Circle of Breath

How I can find calm in the chaos

I had a great yoga class this morning. Sweaty and lots of stretching with the right number of Chaturangas, plus my favorite 2 poses at the end (pigeon and a juicy supine twist) and then of course -how every yoga class ends - with Shavasana. Corpse pose. It should be easy. You just have to lay there. Do any other Yogis suck at Shavasana or is it just me? I STRUGGLE to quiet my mind, focus on my breathing and not immediately move on in my head to my to-do list for the day. But then the instructor called us to envision a Circle of Breath, and I was able to lock-the-fuck-in. It made me think of the other times in my life I have been able to use this technique and I wanted to share them with you all.

I am a Circle of Breath veteran and acolyte. I use it with my kids. I use it with my patients, especially during uncomfortable procedures. I learned the Circle of Breath from my friend, mentor, coach, trainer, and unofficial therapist Robin. I, along with two former partners and still friends, have been working out with Robin for over 6 years now. Robin has taught me I am strong, and can lift more than I think I can. She makes me wear the damn weighted vest of doom, and at the end of every workout session she leads us in a meditation. This meditation often involves the concept called “Circle of Breath.” Usually, she will make us do a cardio burst, or really hard ab exercises right before we meditate. We then practice circle of breath when our bodies are in internal chaos. Before Blake died, it was a neat thing to do at the end of a good workout.

However after his death, I had to use it to pull myself out of the fire, out of internal emergency status. So many stimuli felt like danger to me during those raw days, weeks, months (and years let’s be honest) after he died. The first day I went back to work was so hard for so many reasons. The last time I had been in the parking garage was the day he died. Pulling into that parking garage set off every alarm bell in my body. I could practically see myself sprinting to my car from the hospital to confront my new horrible reality. I parked in my usual spot, where I had last tore out of in a panic on the day of his death. Thankfully my sister had talked with me on the drive into work (as she has talked to me every day going to work since then). She told me to take a deep breath, then sat with me in silent companionship Out of habit, I started breathing in my circle of breath. She stayed on the phone with me while I breathed and cried until I was calm enough to open my car door.

A few days alter, I had to operate. Blake was so engrained with my identity as a surgeon. We did our surgery rotation together at 3rd year medical students. We practiced knot tying together for hours on end. We talked about our cases together. We took tips and tricks from one another. I was waiting to operate when I learned of his death. Every bit of going into that case felt like a betrayal. How could I do it without him in the world? I stood outside the OR at the scrub sink with heart pounding and tears in my eyes. One of the CRNAs walked by, enveloped me in a hug, and told me to breathe. It happened again. My circle of breath was there for me and allowed me to ground in my body, scrub my shaking hands, and do the case.

The first time I was invited to talk publicly about Blake’s death in an academic setting was about 18 months after his death. I had been approached by a surgeon leader in my hospital system who had known Blake from during her training, had her own brush with mortality and burnout, and wanted to talk about physician mental health at a system-wide peri-operative retreat. I had been given complete grace to say no, or back out at any time. But talking about Blake felt like the right thing to do. The moments before the event however, I began to get an overwhelming sense of panic. I took one deep breath with no effect. Then tried box breathing, as I felt that seems less conspicuous. That did not work either. So I closed my eyes and did my circle of breath, and was able to get up, walk to the podium and start telling my story and Blake’s story, which ultimately has led me here…to the ashes.

So why do techniques like the circle of breath work?

Let’s talk about our nervous systems.

The 2 pain modes of our nervous system sympathetic aka the “fight or flight” side and our parasympathetic or “rest and digest” side. When we enter times of stress or danger, our sympathetic nervous system turns on. This is an evolved protective mechanism - it allows us to sense danger and act accordingly. Our pupils dilate, allowing for more light and better far vision. Our hear rate speeds up to improve our cardiac output. We experience broncho-dilation to allow for better airflow in our lungs. GI functions shut down. Our pancreas down regulates it’s secretion of insulin. Our bladder relaxes and kidneys decrease their function to maintain our blood volume. We are readied for the fight.

When I had these moments of physiologic activation after Blake died, my primitive nervous system was telling me I was in danger. I could feel it, mostly through my heart rate. My body knew the last time I was in these circumstances - something dangerous happened, and/or I was getting ready to do a very vulnerable and scary thing. Since the nervous system doesn’t really listen to logic or words, I could not talk myself out of the anxiety. But things like Circle of Breath, especially since I had practice using it during times of internal chaos, worked to tell my nervous system I was safe. Circular breathing activates the Vagus Nerve which is the main driver of the parasympathetic nervous system. This action sends an immediate signal to the brain that the body is safe, reducing heart rate and blood pressure. It undoes all of those mechanisms from the activation of the sympathetic system. The “circular” part of breathing with this modality removes the pauses in breathing and prevents the bunching of tension that occurs when our breath gets shallow with panic. The longer exhale that we experience when we use the circle of breath reduces our carbon dioxide levels in our blood, which can quickly reduce feelings of anxiety.

Having the wherewithal to do something like circle of breath takes practice, and doing these techniques when your body is physically activated by exercise can make it more natural to use them when anxiety or stress activates it similarly. An elevated heart rate is an elevated heart rate, and our body at it’s most basic level does not know the difference between exercise for pleasure/fitness and fear/anxiety/panic. It’s all sympathetic activation. I experienced this the first time I tried to exercise after Blake died- I had to stop almost immediately. I didn’t have insight as to what was happening until I discussed it later with my therapist. I can now say I had a full blown panic attack. The sensation of my heart rate increasing just took me back to the moments after I found out Blake had died. At that point in time, I was still in the depths of my EMDR therapy and my body was clearly still keeping the score of my incompletely processed trauma. My system was still off line and unable to access any of my practiced resources. As my system healed through EMDR, I was able to separate the feeling of aerobic exercise and anxiety, and access tools to pull me back from the brink when anxiety did appear.

So I encourage you all to form some sort of meditative practice, specifically after exercise. When you learn how to slow your nervous system down during intentional inner chaos of, you’ll be able to access it when the chaos is occurring out of your control. Because if we don’t practice it, we won’t use it. Run it like you would run a simulation at work. This is like a code, a shoulder dystocia, an AFE, a postpartum hemorrhage (sorry to all other physicians, but all of my simulation references are OB). If you don’t drill it, it won’t be second nature when you’re in the thick of an emergency. And controlling our nervous system is how we can get out of the fire. Out of the emergency. Recover and rebuild.

From the ashes,

Andrea