Two brave women

My list of non-fiction recommendations for 2019 will include two biographical books about women who sustained life-changing injuries in middle age. By coincidence, both books arrived together from my local library last week, and I noticed several similarities between their subjects: both were born in the late 1950s, grew exceptionally tall and athletic, worked as journalists for the Times newspaper group, and were injured as a result of their chosen activities. But the nature of their traumas, and their ways of coping, were very different.

My former medical career brought me into contact with many people recovering from serious illness or injury. Emotional responses varied tremendously. Initial distress usually resolved, being replaced by the capacity to accept and cope even with longterm impairment, often including some positive changes in attitudes, beliefs, relationships or way of life. But not everyone was able to adjust, and some were left with ongoing psychiatric symptoms. Given the complex interplay of biological, psychological and social factors unique to each case it is unwise to generalise or to predict individual responses, and blanket advice to “think positive” or show a “fighting spirit” can be unhelpful. The stories of the women in these two books illustrate this diversity. 

Melanie Reid (1957 – ) was thrown from her horse in 2010 when he refused a cross-country jump. She sustained spinal fractures which rendered her tetraplegic apart from having limited function in her right hand. Her memoir The World I Fell Out Of describes the months she spent in hospital, and subsequent years back at home with her husband. The practical limitations of being largely confined to a wheelchair mean that the mundane essentials of living – washing, dressing, toileting, eating and drinking – require assistance, and occupy a large part of each day. The inability to move, the bodily disfigurement, the loss of sexual attractiveness, being deprived of the sense of touch, have a huge emotional impact for patients themselves and for those close to them. To a healthy person all this might sound so horrific that it would inevitably lead to deep despair and the desire to end it all. Spinal cord injury is in fact one of the few medical disorders shown to be associated with a raised suicide rate (Harris and Barraclough 1994). Melanie Reid does make brief reference to considering a one-way trip to Switzerland, and to taking antidepressants, but on the whole her mood stays upbeat. With tenacious determination to work on rehabilitation, her physical function improved much more than her doctors predicted. She was eventually able to drive a car, and even return ride a horse until she was thrown off again and suffered further injuries. She has overcome this setback, and continues to channel her mental energy into writing. This book, and her “Spinal Column” in The Times, contain frank and often darkly humorous accounts of life following her accident.

Marie Colvin (1956-2012) lost the sight of one eye after being shot in the face and chest by snipers in Sri Lanka in 2001. In Extremis: the life of war correspondent Marie Colvin, written by her friend and colleague Lindsey Hilsum, gives a comprehensive account of her life and complex character. Described as brave, passionate, driven, intellectually outstanding, beautiful, glamorous and generous, she has been hailed as the greatest war correspondent of her generation. Yet quotations from her diaries reveal an inner insecurity and her personal life was tumultuous, marked by heavy drinking and smoking and a succession of doomed love affairs. The optic nerve injury, though not the main focus of the book, was a watershed. Her blind eye had been preserved and looked normal from outside, but she always covered it with a large black patch: “part of me in a way, something that would make a clear division between life before and after”. She also replaced all her clothes with those of a more “architectural” cut than her previous “lacy or flowing styles”. As soon as she was physically fit she resumed assignments in the Middle East but worsening nightmares, panic attacks, anxiety and depression eventually forced her to take leave and undergo psychiatric treatment for post traumatic stress disorder. Over the next few years, while her intrepid forays into war zones and graphic dispatches brought international acclaim, her private life became increasingly miserable and chaotic. She was killed by a rocket attack in Syria in 2012.  

Inevitably, reading such stories makes me wonder how I would cope with a life-changing injury myself. And it could happen to anyone, even someone like me who is neither athletic nor adventurous and is not attracted to extreme sports or situations. My most demanding activity is dog-walking and even this can be hazardous – I have already had two bony fractures due to being knocked or pulled over by excited canines. Both injuries have healed perfectly but I know they could have been much worse, in which case I very much doubt that I would have been able to marshal such courage and determination as that shown by Marie Colvin or Melanie Reid. But none of us can predict how we will respond if faced with a health challenge of such magnitude as theirs. 

