“I can’t breathe,” “I can’t breathe,” “I can’t breathe.”

I heard these words cried by my patients throughout ICU rooms in Los Angeles as I labored in during the early weeks of March, shortly before COVID-19 was declared a global pandemic. Desperate to hang onto the life they sensed slipping away to the virus, I felt powerless as to how to help them.

Using the best advice coming out of China and Italy at the time, my team of nurses, respiratory therapists, physicians and I quickly placed each patient who showed any shortness of breath with low oxygen saturations on a ventilator to relieve their struggle to breathe.

After a few weeks, I noticed a pattern associated between their breathlessness and laboratory markers, and I knew that placing them on a ventilator wasn’t the best answer to helping each of them catch their breath. The answer rested in using medications to suppress their immune system; something I had never done in my 20 years of taking care of critical care patients. 

Needless to say, I was hesitant to start therapy that is counter-intuitive; giving patients with a life-threatening infection medication that would suppress, not boost, their immune systems. Each day I questioned: will this therapy harm or kill my patient, or will it save their life? The team of nurses, respiratory therapists and physicians I work with seek to relieve this breathlessness with our shared knowledge and fundamental value of human life that we vowed with the Hippocratic Oath: above all, do no harm.

As I watch what’s going on throughout this country, I can’t help but think of that other oath that police officers make: to serve and protect. Unfortunately, many times it has not been the case as we all recently witnessed in Minnesota.

In this country, we are currently fighting two diseases that are killing our citizens. George Floyd, and far too many before him, have cried out for breath. The disease causing their collective breathlessness is not one caused by a virus, but instead, inflicted by outward ignorance that each life is sacred. 

Horrifically, I watch with my fellow Americans, the injustice and callousness exhibited towards the sanctity of a human life. Not just by any civilian, but by someone who took an oath to protect and serve his community, and yet chose to choke the breath out of a man he vowed to protect. Equally disturbing is the blatant silence and inaction of those surrounding him, wearing the same uniform that stands for service and protection of others.

Those values have been lost in a political sea of systemic racism, intolerance and overall unwillingness to address ongoing societal issues that continue to divide our nation. 

As a child growing up in Iran, America was viewed as a symbol of endless opportunities and a land where all people are free. I was fortunate when my parents decided to come here in 1979, as Iran was in the middle of a revolution. We sought improvements in our lives, and since coming here, have been given so many opportunities. I was able to attend medical school at the University of Southern California and vow what would become the guiding principle of my medical career: above all, do no harm.

Throughout my years training at LAC + USC, a public hospital that treats primarily lower socioeconomic status Latino and Black communities, I was aware of the innate disparities in health care access that affects these marginalized communities, and made every effort to treat my patients with equity.

Working with unprecedented levels of disparity and desperation associated with exclusively treating critically-ill COVID-19 patients, I grew disheartened. Seeing my frustration with the scope of work, my wife cited a verse from Mishnah, the first major written collection of the Jewish oral traditions: “If you save one life, you save the world.” I have reflected on this each day so I can concentrate on one patient at a time, such that I can help all of my patients.

As I adjusted my approach to treating COVID-19 with understanding that it consists of two disease states: a known viral infection and a hyper-activated immune-mediated process going awry within the most critically-ill patients, relieving their shortness of breath became less daunting.

Despite my continuous agonizing over individualizing each patient’s treatment plan, I knew I had to take action in giving them medications early and aggressively. And as I saw less patients requiring mechanical ventilation, shorter ICU stays, and better outcomes overall, I was comforted with the knowledge that my three months of sleepless nights filled with research, ICU calls, and individualizing treatment plans was well worth it. My patients’ cries of breathlessness were heard, thoroughly understood and treated.

 We are in the midst of two pandemics. One is a disease of the body, and the other, a disease of the heart. The novel one does not discriminate against race, gender, age or socioeconomic status, and it does not have a vaccine or cure. The other has been around for years, targets marginalized communities, and has a cure that requires great, achievable action across all communities. We know how to treat this second disease, and much of it centers around listening and comprehending those voices we choose to ignore.

In Mishnah, it is also states, “If you take one life, you end the world.” America is a great country, but we are far from a perfect one. We can no longer be silent towards the cries of injustice, just as health care professionals are not silent towards the cries of our patients.

Breath is essential to life, and we must breathe education, acknowledgement, and action into our nation’s life.

Dr. Thomas Yadegar is a pulmonologist and critical care Director with Cedars Sinai-Tarzana Hospital.  Assistant and medical student Katherine Jacobson collaborated with Dr. Yadegar on this commentary.

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