Back to Work: Lifestyle Medicine in the Emergency Department, and Tips for shift workers
Taking a break from medicine, even though it was not by my own design, was the best thing I think could have happened to me, and to my family. Like a lot of professions that require a constant practice, the mind is not only focused on the tasks involved when they are being done, but later on, and before, and a lot of the moments spent needing to do other things. The patient care given and to come, scenarios good and bad, can flood the mind and add to overdue emotions, most commonly anxiety. I imagine many other professions are this way. In my time away I have started to write here and elsewhere, I have started to focus on other forms of art, and find myself contemplating what I have done, but more so, what is to come. What should I write next? Who should be the next character? When is the next adventure? What have I learned from my classes? How can I frame this concept for the next post?
In the time since I have posted here, I have found work back in the Emergency Department. I had theorized what teaching small bits of Lifestyle Medicine and dietary measures to patients through the ED would be like, the time needed, what I would say, how I could lean in depending on the chief complaint. But before all of that, I had to spend time catching up on me. There would be a shift in sleep and energy, physical needs that would need a renewal of my own diet and exercise patterns, and some prioritization of this over that. Common changes some would envision taking on a new job and new schedule.
The jump back in and use of Lifestyle Medicine and dietary teaching was slow, but valuable to me and the patients I involved. It really is a concept many patients, so far all in my limited experience, are eager to know, and welcome as a refreshing talking point they didn’t know was coming and are grateful to hear. I made new information cards, this time with QR codes, to verifiable websites with legitimate material in patient centered language that doesn’t come with a selling point. It had become apparent to me that physicians and other healthcare providers should have these kinds of internet resources available to give to patients depending on medical issue as so much of the truth of health and what can help all achieve peace of mind is hidden underneath the masses of social media tied long advertisements for the new concept or substance that has a way to help someone look better and feel better, temporarily, for a price. As if health actually meant looking and feeling a certain way, or that to achieve it one has to spend more than they can afford. We are living in a time when the truth is free, but as we are so accustomed to price tags equating to better and best, we commonly feel that the next level of health will always cost us. It doesn’t have to.
For the past few months, I have worked already many shifts and seen hundreds of patients. Like riding a bike, I have found my automatic habits, questions, ways of approaching patient care, and a handful of low hanging fruit, if you like, of patient issues that are amendable to Lifestyle Medicine and dietary teaching.
(Nothing written in this post or others is to be taken as medical diagnosis, treatment, or advice. Please seek out care from your personal provider. If you or someone you know is having thoughts of suicide, please dial 988.)
1. Anyone with a Gastrointestinal (GI) complaint, almost anyone. When nausea and vomiting and diarrhea (rarely constipation – so many are chronically constipated, even the young) go a bit farther than expected or lead to pain, dizziness, or interfere with some other element of life, patients usually find their way to the ED. This is bread and butter Emergency Medicine, and if an ED provider didn’t see a GI complaint like this during a shift, they didn’t work. Most patients need some alteration to their diets during recovery, like a clear liquid to bland diet, avoidance of large meals, greasy foods, ultra-spicy foods, and acidic foods. Some of these changes can be incorporated into daily eating even after recovery, along with the addition of more fiber from plant foods, beans, and whole grains to help regulate the GI system from stomach to the very end. Ultra-processed foods and foods made and eaten outside the home are often loaded with salt (70% of what we typically get daily), fat, and are too large for what we need to eat to feel satisfied. Many routine GI complaints can be avoided in the first place by taking control of what is eaten by turning unprocessed food into home-cooked processed food, eating more plants and more fiber, and not eating so much at one time.
2. Anytime an antibiotic is prescribed, it is a good time to think about prebiotics and probiotics. A tremendous number of UTIs, skin infections, and PID is seen through the ED daily, around the clock. Out of all the prescriptions I write for, antibiotics are near the top. Prebiotics are the forms of complex carbohydrates we eat that actually get digested by the probiotics. Only plant foods have them. They are commonly referred to as fiber. Insoluble fiber is the best, but just eating more plant foods, beans, and whole grains will be enough. No one wants to micromanage their diet or have their diet micromanaged. So just focus on the plants, and most everything will take care of itself naturally, and regularly. Probiotics are the bugs, the good kind, the kind we can’t live without, and can be found in a multitude of forms over the counter, but the best way to take them, if more are needed, is to eat the real food they are common in. This would be the yogurts with live and active cultures and fermented foods like kimchi. Near all of us will have already some good probiotics in our GI system, they may just need to be fed what they crave so they can multiply and outnumber any other (bad or just not good) bacteria that would otherwise flourish when antibiotics taken kill off some others. Having an less than diverse microbiome due to antibiotic use leads to diarrhea usually. Cdif is the more feared, as it should be, but more often people get the runs that at best is annoying and at worst painful and dehydrating.
