Self-Care for the Front Line

On the importance of putting your oxygen mask on first.

---Kerry Whitelock, DO

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The airline industry starts every flight with a safety briefing that includes a reminder to put the oxygen mask on yourself first before trying to help someone else put their mask on. Of course, this doesn’t only apply when we’re in the air—in any emergency we need to heed this reminder to take care of ourselves first so that we can then take care of our patients in an effective and efficient manner.

Self-care is not a new concept for us in the medical field. We routinely remind our patients to exercise, to follow a healthy diet, to get enough sleep, to be mindful of mood and attitude. However, during the COVID-19 pandemic, as we are inundated with patients to care for while managing guidelines and protocols that change constantly, it is easy to forget about self-care. It is a classic case of “do as I say, not as I do.” With practice though, self-care can be easily incorporated into your daily routine as my coauthor and I discussed in our book, “Code Calm on the Streets: Mental Toughness Skills for Pre-Hospital Emergency Personnel.” In this post, we look at basic strategies to improve self-care along three crucial dimensions: exercise, sleep, and attitude.

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Exercise

The first critical component of self-care is exercise. Your level of fitness directly affects the quality of care you provide to your patients—as a very concrete example, Ochoa et al (1998) studied ICU and ED staff and found that the quality of chest compressions during CPR decreased due to fatigue. Your level of fitness can also directly contribute to your safety when you deal with combative, delirious, or psychotic patients.

As we pointed out in our book, functional conditioning is an approach to exercise that reflects real world skills so that workouts prepare you for the physical requirements of your job. You can improve motivation and compliance with your conditioning program by using different techniques, such as strength training, stretching, cardiovascular training, working out with someone, setting short and long-term goals.

Scott (2019) suggested to wear a pedometer to mark your daily step count, which can inspire you to move more. Take the stairs instead of the elevator, park further away from your destination to increase your step count. Total body workouts, such as high intensity interval training, are short and invigorating and focus on working smarter, not harder, by utilizing multiple major muscle groups. As Tello (2017) reminds us, the goal is to avoid prolonged periods of sitting, so any activity counts!

Sleep

The second critical component is sleep. Shift work does not necessarily lend itself well to good sleep patterns, and many other life commitments demand our time when medical responsibilities do not. Make it a top priority to carve out adequate time to sleep, otherwise sleep deprivation can slow decision making and cognitive processing and decrease motivation and the ability to learn new skills. Define and try to maintain a functional sleep pattern. If you have to change your wake-up hours, the National Sleep Foundation recommends that you move your sleep schedule up or back by 15-minute increments. While this is certainly not always possible during emergencies, it remains an important idea during our off-shift time.

Napping is also important—aim for 20 minutes for an energy boost. Using blackout curtains and white noise machines can facilitate sleep when your sleep schedule does not correlate with usual nighttime. Monitor caffeine use as less is better so that the caffeine will have an effect when you need it. Regular exercise can also improve the quality of sleep. Pay attention to posture as well, as standing may combat fatigue better than sitting. While not always easy, making sleep a priority is crucial for improving both health and high-stakes performance.

Attitude

The third component of self-care we’ll review here is attitude. While attitude has a variety of definitions, Maxwell captured its essential role the way we use it with the following passage:

Attitude is the advance man of our true selves. Its roots are inward, but its fruit outward. It is our best friend and our worst enemy. It is more honest and more consistent than our words. It is an outward look based on past experiences. It is a thing that draws people to us or repels them. It is never content until it is expressed. It is the librarian of our past. It is the speaker of our present. It is the prophet of our future.

Attitude is the essence of success and survival in all kinds of stressful situations. A quick way to boost attitude is by using affirmations, which are positive statements about ourselves that we make to ourselves. Affirmations are truthful statements about our abilities and motivations, not boasts that create unrealistic expectations or hopes. They remind us of our strengths, talents, skills, and goals. Affirmations work best when they are in the form of an “I” statement and are most effective when they are stated in the present tense. In 2009, Sherman et al. showed that affirmations can help to reduce the physiological impact of a stressful situation.

You can create your own set of affirmations, such as “In all duties and responsibilities, I take pride in my preparation.” Affirmations should be reviewed, stated, or meditated upon regularly as their related positive thinking can boost your motivation. Remember, you can change your affirmations as your personal and professional development dictates.

Practicing gratitude is another way to maintain a positive attitude, for it helps you to slow down and recognize the good things in your life. So is meditation with its focus on mindfulness, being present, focusing on breathing. However you work to achieve it, effective attitude is your confidence in your ability to perform physically and psychologically.

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During the COVID-19 pandemic, we are called on to step up our patient care responsibilities in an unprecedented manner. Self-care habits, such as exercise, sleep, and maintaining a positive attitude, are powerful habits that can help us take care of ourselves first so that we can then take care of others.

Remember, oxygen and self-care are essential. Don your oxygen mask first.

Thank you for all that you are doing to take care of your patients, your families, and yourselves!

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REFERENCES

Drake, C. (2020, July 28). Shift Work and Sleep. Retrieved from https://www.sleepfoundation.org/articles/shift-work-and-sleep.

Maxwell, J. (2001). The 17 Indisputable Laws of Teamwork. Nashville: Thomas Nelson.

Ochoa, F., Ramalle-Gomara, E., Lisa, V., et al. (1998). The effect of rescuer fatigue on the quality of chest compressions. Resuscitation, 37, (3), 149-152.

Scott, E. (2019, June 24). Exercise for Energy: Get More Out of Your Day. Retrieved from https://verywellmind.com/exercise-options-for-stressed-and-busy-people.

Sherman, D., Bunyan, D., Cresswell, J., Jaremka, L. (2009). Psychological vulnerability and stress: The effects of self-affirmations on sympathetic nervous system response to naturalistic stressors. Health Psychology, 28, (5), 554-562.

Tello, M. (2017, October 30). Fitting in Fitness for Busy People. Retrieved from Havard Health Blog.

Whitelock, K, and Asken, M. (2012). Code Calm on the Streets: Mental Toughness Skills for Pre-Hospital Emergency Personnel. Mechanicsburg, PA: Sunbury Press.

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Kerry Whitelock, DO, is an internal medicine physician, a former EMT, and the co-author of Code Calm on the Streets: Mental Toughness Skills for Pre-Hospital Emergency Personnel. She can be reached at emscodecalm@gmail.com