Volume 40

April - 2023

 
 

By: Andrew Thorne, MD

Cover: The Face of Ama Dablam

Hiking to Everest Base Camp was one of the most breathtaking experiences of my life (pun intended). Ama Dablam was an awe inspiring companion throughout much of our trek. Capturing this image through the prayer flags has been one of my favorite of the trip.

 
 

Environmental Wellness

By: Jonathan Warren, MD

Recently I went on a vacation and it really made me appreciate the benefit that spending time in nature and the outdoors contributes to my wellness. With Earth Day happening today, in this introduction to the 40th volume of Art of Emergency Medicine, we’ll be exploring how access to the outdoors improves overall wellness and how to grow that connection even when you don’t have the ability to vacation or spend days on end outside. How is it that by supporting the planet we can continue to support our own wellness?

Well, to start, what happens when we don’t have access to nature, clean air, and sunlight? Recognizing that there is a significant risk to physical health that the environment can play, what are the benefits? Not only does pollution increase rates of respiratory disease, cardiovascular disease, and cancer, but a warming global climate has led to more heat stress and infectious disease as well.1-5 Beyond these health risks, lack of nature can lead to worsening mental fatigue, increased aggression and violence as demonstrated in a study that compared people who lived in barren areas to those with nearby nature.6

It is also important to note that it isn’t just a lack of nature that results in bad outcomes, but spending 120 minutes of time in nature weekly has been shown to improve both well-being and overall health with peak positive association between 200-300 minutes.7 We have even seen that just access to seeing nature may help improve recovery from surgery and overall positive outlook on hospitalization.8 Living closer to places with access to green spaces such as parks, wildlife protected areas, or gardens improves well-being and lowers mental distress.9 Beyond the mental health benefits, there is a significant improvement in cardiovascular related mortality.10

Some may argue that exposure to nature by necessity requires physical activity, and perhaps it is this increased physical activity that leads to improved mental health. It is a reasonable thought, as previous meta-analyses have demonstrated that even with low levels of physical activity (<150 minutes/week) there is a significant reduction in risk of depression.11 Another study demonstrated that exposure to nature may have a synergistic effect with this improvement and lead to greater impacts on self-esteem than exercise alone, with some reduction in the previous expected benefits of exercise when performed in barren locations.12 Moreover, other reviews have demonstrated that health benefits of proximity to green spaces is not related to an increased amount of physical activity in those residents.13,14

It’s one thing to identify this relationship, but there have been a number of studies that look into various pathways for exactly how nature can improve both our mental and physical health as it does not seem to solely come from an increase in exercise. So let’s break it down a bit further.

In regards to physical health, exposure to nature decreases sympathetic nervous system activity and increases parasympathetic nervous system activation which may have far reaching effects on the immune system and subsequently chronic disease development.15,16 Beyond these effects, simply being in a forest or walking in a forest has demonstrated increased levels of DHEA (which provides cardioprotective and anti-diabetic properties), reductions in blood sugar, and inhibition of the renin-angiotensin system which combined may improve cardiovascular and health outcomes.17-19 Finally, event small amounts of trees planted in an area have demonstrated a buffer and cooling effect that may combat heat stress.20

In regards to mental health there appear to be a number of benefits that may contribute to the decreased risk of depression and improved self-esteem that is seen with increased exposure to nature. Some of this may come from restoration of attentional capacity, which improves our ability to focus and clears the fatigue that we gather through the days and weeks.21 Moreover, it has been demonstrated that green spaces decrease the maladaptive nature of rumination and decrease prefrontal cortex activity.22 This decreased rumination may help provide a buffer to mentally stressful events and allow for more rapid restoration that is associated with nature.23

Enjoying nature, thus, has demonstrated some quite amazing benefits in regards to health and mental well-being, and similarly doing your part to help protect nature and the environment can improve wellness as well. Some studies have demonstrated an improved sense of purpose and life satisfaction when participating in pro-environmental behaviors.24

It being Earth Day, I would be remiss if we didn’t review a number of ways for you to make a significant contribution to environmental wellness so that you may continue to enjoy nature and those green spaces within cities that provide such drastic benefits:

