Breathing
Shanda McManus
March 2020
My office is quiet except for the noise I make: the click of the light switch, the hum of the computer, the crinkle of my paper gown as I unwrap it. I pull on my PPE—gown, gloves, mask, and goggles—makeshift protection as I evaluate patients for suspected Covid infection. There are no face-shields or N95 masks for us, so I use a loose surgical mask. I wear the same mask and gown for my whole shift, changing only my gloves between patients. The single pair of goggles in the office has to be shared.
Breath fogs up my goggles and sweat starts to trickle down the bridge of my nose. The PPE encases me; I feel smothered. When I first suit up for the day, my chest tightens. I have to talk myself out of feeling suffocated. Take a slow deep breath. Again, slow deep breath.
As a family medicine physician, I usually skip the white coat; the stethoscope is my only doctor identifier. As a black female physician, especially one without a white coat, I have to dress with extra care. I have to be sure that my clothes project competence and authority but also friendliness. They can’t seem too young or too sexy or too frumpy, or too reserved. But now, it’s just blue scrubs.
Wrapped in protective paper and plastic, I wave in patients waiting in their cars. Through the fog of my goggles, I see some wearing masks and some with no face covering at all. I try to smile with my voice since the mask covers my mouth and hope my posture seems straight with confidence. A physician should try to reassure even when she herself is unsure.
Before Covid, a medical assistant would set up each patient in the room for me, but now I do it on my own. Fear shadows each patient— fear for themselves and those they love. We share these fears. Usually, I would reassure a patient by a touch on the arm or shoulder but now I touch my patients only as much as needed to examine them. The distance between patient and doctor widens as I see only eyes, not whole faces. Every patient complains of some combination of cough, fever, or fatigue. Breathing problems worry me the most.
Our supply cabinet has only seven Covid test kits; the pandemic has far outpaced our need. If I identify a Covid patient early I may save his or her life, so I must choose: Who will I test? Who will I turn away? Every day, it feels like too many or too few.
I improvise criteria for testing, using CDC recommendations and my gut. Do they look sick? Will this change what I do for them? What is the probability of a positive test? Sometimes a story will tempt me away from my criteria. But I have to be strong. I only have seven tests.
I evaluate an older woman whose pregnant daughter is coming to live with her until she delivers. “Please, please, I need a test,” she begs. I bend my rules and test her, but feel guilty afterwards; maybe someone else deserved the test more.
The test swab has to travel through the nose to the back of the throat. Every patient I test chokes, gags, and coughs; their eyes water and spill tears. Invisible droplets float in the exam room, infectious droplets that surround me. I hold my breath under my mask while I swab and patients cough. I move quickly, sealing the test swabs in biohazard bags and sending them to the lab. Results take too long to be clinically useful—a week or more—so I instruct my patients to call immediately if breathing becomes difficult.
After each patient leaves, I worry about the exact order of cleaning the room and myself. I clean my gloves with hand sanitizer, tear off the disposable paper from the exam table, then wipe the exam table with Clorox wipes. Then I wipe down the computer, thermometer, pulse oximeter, the desk, and doorknob. I throw away my gloves and pull off my mask and goggles. Bleach-scented air rushes into my nose and I take a deep maskless breath. I relish the easy breathing until I have to mask up for the next patient.
Now, I have to write my note, but the computer requires a billing code? This is a new disease for me, so I use my phone to google the ICD- 10 code for possible Covid exposure. Then I wipe down my phone with another Clorox wipe. I check the box for a level-four visit, since it feels like it involves “moderately complex” decision-making. Soon after, I get a message from my office manager that I need more diagnosis codes to support a level-four visit. Coding and billing stress does not stop during a pandemic.
One patient, who already tested positive for Covid, comes back short of breath. Her sentences come out choppy and she is struggling to breathe beneath the mask. I let her take it off while she tries to speak so I can understand her. My doctor sense tells me she’s a sick one. This is confirmed when her pulse oximetry comes back in the low 80s.
“You have to go to the hospital,” I tell her.
“I really don’t want to,” she says. “Please let me go back home.”
“No,” I say. “You have to go now. You have a son at home—do you want to stop breathing with him in the house?” I want to scare her so she’ll agree. Every tactic is fair when you’re trying to save a life. She relents and is admitted to the hospital and put on oxygen.
I hope my PPE has been enough to protect me.
Before Covid, I spent my office hours seeing patients for blood pressure checks, sinus infections, and back pain; health concerns that posed no risk to me. Now, I am evaluating patients for a new deadly infection. It’s not that I’m afraid of facing risk—I trained during the height of the HIV/AIDS epidemic. Later as an attending physician, I volunteered at a rural hospital in Kenya where all my patients had a combination of AIDS and drug-resistant tuberculosis. But with those infections, I at least knew what I was dealing with. With Covid, I am feeling my way in the dark.
And even if I accept the risk to myself, what about my five children and my husband? What will I bring home to them? Some physicians in my group refuse to work at our Covid test site. Too risky. We read about doctors dying from Covid in Italy and China.
I took the Hippocratic oath in medical school: I will prescribe a regimen for the good of my patients according to my ability and judgment and never do harm to anyone. To please no one will I prescribe a deadly drug, nor give advice, which may cause his death.
What about my death? Covid-19 is only two months old and little guidance exists for physicians, but especially those of us working in small community practices away from large academic centers. I feel like I am alone in the fight to keep my patients and myself breathing.
When I get home after my shift, I strip in the laundry room and head straight for the shower. Thoughts of my own mortality bounce in my mind. I think of my mother who died when I was fourteen and how it changed my life. Can I accept the impact my death would have on my children? I focus on a simpler question instead—do I wash my hair tonight and then spend an hour afterwards combing, blow drying, and re-twisting my tight curls? No, it’s too much to ask. Not today. I concentrate on the steam of the shower and take three deep, cleansing breaths.
