around your neighborhood or guided yoga session. For those more advanced or physically active you may develop a habit of running, biking, or weightlifting. 

  • Hobbies/Artwork/Writing:

    • We’re biased, but we think that expressing your emotions and feelings through artwork is one of the best ways to combat anxiety. Making physical the emotions you are experiencing provides a method of mindfulness where you may experience, react, and then release the stressors of your daily life. 

    • Try multiple modalities, find which works best for you, and keep at it. Your skills will grow and you will find that it provides an opportunity to step away from anxiety and process the triggers/events that are resulting in your anxiety. 

    • If nothing more, consider a daily journal or writing down those things that are making you anxious. Seeing them in physical form allows the abstract to appear less daunting and allows you to see a path where you may begin to address your anxiety. 

• Ground Yourself in Reality

  • When we become anxious and our sympathetic surge is triggered, it can be difficult for our brain to perceive that a normal baseline is achievable and work can proceed. Having a routine or back-up plans may help in grounding yourself particularly during panic attacks. 

  • Have a Routine

    • Turns out athletes who have pre-game rituals were not so wrong to be doing it. Studies have shown that development of a standard daily routine in life (be it putting on socks a certain way, walking a certain time of the day, etc.) can allow individuals to focus their attention and control actions. 

    • It is the belief that your preparatory actions or daily routine will result in your success in the task at hand. Beyond this, it allows a moment of grounding where your brain can recognize the action as routine and “safe” to prevent further spiraling of anxiety.

  • Practice 3-3-3-3

    • In a spiral of anxiety, it may be difficult to rationalize and see the greater picture of what is occurring. One may break this spiral grounding yourself in the world around you at that moment.

    • Take 1-2 minutes to name 3 things you see around you, 3 sounds that you hear, move 3 parts of your body, and take 3 deep breaths. 

    • By separating yourself from the emotions of an anxiety attack and grounding yourself in reality, you may be able to refocus your attention.

In the end remember that these techniques are a start and a pathway and the course of managing anxiety is something that will take years to master. Share the load, talk with others. Everyone is experiencing it and sharing support and techniques leads to mutual benefit. While some of the interventions above have demonstrated efficacy similar to pharmaceuticals, if needed, seek professional help without stigma. Learn to identify and control your triggers.

Most importantly beyond all of this, be kind to yourself and realize that change and managing anxiety will not come in one day. It is a constant struggle and journey that everyone is on.

Cast Art Patches

The emergency department isn't very fun for kids, especially if something traumatic requiring a cast has happened. The patches I make help make the entire situation less scary. I use the medical materials for my art to make the entire process less intimidating. If they see that the fun designs on their cast or bandage are made out of the same material the whole process seems less frightening.

July 1st

Fresh creased scrubs right out of the package
Pounding heart, wide eyes, this place feels so massive
A shiny ID badge labeled “Intern Physician” 
You’ve been preparing for years to be in this position.
BUT! You feel like an imposter, there is fear and self-doubting
Surrounded by Alarms, and sirens, and patients are shouting
We need orders on eight, a nurse yells your way
I haven’t even logged in, Today’s my first day! 
You spot an R2, they sit you at a PC
“Open the tracker and try to keep up with me.”
With a 3-minute tutorial you’ve got the basics down
You feel more at ease, confidence abound. 
Day 1 as a doctor, you’ve got this, you’ve been training
EMS rolls in, a new patient chest paining 
A calm washes over, the training kicks in
Hello I’m your doctor, you say with a grin

Breaking The News

“A tumor is a form of cancer...” I explained, “…but not all tumors have spread. Does that make sense?” I asked purposefully, slowly, with a grave and sallow voice. Meanwhile, the interpreter on the telephone was fucking up my tone. He spoke too loudly, too quickly, too high-pitched, too ‘literal.’  “Shit,” I thought, this is not how I wanted to break the news

I figured out what he actually knew and didn’t by the way his chest heaved when I said the word “cancer,” the way his jaundiced eyes darted across the room, the way he clutched his rosary beads and bible closer. The private hospital down the street that sent him spoke of a “tumor” in his gallbladder, but cancer? This was apparently a very different story. 

I clicked through his CT scan and foresaw what was in store for him. His otherwise healthy forty-two year-old body would start to fail him. He would slide uncontrollably into a self that wasn’t his, one that would distend and itch and swell and yellow in the coming weeks. I knew, because my own mother’s body betrayed her in the same way. She would die within four months of her diagnosis, leaving me to wonder whether she would have been better off without aggressive treatments that left her unable to get out of bed. 

“Are there different kinds of cancer or just one?” he asked pleadingly, hoping the answer would somehow change what had been set in stone. I walked him through my thoughts and the next steps we would need to take prove our suspicions, though mostly as way to offset the burden of truth. Deep down, all I really wanted was for him to forever be out of this ER room and to be with his family. 

A Peaceful Retreat

Monthly Infographic:

Managing Anxiety

Do you want to see your art shared with the community? Don’t forget to submit today!

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This Months Featured Artists:

Jenny Situ, MD

I am an MS4 who recently matched with my home institution for EM residency! When I am not enjoying the wonderful New Mexican outdoors, I find solace in various forms of artistic expression - sketching, acrylic, watercolor, photography, knitting/crochet, and cross stitch.

Jack Cameron

Bandage Art started with a need to entertain children in a fast-paced emergency department. I had an abundance of medical supplies but a lack of toys. I started designing cast art of popular children’s characters made out of coban. From there the designs became more requested and I developed a way to apply them better to their casts. I would work on them in my spare time to hand them out to my patients. The figures were so popular that I created an IG account, bandageartists, to share with the medical and veterinary communities. From there the demand has only grown and we send cast art all over the world.

Rob McMickle, MD

An upcoming 4th year chief resident at Harbor-UCLA. He enjoys writing prose pieces inspired by his shifts in a busy level 1 trauma center.

Vincenzo Happach, DO

I graduated from Des Moines University College of Osteopathic Medicine in 2013. I spent 7 years as an active duty US Navy Medical officer, 5 of which were as an Aeromedical Officer. I'm currently an Emergency Medicine PGY-1 at the Coliseum Medical Center Emergency Medicine Residency in Macon, GA. See more of his work on instagram.

Soujanya Kondameedi

I am a third year medical student in New York City. I have always loved the camera and though not a professional, I enjoy capturing moments that stand out to me whenever I can. I also enjoy reading fantasy novels, making an excessive amount of chai, and wandering aimlessly in the busy streets of NYC. See more of her work on Twitter.

You can learn more about the artists featured in this and other volumes at our contributors page!