  • Practice sustainable living practices
    • Repair and reuse items in your home as opposed to buying new ones. If you do need to buy a new item, consider purchasing one made from sustainable resources. Consider buying vintage or secondhand items.
    • Bring your own reusable bags to avoid using plastic bags or purchasing recurrent reusable bags next time you’re at the store. Along this same vein, bring reusable containers to restaurants or coffee shops the next time you go.
    • Plan meals in advance and reincorporate those leftovers into a new meal to reduce food waste
    • Consider establishing a recycling and composting system in your home with reusable containers
  • Transition to a plant-based diet
    • Meat production is one of the largest drivers of methane production, which is a key factor in climate change and increasing temperatures
    • Consider changing your diet for one day a week or one meal a day for the week to a plant-based alternative:
      • Bacon and eggs? Try oatmeal and nuts instead
      • Sandwich with turkey? Consider a grilled tempeh or zucchini sandwich
      • Steak and potatoes? Portobello mushrooms when cooked properly may provide the same umami flavor and texture of steak
    • Focus on healthy plant-based foods (whole grains, fruits/vegetables, nuts/legumes, tea/coffee) as opposed to refined grains, fries, juices.
      • This had demonstrated a significant effect on cardiovascular health as well.25
    • Ensure adequate protein by incorporating tofu, tempeh, lentils, and chickpeas.
    • If you truly enjoy the diet, you can consider starting to grow some of your own food on a balcony or in a yard.
  • Conserve energy and natural resources
    • Turn off lights when you are not in the room and consider setting up smart-home systems to turn lights off when you leave the room/house.
    • Seek energy efficient appliances and use natural light and ventilation when available.
    • Consider walking or biking to work/school instead of driving yourself. Public transportation provides another option to reduce carbon emissions.
    • Turn water off when not in use, limit the length of showers/baths. Consider using a dishwasher if available (as this actually saves water even when the load is not full).
  • Promote environmental education
    • Attend local environmental education events, which are frequently held and may teach on topics from climate change to sustainability. You may find these with groups like the Sierra Club, the National Environmental Education Foundation or National Geographic’s Geo-Inquiry Process.
    • Use social media to spread awareness and updates in your community and beyond.
  • Get involved!
    • Volunteer with regional or national parks and organizations to effect change. The National Park Service has a strong year-round volunteer program.26
    • Join a Citizen Science project to help chronicle the changing landscape, support NASA research, and address real-world problems.27
    • Join coordinated efforts to advocate for green policies at local, state, and federal levels or support organizations who are trying to do the same such as the Environmental Defense Fund.28

Are you interested in writing an article for Art of Emergency medicine?

Reach out to us through our contact form and we would love to work with you to make this a reality!

By: Diana Halloran, MD

Next Chapter

I've been working on this piece for a while - making small changes every few months. I want art to feel exciting, something I get to do, rather than something I have to do. As a result my pace might have slowed but my enjoyment has increased. Painting in the winter is especially relaxing - cold outside and cozy inside with the bright sun coming through my living room windows.

Oil on canvas

Chronicle of a traumatic Death

On a December night in the city of the not-so-eternal spring, as gray clouds enveloped the moon like a wad of gum, a great murmur awoke the alarms of those who were dancing. It wasn't the dusty detonations, much less the music bass. Three meters below their land, visible without steeps from a balcony, appeared the image of the lord who lived the party at such a level that euphoria led him to lose even the consciousness of physical barriers or that gravity can even give pushes down. He attempted to dance but failed, tried to walk in short steps and failed, held back and held back, but failed, until he had no choice but to seek a doctor.

The fragmentation of his hip, the one he used to dance from side to side with Rodolfo Aicardi's records, at first glance had been the main consequence of such a collapse and it never crossed his mind that those bruises or those lacerating perceptions that came from his body could indicate greater damage. He didn't seem to remember, neither him nor the others, that his chest attempted to embrace the ground as it fell as if it lunged towards its new dance partner and that his ribs and lungs didn't fit with the sadness of seeing it was not true until they broke from within. They mentioned to him that his right hip needed to be intervened, corrected, sculpted again with screws and bars, like an engineering work.

However, as the hours passed his ailments turned and a sense of anxiety to breathe and inhale environmental gases grew, leaving his room empty just like the bottles he drank, but he continued. They said it was COPD or a consequence of the fact that he was a stubborn smoker, or perhaps a bit of both. By this time his heartbeats accelerated and a greater sample of incessant difficulty breathing took hold of him despite the oxygen, inhalers and painkillers for his pain. Not being able to withstand his blood pressure anymore he began to collapse, his lungs continue to plummet towards failure and his cells, each one of them, thus entered into a deep shock impossible to control.

After the third day, the etiology of such agony was finally discovered, and a blood bath covered by his pleura became the enemy to fight against. The invisible but not so invisible enemy, the white-collar thief in this legal investigation. The therapists tried every possible science: the tubes in his throat and chest, packed blood and vasoactive drugs. They tried everything, but his heartbeats fell, his blood pressure also collapsed to the ground. Sweat took over his body and a rising body temperature dominated him until it put him red-hot, and at 11:12 am on his fourth day of suffering, the breaths took one last great gasp, his heart stopped, releasing his anemic soul and thus ending the greatest of all parties: life.

