Three days after my first shift in my hospital’s new coronavirus screening clinic, I woke up to the news that two American emergency doctors were in critical condition.
But even as the first people tested positive in the San Francisco Bay area where I practice family medicine, I was so focused on the well-being of patients, friends and family that I had not contemplated my own risk.
I was telling myself that it would be different in the United States, that we had better protective wear and protocols, that we’ve learned from other countries. And if I were to contract the virus, I would be fine. After all, I’m only 54, I exercise regularly, eat vegetables and don’t smoke.
But no, two American doctors were in the intensive care unit in mid-March, and one of them was at least 14 years my junior and the other was in charge of the infection protocols in his hospital. I stared at my phone, hearing sirens in the distance, and suddenly felt woozy with dread.
Stay calm, I whispered.
But instantly I noticed my scratchy throat and a mysterious constriction deep in my chest. I began to replay scenes from that shift three days earlier. My job was to sort patients into three categories, keeping in mind that testing capacity was limited: 1) test and send home to isolate, 2) no test and send home, 3) test and send to the Emergency Department across the street.
That was the screening clinic’s second day of operation but already the doctor who signed out to me had the ragged look of a war-weary soldier.
“Protocols are changing by the minute,” he said as he oriented me to the workings of the place. We were almost out of yellow gowns and N95 masks and the stash of viral swabs was dwindling. “Make do,” I thought as I hustled from room to room, deciding who should get these precious tests or a higher level of care. The simple act of swabbing tonsils and nostrils was risky because of the sharp cough and spray it provoked.
Reading about the critically ill emergency medicine doctors, I suddenly understood my own vulnerability. After all, 54 was not exactly low risk, I was somewhere in the gray zone. Also, whom might I infect? Should I send my family away? My partner is almost 60; he seems to get every respiratory infection that comes his way. My daughter is part of a skeleton crew working in a dementia unit in a nursing home. My sore throat and the tightness in my chest were making it hard to think straight.
Then I remembered a therapy I’ve been prescribing for years, one that should remain plentiful, even as other resources dwindle. A therapy which, ironically, deploys the same organ that covid-19 attacks: our lungs.
The technical term for this therapy is “regulated breathing” but it is a practice borrowed from ancient Eastern traditions — including yoga and Zen meditation — and has been recognized for centuries as a way to fight stress and quiet a racing mind. Experiments show that regulated breathing can slow heart rate, improve digestion, lower blood pressure and ease anxiety. Other research shows that conscious breathing patterns can lower cortisol levels and can even downregulate the amygdala, the anxiety center in the brain.
One such pattern, popularized by integrative medicine doctor Andrew Weil, is called 4-7-8. (Breathe in for 4 counts, hold for 7 and breath out for 8.) “Takes no time, needs no equipment. Very cost effective,” he says in his instructional video.
James Gordon, a psychiatrist and mindfulness practitioner, uses “soft belly” breathing to help communities cope with trauma. In the past 45 years, he’s brought this technique to the war-torn Balkans, Haiti after the earthquake, schools after mass shootings, and other disaster zones worldwide.
“Often, [soft belly breathing] is the first step toward healing a variety of different kinds of trauma, dealing with chronic stress, and getting on the road to much greater resiliency,” he said in a recent interview with a wellness writer. “It’s an antidote to fight or flight — but it’s also an antidote to those feelings of helplessness and hopelessness.”
In 2016, presidential candidate Hillary Clinton used another form of focused breath, alternate nostril breathing, to get through her post-election despair.
In these examples, breathing patterns varied but had three things in common: slowed respiratory rate, an exhale that is longer than the inhale and a breath that starts deep in the belly rather than high in the throat. The theory is that these activities turn on the vagus nerve, which sends calming messages to our brain and other organs.
For years, I’d encouraged patients to mindfully breathe their way through stress and pain. Now, standing in the predawn darkness of my bedroom, thoughts racing, I realized that I needed to get a taste of my own medicine: I touched my tongue to the roof of my mouth and practiced three cycles of 4-7-8.
The band around my lungs released and my throat felt better. I kept on doing this simple breathing cycle throughout the day, whenever I felt overwhelmed, and it reliably gave me some quick relief.
Two days later, I had my first shift in our respiratory video clinic, another service that has been hastily created to deal with the pandemic. Once again, this was a sorting exercise: Who could stay at home, who needed to come to the hospital for testing, and who should be routed straight to the Emergency Department?
I worked from the safety of my kitchen counter but this experience was almost as stressful as the screening clinic, because of what was at stake. I did not want to overwhelm the packed hospital clinics but at the same time I didn’t want to miss anyone who was sick and doing poorly, or anyone who needed testing because they were likely to infect many others even as they sheltered in place.
“Can you please lean in closer to the screen and breathe as naturally as you can?” I asked a young woman with a cough. I was trying to count her respirations and she seemed to be breathing quite fast.
“I’m really scared,” she said, fogging up her camera. I looked at the clock. I had 10 minutes until my next patient was expected in my virtual waiting room.
“Let’s practice 4-7-8,” I suggested.
It turns out that video visits are a great way to teach breathing techniques. Her respirations slowed down, and so did mine.
“Wow, works like Valium,” she said.
There is some evidence that chloroquine, a plant-derived drug used as medicine by indigenous peoples for centuries, might help prevent the severe pneumonias associated with covid-19. This has been observed only in a test tube and it’s still unclear whether this will prove to be an effective treatment. But as we deploy a raft of modern technologies — from AI to Zoom — to fight this disease and cope with our fear, our stress and our isolation, let’s not forget another ancient treatment that has been on hand all along: our breath.
Inhale, Exhaaaaale and repeat.
Daphne Miller is a primary care physician and science writer who is part of the covid-19 response at her hospital in San Francisco. She is on twitter @drdaphnemiller.