 

 

Our “Optimum Wellbeing Retreat”

Brian and I spent five days at Gwinganna, an upmarket “lifestyle retreat” set in 200 hectares of native bushland high above Australia’s Gold Coast. We stayed in the Billabong Villas.

Billabong Villas Gwinganna

I was apprehensive about being woken at 5.30 a.m., deprived of caffeine, alcohol, sugar, dairy and gluten (any guest caught smuggling in such items is sent away without a refund), and having only limited access to my iPhone. I had cut down on coffee and tea beforehand in the hope of avoiding withdrawal symptoms but, in common with several of the other 50-odd other guests, I had a mild headache for the first two days. Then I felt well for the rest of the course.

The environment is beautiful, with walking tracks traversing the woodlands and valleys, and two outdoor swimming pools. There are plenty of wallabies and birds, the occasional koala and one sociable peacock.

 

The morning timetable is intensive, with just a cup of herbal tea at 6 a.m. before the qi gong session held in a field overlooking the sea. Then a choice of activities: an energetic walk, a gentle walk, or a guided tour of the orchards and vegetable gardens. A substantial breakfast at 8 a.m. is followed by a stretch class, then again a choice of activities such as yoga, Pilates or dance. More herbal tea at 11 a.m. and then a talk on nutrition, exercise or managing stress. Lunch at 1 p.m. includes fish or chicken with large salads and sometimes vegetable soup. Afternoons are free to rest, swim, or experience one of the many special therapies. A massage and a facial are included in the price of the retreat, and over 80 other modalities ranging from Reiki to colonic irrigation are available at extra cost. Missing my own animals, I had a session of Equine Assisted Therapy.

Horse therapy Gwinganna

Dinner is at 7 p.m. with fish or meat or vegetarian options. After that most people are ready for bed, though on some evenings there are group meditation sessions.

All the staff are passionate about Gwinganna’s approach and most have worked there for many years. Several of the guests are also old hands, attending once or twice each year because they are stressed by high pressure jobs or coping with chronic illness. Brian and I had already been feeling alright before we went there, but we both enjoyed the experience, and returned feeling refreshed and relaxed. Pleased that my body composition analysis showed a normal bone mass and low belly fat, I decided that my usual diet and lifestyle are healthy enough, and do not intend to make any major changes although I feel less desire for coffee and wine. My muscle mass was a bit on the low side so I am back to cold water swimming.

 

 

Choice at the end of life

A bill to legalise voluntary euthanasia and assisted suicide is currently being considered here in New Zealand. Passionate campaigners both for and against have put forward compelling reasons to support their case. At one extreme are those who believe that human lives are sacred and only God can determine when they should end. At the other extreme are those who believe that each individual has the right to control the timing of his or her own death. Logically it is not possible to agree with both views, but perhaps there is scope for some compromise between them.

The term euthanasia, according to its Greek origin, means a “good death”. Much as I dislike the idea of deliberately ending a life, I do think there is a place for assisted dying for patients who are already finding their situation unbearable, or who wish to avoid likely suffering and loss of dignity in the future. But such cases are a minority. When I was in medical practice I got to know many patients with terminal or incurable conditions, mostly advanced cancer, and I do not believe that most of them would have wanted euthanasia or assisted suicide even if these options were legally available – though I remember a few who did. Similarly, recent surveys have found that many people with severe permanent disabilities have no desire for euthanasia, and are often worried that they might be pressurised into having it if the bill becomes law.

There are some strong arguments against euthanasia, but I think they need to be qualified. Looking at some of them in more detail:

“Euthanasia goes against the sanctity of life and the will of God.” This is the position of the Catholic Church and many other religious traditions. While respecting this belief myself, I do not think it justifies withholding the option of euthanasia from those who hold a different view. For this reason, when an anti-euthanasia submission was recently presented to our local congregation after Mass, I did not sign it.

“There is no need for euthanasia because symptoms and suffering can be so well controlled with modern palliative care.” I disagree with this one. Only a minority of dying patients have access to specialist palliative care. Even with the best of care, there are a few terminally ill patients whose symptoms and suffering cannot be relieved. And what about old people who may not have any specific life-limiting disease but would welcome death to release them from weakness and frailty, aches and pains, failing physical and mental faculties, loneliness and lack of purpose?

