The Power of Now; Practice Presence to Keep a Healthy Mindset in the ED

Flashback to September 2010, a few hours into some rather serious “Welcome” lectures, an older gentleman comes up on stage and tells us; “Being a successful pharmacist is hard work. These next four years will likely be one of your greatest challenges, but also one of the most rewarding experiences. Becoming a successful pharmacist requires a blend of hard work, determination, intelligence, creativity, critical thinking, and unfortunately a little bit of neuroticism and obsessive compulsive disorder.” As we all laughed, I looked around. It was a nice bit of comic relief, and the looks on everybody’s faces said the same thing; “I’m in the right place.”

Fast forward to 2017, I’m still a budding pharmacist, practicing in the ED for 2 years. Add in a few unfortunate circumstances, a few difficult cases, and I was led to a book titled The Power of Now by Eckhart Tolle. I reluctantly ordered it on my Kindle but started reading and didn’t put it down until I was finished. I had often wondered what had drawn me to the ED, it always felt like there was some kind of x-factor that had always intrigued me. As I read the book, I realized I had finally found words for what that x-factor was, presence. I realized this was something I had long been yearning for, and that the ED was just one of many ways to find this state. I now believe that our true presence is one of the greatest gifts we can offer, and have applied some of the lessons from The Power of Now to help me become a better pharmacist, friend, family member, co-worker, and overall, a better human. I’ve taken bits and pieces from my favorite chapters and elaborated on how they relate to the ED. Examples I use will be from the ED, but the underlying lessons can be applied to any practice setting, and many other situations in life.

You are not your mind


Favorite Chapter Quote: “The mind is a superb instrument if used rightly. Used wrongly, however, it becomes very destructive. To put it more accurately, it is not so much that you use your mind wrongly – you usually don’t use it at all. It uses you. This is the disease. You believe that you are your mind. This is the delusion. The instrument has taken you over.” (Page 14)

In Chapter 1, the concept of “Being” is introduced. What is “Being?” It is connectedness, being engaged, absorbed, so focused on your task that you lose the sense of time. Athletes and some fields of psychology call it “flow”, or “being in the zone.” However, this concept doesn’t have to be limited to sports, as you may have noticed in your life. For others it may be found in cooking, being a parent, traveling, talking with friends, dancing, it can really be found anywhere.

So what prevents most people from this state all the time? According to the book, the answer is compulsive thinking. I think of compulsive thinking as the thinking when you’re zoning out. Perhaps when you’re brushing your teeth or on a long drive. Others may call it the primitive monkey brain. Some common compulsive thinking topics may be to-do lists, worrying about finances, replaying something that was bothersome last week, or the type of thinking that when you snap back and wonder, “where was I going with that one??” Tolle calls this the “thinker.” He states that many people become identified with this “thinker,” so much so that they live their life through the thinker. The premise of the book is that there is another, higher dimension that can be achieved with some practice.


The higher dimension is learning how to “watch the thinker.” In simplest terms, this means start listening to the compulsive voice in your head as often as you can. When you do listen, listen impartially. Don’t judge or get caught up in the thought, just watch it. In a way, it’s another form of mediation, and can be done with any menial task throughout the day. An easy way to begin doing this is to take any simple task that is normally a means to an end, like washing your hands, or walking up the stairs, and give it your fullest attention. Instead of zoning off, become fully present, and observe any thoughts that may come up. Allow the task to become an end in itself. As you start to practice this, the “thinker” and the “watcher” will become more prominent, and you’ll start to noticed the difference between the two.

I’m sure I’m not alone in saying that I’ll never forget my first “real” ED day. It was early in my residency rotation, and I spent the day chasing after my preceptor as he juggled a cardiac arrest, STEMI, stroke alert, and an aortic dissection. Then we got back to the desk and he asked me to follow up on the culture results that had resulted for the day. As I finished up, I looked at the clock, and realized I had an hour left in the shift. I had gone the whole day being in the zone, absent of wondering when I’d be able to break away for lunch, refill my water bottle, or even use the bathroom.

ED Application: This is what I had originally found so intriguing about the ED. Forcing myself to become present was the x-factor. Whatever was happening outside of the emergency department didn’t matter at the time. Social media became irrelevant, I no longer felt obligated to answer emails as soon I could, or didn’t seem to care about outer distractions. My plans for when I got home, what I was doing tomorrow, the weekend, or other times in the future were to be figured out later.

Being a pharmacist in the ED, this might seem somewhat contradictory at first, as a good number of interventions come from eavesdropping. Or in the previous example about my first day, if you’re in the cardiac arrest, you can’t simply forget about the other staff asking for help on how to titrate the esmolol drip for the dissection. However, presence can be applied in all places. If you’re going to eavesdrop, do it with full attention. As you’re mixing the epi drip for the cardiac arrest, watch the “thinker” start to wander and list off tpa exclusion criteria and esmolol doses, and come back to full attention. “Watching the thinker” can help keep the others in your awareness and tend as needed, while also giving full attention to the task at hand.

Moving Deeply into the Now

Favorite Chapter Quote: “If you found yourself in paradise, it wouldn’t be long before your mind would say ‘yes, but……’ Ultimately, this is not about solving your problems. It’s about realizing there are no problems. Only situations – to be dealt with now, or to be left alone and accepted as part of the “isness” of the present moment until they change or can be dealt with. Problems are mind-made and need time to survive. They cannot survive in the actuality of the Now.” (Page 62)

This chapter gets deep, but the major teaching is that time is an illusion. In simplest terms = identification with the mind (or the thinker) is trapped in time, living almost exclusively through memory and anticipation. In turn, this creates preoccupation with past and future, and the inability to acknowledge the present moment, which is where all of life actually happens. He says “Nothing ever happened in the past; it happened in the Now. Nothing ever happened in the future; it will happen in the Now.” This doesn’t mean stop learning from lessons in the past, or to stop making goals and working hard for them. This simply means don’t lose yourself in either the past or the present. If you’re using the current moment as a stepping stone to somewhere in the future, or dwelling too much in the past, life is no longer an adventure, just an “obsessive need to arrive.”