3. Wildly high blood pressures and blood sugars, with and without symptoms, are also a common issue for patients to seek out the ED. While blood pressure and blood sugar should be treated in most according to its average over time, and as an outpatient, everyone can have a bad blood pressure (BP) or bad blood sugar (BS) day. Often stress can escalate either or both of these. A change in routine, sleep, eating pattern, medication intake, or another illness can as well. When the high BP or BS is not found to be due to an underlying new issue, or exacerbation of a known issue, then lifestyle can be entertained, and should be anyway. When sleep is interrupted, the BP nadir (lowest point) is missed and the BP then has a new, higher, set point. From this new higher setpoint, the day’s BP can climb and be higher than normal throughout the day. Overtime, one can imagine what this can do to the average and need for more medication, not to mention havoc on the rest of the body. Stress can also raise BP and BS by escalating a cortisol response and keeping it high instead of letting it drop back to baseline. Stress is like the burning coal in the firepit that can ignite quickly when given more to burn and keeps the body too “hot” or inflamed. It’s the inflammation that trickles into the body over time that instigates most chronic disease. We need some stress and inflammation at times, but we don’t need it all the time. We need our bodies to come back to baseline, have our stress lower all the way, and avoid adding to our inflammation by way of lifestyle.
4. When there is unneeded inflammation due to a disease process in which it is hampering rather than helping, steroids are a common go to for relief. Asthma and COPD flares are an example of this, an also very common issues for patients to come to the ED. In anyone, steroids can elevate blood sugars, at least while they are being used. For the non-diabetic, this is usually not an issue. But for the diabetic, this can be a problem as it can send their BS overboard if they are not prepared or careful. This is another time where the importance of fiber comes in. Fiber, like stated above, is not digested by us, but by our microbiome. In that way, it is like free calories, free carbs, that not only not count in our carb intake (or shouldn’t), but by feeding our microbiome, we get chemicals made within us that help to control BS spikes. Fiber also regulates the digestion of all the other things we eat, helping to make sure that the other food elements travel along at a steady MPH, not too fast and not too slow. This way, the body then can absorb the non-fiber carbs at a steady rate helping to prevent BS spikes. We sometimes cann’t take away all not-good things steroid do in our bodies, but we can combat the worst.
5. On the topic of GI transit being regulated by fiber and traveling at a not too slow and not too fast rate, this can also be a good time to talked about pain medications and any medication that can cause the GI system to slow down, namely opiates and Zofran (the miracle drug often given for nausea and vomiting, hence popular in the ED). Constipation is not only a side effect of many opiate pain meds, but it can also be a new problem when one is sick and in pain. People who are in pain tend not to want to move around. When people go from being active to not, the GI system thinks it is time to slow down as well. Fiber as part of a healthy diet even before the painful issue or injury, can help to keep things moving at a comfortable clip. There is no upper limit to the amount of fiber a person can consume, but any incorporation of more should be done slowly, get the GI system used to it little by little, and it will reciprocate. Trying to increase fiber intake too fast and by too much may lead to more problems. The GI system and our microbiome has a tolerance for fiber, but one that can be increased, and one we want to increase. The good bugs need time to grow, and you wouldn’t feed a baby the meal of a teenager hoping to get them to grow, so you wouldn’t do the same to your good bugs.
6. There is growing acceptance that the ways we read about how to handle sprains and strains, especially non-traumatic low back pain, from the textbooks written a half century ago, are really the way to treat another bread and butter ED issue. A short, like 24 hours or less, time in rest before gradually increasing movement over drugs is the standard, and has been for a long time. While every sprain and strain has a different story, different body it happened to, and different capacity for healing, what is safer than taking a medication (opiates especially) or laying around waiting to follow up for a surgery consult, is gentle stretching, low impact movement, and advancing over days to weeks. A referral to physical therapy is something I write for regularly. Beyond that, personalized discharge instructions, and even an okay to search YouTube for videos, that incorporate physical activity over none is a winner. There is getting to be more and more evidence that it is not just moving our bodies, but how we move them, and how often, matters. An investment in a personalized approach to incorporating more physical activity via gym personal trainers, physical therapists, or exercise physiologist depending on needs can go a longer way even if the help is temporary. We attend cooking classes and watch shows on food that can help us change our eating patterns and learn new techniques, we can do the same by learning from those whose profession is being physical.
