Square Breathing

Last winter I ran a lady who slipped on some ice, landing on her outstretched hand. The fall hyperextended her right elbow and she felt pain in that joint. There were no other injuries, including her head and neck. She passed my amateur distracting injury test. I examined her right elbow and found pain and tenderness both in her distal biceps and proximal brachioradialis muscles. The elbow joint itself was stable, as was her humerus, radius, and ulna – as far as I could tell. The biceps muscle had a lump in the distal end that gave a step-off appearance and it was already starting to bruise.

From Gray's Anatomy (1918) via Wikimedia Commons

I felt like she tore her biceps, at least. I mean, you could pretty much see it.  The brachioradialis may have been torn, as well. I was also suspicious of an elbow sprain and kept the possibility of fractures in mind. My plan was to start an IV, dose her up with some fentanyl, splint the arm, and then take her to the hospital. She was in a significant amount of pain, however, and it would take me a couple of minutes to start the IV. I needed to distract her.

“Listen, Sally,” I told her. “I know your arm is hurting really badly right now, so I am going to give you some pain medications that will make you more comfortable. While I do that, I need you to slow your breathing.”

She nodded and did what almost everyone does – she slowed her breathing by taking very deep breaths.

“That’s good, Sally. Believe it or not, slowing your breathing will help your arm hurt less. But I have a great technique I want you to try. It helps a lot. Are you willing to try it out?”

She nodded, with tears in her eyes.

“Cool. The technique is called square breathing. Have you heard of it?” She shook her head no. “That’s alright. It works really well. As a matter of fact, snipers use the technique to control their nervous systems. It is really simple. Are you ready?”

Sally nodded, paying attention.

“It is based on the count of three. We are going to breathe based on a three-count. Inhale for three, hold it for three, exhale slowly for a three count, and then hold your breath empty for three. Got it? I will count.”

I began a slow count: “Inhale, two three. Hold it, two, three. Exhale, two, three. Hold it out, hold it out, hold it out. That was great, Sally. Here we go again.”

I began the counting pattern again, while I started the IV.

The technique works as a distraction. The need to count and maintain a pattern focuses the patient’s attention on counting and breathing, rather than on what’s hurting. Instead of focusing on the anxiety of an injury, the pain it is causing, and the fear of what is going to happen, I can often get a patient to focus on breathing through a three count. My goal is to stretch the three-count to fours. Fives would be great, too. The pattern is easy enough for me to quickly explain. I can count out the pattern while my attention is on starting the IV, or drawing up analgesia, without distracting myself too much.

It probably doesn’t work as well as I think it does, but it is better than doing nothing and watching a patient hyperventilate. At least, it is a good second-line action. The best thing for a patient like this is opioid analgesics, of course.

As for Sally, I maxed out her first dose of fentanyl as soon as I started the IV. I like to start with two mikes per kilo IV as the initial dose, except in the case of elderly people. Sally handled the analgesia well, relaxed a bit, and continued the square breathing pattern while I splinted her arm.

*Edit: The incorrect dose units in the last paragraph has been changed...