“Euthanasia may be undertaken too lightly, and against patients’ real wishes.” This is a real risk. Some people will feel obliged to request euthanasia to avoid being a burden to others. Well-meaning medical staff can judge that some patients’ lives are not worth continuing, when the patients themselves might disagree. This can also apply to the withholding of life-sustaining treatment, which could be called passive euthanasia. I have just read It’s Not Yet Dark, a memoir by the late Irish film maker Simon FitzMaurice. He describes being discharged from a hospital without being offered home ventilation because doctors had assumed that someone with his diagnosis, namely motor neurone disease, would not want their life prolonged. In his case they were quite wrong, and he was able to obtain a ventilator and spend several more worthwhile years with his family. A less informed and articulate patient could not have achieved this.

“There could be deliberate abuse.” Going further down the “slippery slope”, legalised euthanasia could provide a cover for murder. Family members might want to dispose of a sick or elderly relative, in order to make their own lives easier, or to get hold of an inheritance. Euthanising incurable chronic patients, who require expensive and time-consuming care, could be said to enable the more efficient use of scarce health care resources. Recent history has shown the potential for mass killings by authorities in the name of racial cleansing or medical research.

“There can be psychological damage to the staff involved.”  The same applies to clinicians carrying out abortions, and veterinary surgeons putting animals to sleep. There is certainly scope for conflict and distress when those trained to preserve life are called upon to end it, depending on whether they believe they are doing the right thing, and on the method used. Prescribing a fatal quantity of drugs, for the patient to take at a time of his or her own choosing, would seem a less harrowing experience for a doctor than administering a lethal injection – although the end result would be the same. Besides affecting staff, unnatural deaths can have a deep impact on the family and friends of the deceased. Consenting to euthanasia of a sick pet, and hearing about the suicide of a colleague, have counted among the most distressing events in my own life.

In summary my own view is that euthanasia and assisted suicide can be justified occasionally, though literally as a last resort, on condition that the patients concerned have given informed consent; if other treatment options have been carefully considered and excluded; if clinicians with religious or ethical objections are not obliged to take part, and if there are safeguards against abuse of the system. I suspect that many people who support euthanasia in theory might sign up in advance when still in reasonable health, then decide not to go through with the option when it actually came to the point – but having a sense of control is a very important aspect of coping with illness, and I believe patients should be allowed that choice.

 

 

 

 

 

 

Medical cannabis

Access to medical cannabis is tightly restricted here in New Zealand, and progress towards a more liberal approach is slow. I understand that doctors are allowed to prescribe Sativex on an individual basis for such conditions as advanced multiple sclerosis or intractable epilepsy, but that many are reluctant to do so, and that patients have to meet the high cost of the product themselves. And following a recent law change, people with terminal illness can now use home grown cannabis without fear of prosecution for themselves or those who supply them. But using cannabis outside of these circumstances still carries heavy penalties; according to the police website, these range from a $500 fine for possession to a 14 year jail term for supply or manufacture. This despite the fact that cannabis, with its analgesic, anti-inflammatory, anti-tumour, anticonvulsant, antispasmodic, anxiolytic and sedative effects, has been used for healing purposes for thousands of years and is now legal in many other parts of the world. Cannabis oil can be taken by mouth, inhaled, or applied to the skin.

My personal interest in this topic began in an unusual way. Unlike many students I never tried cannabis at university, because I moved in fairly conventional circles and also had an aversion to smoking. Then last year I was intrigued when a homeopath suggested that Cannabis sativa would be a good remedy for me. Shortly after this I came across a series of online documentaries called The Sacred Plant promoting the value of cannabis for treating cancer, epilepsy, arthritis, multiple sclerosis, other autoimmune disorders, and AIDS. While this series was focused on the benefits of cannabis, with minimal discussion of any potential downside, it convinced me that this plant has huge medicinal potential and has been unfairly stigmatised. Heavy recreational use can certainly be harmful especially for adolescents, but it seems wrong to criminalise sick people who are seeking the plant’s therapeutic effects.