By: Sebastian Osorio, MD

The text arises from the analysis of one of the cases of traumatic deaths that have potentially been preventable and have impacted me in my rotation of General Emergency. Gabriel Garcia Marquez is one of my favorite local writers and this particular case reminded me of two of his works. Chronicle of a Death Foretold (which inspired the title of the text) and Love in the Time of Cholera, where one of the main characters also dies due to a fall from height. Writing about the emotional and impactful side of these sad outcomes helps me to cope with the dissatisfaction of knowing that a patient has passed away.

By: Hassan Masood Jafri, MD

Unchaining from the rhythm

Shift after shift, day in and day out, we are chained to the rhythm of life and death. As emergency physicians, we are constantly juggling the most critically ill patients with the demands of our own lives. It is a difficult and demanding profession, both mentally and physically.

But it is also a rewarding one. Every day, we get to save lives and make a difference in the lives of our patients. We get to see the joy on a parent's face when their child recovers from a serious acute illness, or the relief on a patient's face when we alleviate their pain.
However, the constant exposure to tragedy and trauma can take its toll on our mental and physical health. It is important to find ways to de-stress and unwind, both during and after our shifts. Exercise, meditation, and spending time with family and friends are all great ways to decompress.

We are chained to the rhythm of life and death, but it is our choice how we deal with it. With self-care and a positive outlook, we can thrive in this rewarding but demanding profession.

Created on DALL-E

By: Scott GOldstein, DO

Lurking

I found painting to be a very therapeutic hobby. When I paint, I just think about the process of painting. I don’t think about bills , work, stress, patients, etc.... My brain is focused on the painting and gives my mind and body a break from the everyday stressors. Without painting, I think I would have burned out long ago, as the process of putting paint on a canvas, slows my brain down to process.

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

Finally, don’t forget to share Art of Emergency Medicine with your colleagues, friends, and family on Twitter or Instagram and like us on Facebook for all the latest news!

References:

1. Shahrbaf MA, Akbarzadeh MA, Tabary M, Khaheshi I. Air Pollution and Cardiac Arrhythmias: A Comprehensive Review. Curr Probl Cardiol. 2021;46(3):100649. doi:10.1016/j.cpcardiol.2020.100649

2. Tiotiu AI, Novakova P, Nedeva D, et al. Impact of Air Pollution on Asthma Outcomes. Int J Environ Res Public Health. 2020;17(17):6212. doi:10.3390/ijerph17176212

3. Glencross DA, Ho TR, Camiña N, Hawrylowicz CM, Pfeffer PE. Air pollution and its effects on the immune system. Free Radic Biol Med. 2020;151:56-68. doi:10.1016/j.freeradbiomed.2020.01.179

4. Watts N, Amann M, Arnell N, et al. The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate. The Lancet. 2019;394(10211):1836-1878. doi:10.1016/S0140-6736(19)32596-6

5. Villarreal-Calderon R, Reed W, Palacios-Moreno J, et al. Urban air pollution produces up-regulation of myocardial inflammatory genes and dark chocolate provides cardioprotection. Exp Toxicol Pathol. 2012;64(4):297-306. doi:10.1016/j.etp.2010.09.002

6. Kuo FE, Sullivan WC. Aggression and Violence in the Inner City: Effects of Environment via Mental Fatigue. Environ Behav. 2001;33(4):543-571. doi:10.1177/00139160121973124

7. White MP, Alcock I, Grellier J, et al. Spending at least 120 minutes a week in nature is associated with good health and wellbeing. Sci Rep. 2019;9(1):7730. doi:10.1038/s41598-019-44097-3

8. Ulrich RS. View through a window may influence recovery from surgery. Science. 1984;224(4647):420-421. doi:10.1126/science.6143402

9. White MP, Alcock I, Wheeler BW, Depledge MH. Would you be happier living in a greener urban area? A fixed-effects analysis of panel data. Psychol Sci. 2013;24(6):920-928. doi:10.1177/0956797612464659

10. Gascon M, Triguero-Mas M, Martínez D, et al. Residential green spaces and mortality: A systematic review. Environ Int. 2016;86:60-67. doi:10.1016/j.envint.2015.10.013

11. Mammen G, Faulkner G. Physical activity and the prevention of depression: a systematic review of prospective studies. Am J Prev Med. 2013;45(5):649-657. doi:10.1016/j.amepre.2013.08.001

12. Pretty J, Peacock J, Sellens M, Griffin M. The mental and physical health outcomes of green exercise. Int J Environ Health Res. 2005;15(5):319-337. doi:10.1080/09603120500155963

13. Lachowycz K, Jones AP. Greenspace and obesity: a systematic review of the evidence. Obes Rev Off J Int Assoc Study Obes. 2011;12(5):e183-189. doi:10.1111/j.1467-789X.2010.00827.x