May/ June 2020
After weeks at the Covid testing site, I am back in my office. I still wear scrubs and a mask but not a gown, gloves, or goggles. There are no official guidelines in my small practice, so I make up my own rules to limit my exposure.
Patients request notes that exempt them from wearing masks because they can’t breathe, notes to excuse them from teaching because they’re pregnant, or notes excusing them from work because they are caring for a spouse with Covid.
Some patients I see in the office, some on the computer screen, and some in their cars. I put on full PPE when I go out to the parking lot and lean into the open car windows to test patients for Covid. We have two Covid tests now: one that takes 15 minutes for results; the other, 48 hours. I have to choose and hope patients have faith in my choice. They ask me: How long do you think this will last? When will we get a vaccine? Will it be safe? I reassure them with authority I don’t feel, sharing in their uncertainty but hiding my own. We all wish to breathe without the fear of Covid again.
A middle-aged white lady is in tears. I hand her the tissue box, a practiced move. Since the pandemic hit, my exam room is a place for tears. Overwhelmed mothers, fathers, teachers, and nurses cry in my office; everyone is crying.
“I just want to apologize and take responsibility for my role in what’s happening in our country,” she sobs out. These are not Covid tears, I realize. Under the mask, I find it harder to breathe as I’m reminded that I am a black woman in medicine—a space traditionally white and male.
The shadows of racism and prejudice linger around the edges of my clinical practice, though outright displays are rare. No one says, What are you doing here? But I get comments like: “You look too young to be a doctor,” or “I thought you’d be Irish from your name.” Professionalism demands I downplay these interactions and after twenty years in practice these comments bounce off me. All physicians protect themselves behind a veneer during patient interactions and mine is thicker than most. It’s my special brand of PPE against racism and discrimination. It allows me to do my job without exposing my vulnerabilities. Patient encounters are about the patient, not me. But faced with this patient’s tears and apology, my veneer cracks, letting the realities of being black in America rush in.
Last week, we witnessed the murder of George Floyd. Black Lives Matter protests are all over the news. Pinned by three officers with a knee on his neck, Floyd struggled for breath. His last words were: “I can’t breathe.” One month after surviving Covid-19, Floyd died from lack of oxygen anyway.
I’ve lived with the specter of police brutality and racism my whole life. At fourteen, I watched as the Philadelphia police bombed the headquarters of the radical black power and back-to-nature group MOVE. Eleven MOVE members died and sixty-five homes were destroyed. As a college student, I watched the beating of Rodney King by the LAPD from my dorm room TV. In the last decade, snuff videos like George Floyd’s have given visibility to injustice. But no change has come. Michael Brown, Trayvon Martin, Philando Castile, and Eric Garner came before George Floyd, and still he died crying, “I can’t breathe.” Seeing modern day lynchings over and over again has left me feeling numb. I think it’s a form of self-protection from overwhelming despair. But if I shield myself too much, I risk smothering any hope I have for change.
I am caught off guard by this patient. I take a look at her red, splotchy face and offer her a tissue. I thank her for her apology but I stay protected under my veneer. What I want to say is: Don’t look to me for forgiveness. Do something: go to a protest, read a book, widen your circle to include black people. Is it my place to offer her forgiveness? Is she even at fault? I steer the visit back to the easy, her blood pressure.
My patient makes me think about my son, when he began driving on his own. This was after we’d seen the video of Philando Castile being murdered by a cop. My son asked, “What do I do if I’m stopped?” This question hit me in my chest, squeezing the air out of my lungs. There is no good answer.
When he was small, I made sure he wore a bike helmet, looked both ways at streets, and had all his shots. Now some consider my brown- skinned boy, standing at 6’2”, a threat. I tell him: No loud music. No hoodies. Keep your hands on the steering wheel. Say yes sir, no sir. Don’t move. Don’t have anything in your hands. Don’t, just don’t. But nothing I say can protect him from being robbed of his right to breathe.
August 2020
Covid-19 is crushing black and brown communities. Higher rates of diabetes and hypertension explain some of the disparity but not all of it. Racism and discrimination can make you sick. In 1992, Arline Geronimus proposed that the health outcomes of pregnant black women were diminished by social and economic disadvantages. Weathering, she called it. Since then there has been more evidence that black bodies feel the effects of racism on a cellular level, possibly reaching across generations. These health disparities make it easier for black and brown people to lose their breath to Covid infection. I have high blood pressure, despite my plant-based diet and three-times-per-week on the stationary bike. Am I suffering from weathering? Maybe my PPE isn’t as effective as I think.
December 2020 / January 2021
I feel a spark of hope when the FDA approves a Covid vaccine for emergency use. The loss of life and breath has the entire country united in its desire for a remedy to Covid. My patients are hopeful. I field their questions about safety and availability. After I get vaccinated, I find it is easier to breathe under my mask, knowing I have some protection.
Racism today and throughout our history has caused loss of life and breath. It kills like Covid. This time I hope the voices of protest, like a vaccine, lead to real change. But, I watch as rioters storm the Capitol building and my hope dims. I see the police unbelievably restrained, as people with Confederate flags and Nazi T-shirts mount an insurrection. I contrast this with the police in full riot gear during the largely peaceful Black Lives Matter protests in the same city six months earlier. The suffocating effect of racism and discrimination is ever present in our country. Still, I try to hope for a true remedy. I try to keep breathing. Take a slow, deep breath. Again—slow, deep breath.