Formal research on patient populations has been hampered by the legal constraints but there are some published clinical trials, besides many laboratory studies and a wealth of anecdotal evidence, supporting its use. The National Cancer Institute in the USA has produced an excellent review, including a detailed version for professionals and a simpler one for patients, not limited to the cancer setting. Cannabis can alleviate symptoms of pain, nausea and vomiting (including that caused by chemotherapy), lack of appetite and weight loss, anxiety and insomnia. Importantly, it also has potential for treating the disease which underlies these symptoms. Like any effective drug cannabis can have unwanted effects and interactions, but these usually seem to be mild in comparison with those of many orthodox medications.

Two main constituents of Cannabis sativa are THC (tetrahydrocannabinol) and CBD (cannabidiol). Both have medicinal properties but THC is mainly responsible for the “high” sought by recreational users, whereas CBD has minimal psychoactive activity and can be freely purchased over the counter in many countries including UK, Australia and many states of America. The plant also contains hundreds of other chemical compounds, found in varying proportions in the seeds, leaves and stalks and depending on which strain is used, and there is still much to learn about how its extracts can best be prepared and used medicinally.

My own health is reasonably good but I do have a few medical problems of a kind that could be helped by CBD, and am tempted to buy some on my next overseas trip. But I doubt it would get past the clever beagle dogs who patrol Auckland Airport to sniff out illicit drugs.

Cold water swimming

Inspired by Floating, Joe Minihane’s memoir about swimming in seas, rivers and lidos around the UK, I plan to do more outdoor swimming this year. I have ample opportunity here in New Zealand, being lucky enough to live in a house with a pool in the garden and ten minutes walk from the sea. I already swim most days during the hot summer months but intend to try extending the season.

Swimming, especially in cold water and sea water, seems to confer mental and physical health benefits over and above those to be gained from exercise in general. Mechanisms for this include the physiological stimulation of being in cold water, the meditative state induced by rhythmic movement and deep breathing, being surrounded by nature, and absorption of the minerals present in the sea. Many people feel an immediate uplift of mood and energy when they go for a swim. Regular swimming over a period of several months appears to reduce stress, helps to regulate the immune and endocrine systems, and reduces inflammation. Regular swimmers catch fewer colds, and there is preliminary evidence that swimming can help in the management of numerous medical disorders including anxiety and depression, eczema and psoriasis, hypertension and diabetes. However it takes time for the body to adapt to the demands of cold water swimming and reap these health benefits. So it is important to build up the practice gradually, and to be aware of the potential hazards as outlined below.

The shock of getting into cold water can throw all body systems out of balance, causing the sudden onset of breathing difficulties, muscle spasms, raised blood pressure and disordered heart rhythm. Cold water shock can be fatal due to a heart attack, stroke or inhalation of water. Hypothermia can ensue after more prolonged immersion and is manifest by shaking, weakness and confusion. To avoid hypothermia it is important to wrap up and warm up after the swim. Individual tolerance to cold varies but my understanding from various websites is that water temperatures below 15C are always dangerous, and that beginners should probably not start below 20C. Wild swimming in rivers or seas carries the risks of infections, injuries, and drownings due to powerful currents or tides.

Being a person who gets cold easily I considered buying a wetsuit, but after a trial fitting decided against it. I found the suit so cumbersome to take on and off, and so constricting to wear, that I felt it would detract from the pleasure and benefit of swimming. I got leggings and a neoprene jacket instead and am proud to report that yesterday, the last day of winter, managed to swim one length of the pool …

J contemplating water

Taking tablets

“Healthy living” – good diet, regular exercise, enough sleep, stress reduction, positive outlook – and natural therapies can achieve a lot, but in many cases of medical illness they are not enough on their own. I am thankful to have found effective drugs to control my own episodes of high blood pressure and cardiac arrhythmia. At the same time I can well understand why around 50% of people with chronic disease fail to take some or all of the medication prescribed for them.

There are many reasons for non-compliance (or non-adherence). Side-effects: the experience of unpleasant symptoms in the present, or concern about possible permanent damage in the future. Reluctance to accept a need for ongoing treatment: especially if the benefits cannot be felt immediately, if healthcare professionals have not explained them clearly, or if there is genuine uncertainty about the pros and cons of longterm medication. A desire to avoid artificial chemicals. The financial cost of the drugs.