14. Lachowycz K, Jones AP. Does walking explain associations between access to greenspace and lower mortality? Soc Sci Med 1982. 2014;107(100):9-17. doi:10.1016/j.socscimed.2014.02.023

15. Gladwell VF, Brown DK, Barton JL, et al. The effects of views of nature on autonomic control. Eur J Appl Physiol. 2012;112(9):3379-3386. doi:10.1007/s00421-012-2318-8

16. Alvarsson JJ, Wiens S, Nilsson ME. Stress Recovery during Exposure to Nature Sound and Environmental Noise. Int J Environ Res Public Health. 2010;7(3):1036-1046. doi:10.3390/ijerph7031036

17. Mao GX, Cao YB, Lan XG, et al. Therapeutic effect of forest bathing on human hypertension in the elderly. J Cardiol. 2012;60(6):495-502. doi:10.1016/j.jjcc.2012.08.003

18. Ohtsuka Y, Yabunaka N, Takayama S. Shinrin-yoku (forest-air bathing and walking) effectively decreases blood glucose levels in diabetic patients. Int J Biometeorol. 1998;41(3):125-127. doi:10.1007/s004840050064

19. Li Q, Otsuka T, Kobayashi M, et al. Acute effects of walking in forest environments on cardiovascular and metabolic parameters. Eur J Appl Physiol. 2011;111(11):2845-2853. doi:10.1007/s00421-011-1918-z

20. Souch CA, Souch C. The Effect of Trees on Summertime Below Canopy Urban Climates: A Case Study Bloomington, Indiana. Arboric Urban For. 1993;19(5):303-312. doi:10.48044/jauf.1993.049

21. Berto R. Exposure to restorative environments helps restore attentional capacity. J Environ Psychol. 2005;25(3):249-259. doi:10.1016/j.jenvp.2005.07.001

22. Bratman GN, Hamilton JP, Hahn KS, Daily GC, Gross JJ. Nature experience reduces rumination and subgenual prefrontal cortex activation. Proc Natl Acad Sci U S A. 2015;112(28):8567-8572. doi:10.1073/pnas.1510459112

23. van den Berg AE, Maas J, Verheij RA, Groenewegen PP. Green space as a buffer between stressful life events and health. Soc Sci Med 1982. 2010;70(8):1203-1210. doi:10.1016/j.socscimed.2010.01.002

24. Gatersleben B, Murtagh N, Abrahamse W. Values, identity and pro-environmental behaviour. Contemp Soc Sci. 2014;9(4):374-392.

25. Satija A, Bhupathiraju SN, Spiegelman D, et al. Healthful and Unhealthful Plant-Based Diets and the Risk of Coronary Heart Disease in U.S. Adults. J Am Coll Cardiol. 2017;70(4):411-422. doi:10.1016/j.jacc.2017.05.047

26. Volunteer with Us (U.S. National Park Service). Accessed April 20, 2023. https://www.nps.gov/getinvolved/volunteer.htm

27. CitizenScience.gov. Accessed April 20, 2023. https://www.citizenscience.gov/

28. Get involved. Environmental Defense Fund. Accessed April 20, 2023. https://www.edf.org/get-involved

This Months Featured Artists:

Andrew Thorne, MD

Andrew is an emergency medicine physician practicing in Los Angeles with a passion for wilderness medicine and capturing the beauty of the outdoors.

Diana Halloran, MD
I am an emergency medicine resident in Chicago and am originally from Florida. I have been painting and drawing since high school and I majored in Studio Art in college. Painting and creating visual art is a passion of mine which I am striving to continue during residency. See more of her work on Twitter.

Sebastian Osorio, MD

I am a first-year resident physician of Emergency Medicine at the University of Antioquia in Colombia. I obtained my medical degree in 2019 from the same university. My hobbies include dancing in genres such as salsa and bachata, as well as writing. Since I have memory, I have been writing and narrating all my emotions, but I have decided to start writing about the experiences I have had since my contact with critically ill patients due to the COVID-19 deaths that I have witnessed. See more of his work on Twitter.

Hassan Masood Jafri, MD

I am 30 year old doctor from Pakistan, training in emergency medicine from Aga Khan University Hospital. My love for arts begin in school, I was always looking forward to arts class, painted many projects in school, drew many drawings in biology. Then the studies took the better part of my time. But again in medical school when I acquired a smart phone I start taking pictures..I started my Instagram in 2013. I love photography. Wrote for a while as a freelance blogger as well.

Scott Goldstein, DO

I am a dual board certified emergency/EMS physician in the Philadelphia area. After a spending years looking for an outlet I went to one of those paintings with wine one night with my wife. After that, I tried on my own and unknown to anyone (even myself) I wasn't half bad. I became self taught in painting of acrylic on canvas and painting coffee on watercolor. See more of his work on Instagram.

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