By Dr. Paul Ehrlich
One of my real joys in practice is to regularly welcome pediatric residents from NYU into my practice for allergy rotations. NYU doesn’t have an allergy program but it does have an extensive pediatrics department, so I’m the whole show for teaching the young pediatricians allergy basics. Sharing what I know is part of an ancient tradition in medicine. Every good doctor is a custom-made product. We can learn the big things from textbooks and lectures, but knowing the little things often separates one doctor from another, and these are usually learned from other doctors. All our mentors teach us things that other doctors don’t know.
As we wrote in our book, one reason allergies and asthma are so widely uncontrolled is that physicians in general practice, including pediatricians, attempt to treat patients who really ought to see a specialist, although there is also a shortage of allergists.
I was thinking about this the other day when a 26-year-old man, the son of a long-time acquaintance, came to see me about some problems he was having breathing. I suspected a particular problem that is both common and obscure. In the wrong hands it might be regarded as asthma, and treated in cookie-cutter fashion. I asked that my current resident sit in.
On a piece of paper I sketched a line across the bottom and on the left side I perpendicular line—a primitive X-Y graph. Then drew another line parallel to the bottom line and started to draw a bell curve on it. I said, “Think of this as a normal deep breath.” As the line rose higher, I said, “Do you have trouble getting to this other line? Do you feel like you just can’t make it to that point where you feel good and have enough oxygen to keep you going? Yes. “And when you reach the top do you feel relieved?” Again, yes. “Do you find yourself yawning when you aren’t tired or bored?” Yes.
Meanwhile, the resident was studying the drawing and listening carefully. Finally she said, “I get that, too. I always thought it had something to do with our hours at the hospital.” (Hate to sound like an old-timer, but the hours you keep now are nothing compared to the schedules we kept when I was training.)
If this is familiar to any of our readers, my congratulations. I have written about his before. It is called “anxiety breathing” and as the name implies it has nothing to do with allergies or environmental triggers, but the triggers of the everyday life of the mind. I asked the patient if he was encountering any stresses at work. He told me he had two jobs, one of which was quite physical—working in a warehouse. That was the one that gave him trouble. He had suspected that he was allergic to something in the warehouse. He said, “Now that I think about it, the symptoms start as I’m on my way from the subway to work.”
These two twenty-somethings have something in common? They are both under a great deal of pressure. Working at a warehouse at night is very different from keeping resident hours in, say, a neo-natal intensive care unit, but it is physically demanding, and can be quite dangerous. But all that yawning is a reflexive effort to deliver that last measure of oxygen when stress is making the whole respiratory system tighten up. Instead of the chest muscles being flexible, they become stiff and resistant to expansion. It’s important that my resident know this as she enters practice, not for her youngest patients, but anxiety breathing is rampant among teenagers.
Doctors who don’t know about anxiety breathing might spend time looking for some other cause or throw albuterol or bronchodilators at the problem. It might work initially, but not for long. They might do allergy tests. However, to those who know about anxiety breathing (and not allergists do, not even old ones), the answers lie in the facts of a patient’s life. This is a particular symptom profile. The challenge is assessing the cause of the underlying tension and treating that.
In the case of moonlighting in a warehouse, working two jobs is usually done out of necessity, so giving up the night work is not an option in the short run. As for my resident, no training physician is going to find some other line of work. And for her future patients, certainly no medical treatment will make the job of being a teenage any easier. The best anyone in this position can do is to try to relax when they can, possibly doing meditation or other relaxation exercises, improve their sleep hygiene, and make the most of their personal lives.