Wellness Application: I had found my version of workplace paradise. And sure enough, it wasn’t long before my mind started to say “yes, but……”

I’ve only been working for about 4 years, so there are many others who are much better suited to give out career advice than I am. But I’m going to try anyways! This concept is probably very applicable for students reading this, as I feel that a scarcity mentality is very easily adopted during graduate school, but may also apply to some in the workforce. The advice – watch out for the obsessive need to arrive.

-This started for me in high school, but until I was able to become mindful of this pattern, I was always waiting for “the next thing.”

-Once I graduated high school and started undergrad, it was “once I get into pharmacy school, I can finally ______ (fill in your own blank, for me it was somewhere along the lines of relax or be 100% happy.)”
-After I got into pharmacy school, it was “once I graduate and get a job, I can finally be 100% happy.”
-When I was finishing pharmacy school, it was “Once I get a residency, I can be truly happy” and then “Once I pass the NAPLEX, I can be 100% happy.”

-I finished residency, followed by,“Once I get a job, I can be 100% happy” which turned into “Once I get a job in Colorado, I can be 100% happy.”

-After I got a job in Colorado it was “Once I am proficient in my job, I can be 100% happy”

The mind that was always planning, or always distracted was my “thinker.” Reading The Power of Now is eventually what had interrupted this pattern, and allowed me to grasp what it meant to “watch the thinker.” Thankfully, that first bit of time in the ED had given me a glimpse of what was possible as “the watcher of the thinker.”

Consciousness: The Way Out of Pain

Favorite Chapter Quote: “what could be more futile, more insane, than to create inner resistance to something that already is? What could be more insane than to oppose life itself, which is now and always now? Surrender to what is. Say ‘yes’ to life – and see how life suddenly starts working for you rather than against you” (Page 33)


Tolle states, that the majority of pain is self-created by the unobserved mind (the thinker), through some form of non acceptance of the way things are. Yes, sometimes the present moment is painful, awful, unacceptable, but he advises that we observe how the mind labels it and how the continuous sitting in judgement creates further pain and unhappiness. As you watch the mechanics of the mind, you step out of the resistance patterns, and allow the present moment to be as it is, however that may be.

ED Application: Responding to difficult situations. There’s a Buddhist parable called the Sallatha Sutta, or the story of the two arrows. The first arrow is the pain (physical pain, emotional pain, any type of pain), and the second arrow is the emotional reaction to the pain. Following my first pediatric cardiac arrest, somewhere around three years ago, I found myself ruminating quite a bit about it. While normal reflection and debriefing after difficult cases can be very helpful, it seemed like I couldn’t quite get past this one. To this day, I still think that pediatric codes are the most emotionally difficult situations I’ve ever witnessed. However, this particular time, I had a bad case of the “2nd arrow syndrome.” On top of the sadness of the original code (the first arrow), I had internalized the problem, and started telling myself, “it would have gone differently if we had done this, or done that, or what if we tried this? Maybe if I had just been more prepared things would be different.” I had a similar case in January. The pain and sadness of the “first arrow” was certainly still there, but by staying present with it and allowing it to be there, instead of replaying it, the “second arrow” didn’t come.

Mind Strategies for Avoiding the Now

Favorite Chapter Quote: “Gratitude for the present moment and the fullness of life now is true prosperity. It cannot come in the future. Then, In time, that prosperity manifests for you in various ways” (Page 65)

Varying levels of unconsciousness (the thinker), constant wanting, and resistance are all strategies to avoid the present. The way back to the present – dropping negativity, give up waiting as a state of mind, take action, and find gratitude.

Tolle says it perfectly, “If you find your here and now intolerable and it makes you unhappy, you have three options: remove yourself from the situation, change it, or accept it totally. If you want to take responsibility for your life, you must choose one of those three options, and you must choose now. Then accept the consequences. No excuses. No negativity. No psychic pollution. Keep your inner space clear.”

ED Application: While previous examples showed how one can find presence through their work in the emergency department, this is the opposite – how events in the ED can lead one to bring one back to presence. The ED is a complex, and sometimes crazy place. When we see people with athletic injuries, even if having a difficult day, it can be a constant reminder to be thankful for a healthy body. It’s a reminder to be thankful waking up being able to breathe, as one sees a patient with flu or pneumonia struggling for air. When we meet someone with an end stage cancer diagnosis, or another patient that passes away, it’s a reminder that life is fragile and to be thankful for every moment that we have on this planet.

Conclusion

Satori – a sudden flash of insight or clarity, a moment of no-mind and total presence (definition by Eckhart Tolle, page 96.) Maybe you’ve felt a satori in the ED, or while in nature, or a beautiful moment with your family. Maybe you caught one while reading this article or reading something similar. There’s no doubt that ED burnout is a very real issue, but we don’t have to let it get the best of us. By watching your own personal “thinker,” you’ll keep a finger on the pulse of your mindspace. By returning your attention to the present moment, you’ll keep yourself operating at your max potential. By staying thankful, you’ll magnify the positive in your life and keep negativity at bay, allowing more time and energy for you to focus on what truly matters to you.

Disclaimer:  I have no financial interests in this book

Ryan Rogoszewski, PharmD

@RyanRogoPharmD

ED Clinical Pharmacist

University of Colorado Health — North Region

References:

Tolle, E., & OverDrive Inc. (2010). The power of now: A guide to spiritual enlightenment. Novato, CA: New World Library

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