Crozet Annals of Medicine: I Can’t Breathe

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I can’t breathe.

Very few sentences capture the attention of an Emergency Physician more raptly. Very few emotions capture the terror of a human being more acutely. This is a primal fear. 

Have you ever been held underwater in a childhood prank? Then you know. Have you ever had a severe asthma attack? Then you know. COPD? You know. Congestive heart failure? You know. 

And I know. You are going to die. You can’t breathe and unless I can fix that, you are going to die. Most of the time I can fix it. Those are pretty good moments. I can almost see the ER docs reading this and nodding their heads. Sometimes it’s easy, an asthma treatment. Sometimes it’s harder, an intubation and a ventilator. Sometimes it’s really hard, a tracheostomy; a blade to your throat, an incision to where the airway lies hidden, a Hail Mary last-ditch effort to save you. The list goes on. We have many approaches because this is a primal need, the need to breathe and we need to be able to fix it no matter what the cause. 

Breathing is both simple and complex.

Here is simple: You are sitting and reading this and breathing without thinking about it (well, you are probably thinking about it now). This breathing at rest is primarily an automatic function triggered deep within the most ancient part of your brain, the lizard brain. (Anatomically called the brainstem.)

Here is complex: The brainstem sends periodic nervous impulses automatically down your spinal cord to your diaphragm signaling it to contract. The diaphragm is a sheet of muscle and fiber that separates the thorax or chest from the abdomen internally. The diaphragm is shaped like a dome at rest and contracting flattens it. This flattening increases the volume inside of your thorax (chest) thus decreasing the air pressure inside your chest compared to the atmospheric pressure outside your chest. The higher air pressure outside forces air to rush into the lower pressure of your chest through your nose and mouth. This of course assumes that your throat is not being constricted. 

In order for your diaphragm to flatten, one of two things need to happen. One, your belly needs to expand to allow the diaphragm to traverse downward. Try this now while you are sitting there. Belly breathe. Take a deep breath by pushing out your tummy. 

The other way your diaphragm can traverse downward is for your chest wall to expand upward and outward. Try that. Take a deep breath by expanding your chest. 

You will notice that to some degree both belly and thorax are involved in taking a really deep breath and even in the relatively relaxed breathing that you are now doing. If you could not expand your belly or your thorax due to a weight placed on you, then you would not be able to breathe.

But there is one last ditch effort you might use.  

Have you ever seen a sprinter blast across the finish line only to bend over and place his hands on his thighs, gasping for breath? Maybe you have done the same when winded. We see it in the ER all of the time in patients with severe respiratory distress. We call it tripoding. It signals a desperate emergency. There is a physiologic reason for this characteristic posture.

Stabilizing your arms on your thighs allows the muscles in your chest wall that attach to your arms such as the pectoralis major and latissimus dorsi, which normally pull your arms in and down, to now pull your chest wall up and out since the arms are fixed onto the thighs and can’t move down or in. These muscles and many other smaller muscles are only needed in severe respiratory effort and are called the accessory muscles of inspiration. You could not call on them if your arms were restrained behind your back, though.

Most of my professional life has been spent surveilling for life-threatening emergencies and fixing them in an acutely time-sensitive manner. So, while it was agonizing for anyone to watch the George Floyd killing on video, for me my very ingrained instincts were crying out that everything that was happening was so antithetical to the preservation of life. 

An officer appears to kneeling on his belly. No belly breathing possible. 

An officer appears to be kneeling on his chest. No thoracic expansion possible. 

An officer is kneeling on his neck restricting air entry.

His arms are cuffed tightly behind his back. No tripoding will save him.

And so, he died.

The medical term for this is compressive asphyxia or positional asphyxia. 

While the mechanics of this murder were shocking and striking to me, the inherent racism of this kind of policing was not at all surprising. Any American physician with sufficient practice experience recognizes the systemic racism reflected in our country’s health disparities. Certainly COVID has highlighted this. 

Nationally, African Americans are twice as likely as whites to die of COVID-19. While the epidemiology of this is complex, with genetic factors and pre-existing conditions also playing a part, this disparity is seen across all diseases and illnesses. Hispanics and Native Americans are similarly affected.   

So now America is facing three related existential crises; a pandemic, economic collapse, and nation-spanning riots over racial justice. Our system is being tested, and only unified action will save us. 

As we begin leaving our homes and venturing out in public, be kind to one another. Wear a mask. To move about in crowds without a mask is a kind of selfishness we cannot afford right now. Be conscious of your distance; it is a new form of politeness. And where you see injustice, speak up. 

Finally, when it all seems to be too much, just breathe. It is a miracle we never really notice.          

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