All these are valid points and there is no doubt that some prescriptions are unnecessary or harmful. But assuming that taking the drugs is indeed the right thing to do, here are some personal observations about how the physical form of the tablets (or pills or capsules) might affect compliance. These aspects may not be considered by the prescribing doctors, though I expect nurses and pharmacists appreciate them more.

Size: while this is partly determined by the chemical makeup of the drug, big tablets are hard to swallow, and small ones can get lost.

Colour and shape: many generic drugs are presented as small round white pills which are hard to tell apart, and this can lead to mistakes in dosage. Coloured tablets of different shapes are much easier to identify. Incidentally, there are some interesting studies showing that the colour of a tablet affects patients’ reports of its effects.

Strength: having to break tablets into halves or quarters is tedious and often inaccurate. Tablet-cutters can help, but it is better if low-dose versions are available.

Frequency of dosage: again this is partly dependent on the properties of the drug, but if it is possible to get a controlled-release preparation to be taken once daily this is preferable to divided dosing.

Such practicalities were not mentioned in my pharmacology course at medical school, as far as I recall. Perhaps they seemed too simple and obvious to be considered in an academic context. I certainly paid them little attention when I practiced as a doctor, not always being aware what the tablets I was prescribing would look like when dispensed. I now realise that size, colour, strength and frequency of dosage can be quite important to patients, especially those who have problems with eyesight or memory. Here in New Zealand it is impossible to get some of the low-strength and controlled release preparations that are available in the UK and elsewhere, and make patients’ lives easier.

 

Bach flowers: medicine or magic

After taking a few years out from my Bach flower remedy practice due to illness in the family I am now available to see clients again, so it seems timely to revisit the topic on this blog.

The remedies are intended to restore emotional balance. Common presenting problems include anxiety, grief, relationship difficulties, lack of direction in life, and the hardships of physical disease. I am continually impressed with how well the system works: 80 of my first 100 clients reported an improvement, and this figure is in line with the experience of other practitioners. But it is not always easy to reconcile my background in orthodox medicine with my interest in holistic therapies like the Bach flowers. I have to acknowledge there is no accepted scientific explanation for their mode of action, and that when tested in the artificial context of clinical trials they usually perform no better than placebo.

Leaving aside the question of whether the remedies have direct effects, a consultation with a Bach practitioner can be therapeutic because it empowers the client – as the jargon goes – “to take responsibility for their own healing”.  The interview does not follow a set structure, and it is up to the client to decide what they want to talk about and how much detail to reveal. The practitioner listens, and asks questions for clarification, but does not probe for extra information or offer unsolicited advice. The selection of remedies is a cooperative process, with the practitioner making suggestions but the client helping to choose what flowers they need, and sometimes seeing their problems in a new light as a result. The combination of up to six flowers is tailored to the unique individual’s state of mind rather than a symptom or diagnosis.

This is very different from the assessment process used in orthodox medicine and psychiatry. Traditionally, in the orthodox system, the doctor is in charge while the patient takes a passive role. The consultation follows a standard format, with a series of questions followed by examination and investigations, aimed towards establishing a diagnosis. The drugs, surgery or radiation prescribed will usually have evidence-based benefit for the disease concerned, but inevitably carry some risk of side effects. The orthodox approach often works very well, especially for acute conditions and those that are clearly defined, and is sometimes life-saving (as was clearly brought home to me in 2015 when my husband required heart surgery, described in my short memoir Across a Sea of Troubles).

The orthodox approach with its armamentarium of marvellous medical and surgical technology, and the holistic approach which draws on the universal principles of healing and self-help, are truly complementary to each other and can be used together – I think of them as representing the “yin” and “yang” of healthcare. Unfortunately there is considerable antipathy and misunderstanding between practitioners of the two schools and the concept of integrative medicine, which combines the best of both, has not been widely accepted.

While Bach flowers can be used on their own for minor mental or physical imbalances, they are not sufficient as a sole treatment for anything more serious. I often advise clients to seek a medical assessment if they have not done so already because physical diseases, for example over- or under-activity of the thyroid gland which is common especially in women, can present with psychological symptoms.

Clients are attracted to therapies like the Bach flowers because they are natural and safe, treat them as a “whole person” rather than just a case of a particular disease, and provide them with a sense of choice and control.  More information about Bach flowers can be found on this page.