7. Mental health issues, as one can imagine, are also way too common in society and hence care is seen for these in every ED in the US. The range is also very wide, from the sad or anxious, to the violently suicidal. There is also a large number of people with chronic disease and mental health diagnoses that nearly always go hand in hand. It is hard to live with a chronic illness, and many mental health medications can put people at risk for developing chronic illness as well. Certain illnesses, physical and mental, absolutely need medications for stabilization. Lifestyle is not going to be any kind of replacement but can be an adjunct. When I see a patient with a mild form of depression or anxiety, lifestyle can help a great deal. Often it is not the stressor that needs fixing, but the response to it, and then rest. While I don’t prescribe mindfulness (I still hold grievance towards the co-opting of one practice for everyone), I feel more people would do better finding time and space to pause and center on where they are, what they are doing, how they feel, and take a breath break. Just naming the feeling, giving yourself grace, and taking control of at least a few moments a day, can be the first step in management. Then having gratitude. There are days here and there when it doesn’t feel like anything went right. But if we really think about it, we can find things to be grateful for. (Even people in war zones are often finding small things to be grateful for, so can we.) At the end of the day, this can also set the tone for closing out the day and getting some sleep. There are too many good things that happen in our sleep to list, but briefly, one of them is the brain’s ability to erase fear and anxiety. This can be done only when the sleep is obtained naturally. We can help this along by focusing as well on non-sleep activities, like what we eat and how we move. By letting our day prepare us for sleep, our sleep can prepare us for the next day.
8. The newly pregnant female, often young and in the prime of her life, is an overlooked patient when it comes to optimizing health, because it is not only her body, but the body and mind of the child she is growing. Even when as small as a peanut (can look like one too), making sure she is eating her vitamins through a plant rich diet (taking them is also good, I don’t’ think folate poisoning is a problem we will have), maintaining a daily physical activity practice, sleep well, and avoiding unnecessary stress and substance use, can be the things that equate to healthy pregnancy that goes to term, vs not. Pregnancy related BS and BP issues also can put her future health at risk, leading to a mom with chronic disease, but it can also lead to pregnancy loss. There is usually not any one lifestyle practice that makes or breaks the future of a pregnancy other than substance use, but making sure the new mom-to-be knows the basics at her young age can have a ripple effect on her, her pregnancy, and future motherhood.
I hope these few nuggets of information can give a glimpse into how Lifestyle Medicine can be incorporated into the healthcare of even the ED patient. Lifestyle Medicine won’t prevent everything, but it can help prevent most things or help most things recover.
Knowing a fair amount of Lifestyle Medicine by my certification process and staying up to date in order to practice and teach it, Lifestyle Medicine has also helped me survive my reintroduction into my second act in the ED. Everyone knows the ED is a 24/7 gig. We work shifts, but the shifts can be all over the place. ED docs truly flip back and forth, from days to nights and back again, more so than many other professions. It is also a physically and mental demanding job that requires decisions in seconds and being able to mentally jump from one task to another quickly. How the body and mind are prepared and fueled makes a difference, more so even as aging starts to push against the endurance gained. Some of the things that have worked for me may work for others, even if you don’t work shifts or the kind of job that may or may not allow you to take a break.
A. Clean eating before, during, and after. This means high fiber, high plant or lean protein, low fat, low salt, and lots of water. This gives energy that is slower to digest and burns forever, and avoids the high of sugars and the heaviness of fats. Smaller meals without the salt can help avoid distention (bloating) which can slow the body down and be mentally aggravating. Focusing on what is eaten after work can also help prevent sleep disruption.
B. Alcohol avoidance. If you are an ED provider, or just someone in healthcare, you probably know that some tough days/ shifts make us feel like we deserve a drink, or two, something to take our minds off the dozens of encounters we had with others that didn’t give us a break to focus. Alcohol is also a major sleep disruptor and often times only helps to increase our anxiety and rumination of events in our minds.
C. Daily ritual. Depending on shift length, this may be exercise, writing, craft, meditation, cooking, or anything that is not work, is pleasurable, and is something done for the self only. During days of shorter shifts, I can get in some needed exercise. For the time between longer shifts, it’s more meditation. The shift can be an exercise in of itself.
D. Curated nap time and caffeine time. I have told many Emergency Medicine residents that part of the unwritten training curriculum is how to become a professional napper and how to dose your caffeine. Far less of us are true night owls, so most of us are like the rest of humanity in that our physiology is driven best by sleeping at night and being awake during the day. While schedules can sometimes be built to help with this, there is no getting by without the nap and caffeine dose at the right time. A 90-minute nap, enough to get one sleep cycle in, can help with the overnight shift. Building into life anything and everything needed for a good sleep during the day may entail light and sound modifiers, as well as the rest of the house knowing that you are sleeping and being respectful. Everyone’s caffeine metabolism is unique, and knowing what can be gotten away with takes practice. It may be more about taking in less caffeine, rather than more, that does the trick.
I plan to adapt this and add to it in the future. But for now, this is how Lifestyle Medicine and Emergency Medicine, for me, have evolved together, for the better.