Category: Medicine and Health

Soldier’s heart, shellshock and lack of moral fibre

~ Jennifer Barraclough ~ 2 Comments

When I was unwell last year, my husband Brian explained my symptoms in military terms: “You’ve been in the front line, and now you’ve got shell shock.” Brian had researched this condition while editing A Physician in Spite of Himself, the autobiography of DW Carmalt Jones who was in charge of a shell shock hospital during World War 1.

Stressed and exhausted by dealing with a series of medical and surgical emergencies in the family, I had developed a variety of symptoms. Repeated attacks of rapid irregular heart beat and breathlessness accompanied by high blood pressure, on two occasions so severe that I was taken to hospital by ambulance. Separate episodes of feeling very cold, or very hot, shaking all over, or suddenly feeling drained of energy and having to lie down. Loss of appetite and weight. Insomnia. The symptoms were  mainly of a physical nature, but various medical tests did not indicate a definite diagnosis. As a former psychiatrist I knew they might be due to anxiety and depression, but a trial of antidepressant drugs made me worse.

Syndromes of this kind can be triggered by any sort of traumatic experience, especially when there seems no scope for controlling the situation or escaping from it. Most of the early descriptions were carried out on servicemen exposed to great physical and emotional stress in wartime. In the American Civil War, men who complained of palpitations, chest pain, shortness of breath and fatigue but had no signs of organic heart disease were said to have “soldier’s heart”. Other terms included da Costa’s syndrome, cardiac neurosis, and neurasthenia. In World War 1, the condition of “shell shock” could include symptoms in many different bodily systems, for example headache, tremor, confusion, nightmares, loss of balance, impaired sight and hearing, as well as the cardiovascular symptoms listed above. Some sufferers received no sympathy or understanding, being accused of cowardice or malingering and punished by firing squad. Others were sent to field hospitals for a brief period of sleep, food and graded exercise before being returned to duty. In World War 2, British airmen who refused to fly on bombing missions were labelled as “lacking moral fibre” (LMF) and usually demoted to menial jobs. Some of these men would have been suffering from the type of illness described above, others just could not bring themselves to take part in the killing of civilians. LMF was highly stigmatised, and concealed as far as possible, so that when I came to write something about it in my novel Blue Moon for Bombers I found little published information. In more recent conflicts, notably the Vietnam war, attitudes were more sympathetic and it became more acceptable to talk about the psychological side of these conditions. The concept of “post-traumatic stress disorder” (PTSD) was born, and continues to generate a great deal of interest and research.

Body and mind are interconnected, and patients with stress-related illness usually have some combination of physical and mental symptoms. For this reason the orthodox medical system, in which the different specialties are separated, may not be well placed to meet their needs. Patients who present with mainly mental symptoms would often be diagnosed as having PTSD and referred to psychiatrists or psychologists, perhaps without having a medical evaluation to exclude the organic pathology that will in fact be present in some cases. Patients for whom physical symptoms predominate might find their way to cardiac, respiratory, neurological or other specialist clinics, and if no organic disease is found the psychological aspect may not be taken seriously if it is recognised at all. The plethora of terms that have been used for such conditions over the years – psychosomatic, functional, medically unexplained, somatoform, and many more – suggests the difficulty of understanding and managing them. Many patients turn to alternative therapies for a more holistic approach.

There is no specific treatment although different medications, psychological therapies and natural remedies prove helpful for individual patients. Sometimes the illness becomes chronic so I was fortunate that my own symptoms recovered within a year, with support from kind relatives and friends, orthodox and alternative healthcare professionals, and an improvement in my life situation.

Only a minority of people who are exposed to severe stress will develop a stress-related illness. Those who do may well feel ashamed about being over-sensitive and lacking in resilience, as I did myself, even though I have chosen to go public by writing about it in this blog and in a memoir called Across a Sea of Troubles.

Reflections about caring

~ Jennifer Barraclough ~ 2 Comments

This post is an extract from a work in progress, a memoir about the traumatic events that affected my family last year. If you have suggestions about how to make it more readable or relevant, please leave a comment below.

I found that looking after my husband following his heart surgery, and my mother during her last illness, was highly stressful even though it only lasted a few months and involved very little heavy hands-on work. The carers of patients who are disabled or demented must have far more arduous and prolonged ordeals to endure. The experience certainly made me appreciate the challenges of the caring role, with its somewhat uneasy combination of duty and privilege.

Studies from the cancer care setting indicate that levels of emotional distress among patients’ partners are similar, in both frequency and severity, to those for patients themselves. This is not surprising, considering that besides feeling sad and anxious about their loved ones, partners are often physically exhausted by providing practical care and running the household on their own.

There is a sensitive balance between attending to the sick person and meeting one’s own needs. Self-help authorities often say “Look after yourself first, or you will have nothing to give to other people”, usually quoting the airline safety message about putting on your own oxygen mask before assisting anyone else. This is sensible advice, but it can be difficult even to find the time for basic self-care, let alone take a break to enjoy something purely for fun or pleasure. One afternoon when Brian was in hospital, I found myself with half an hour to spare between appointments in the city, and impulsively decided to get a manicure. This frivolity gave a short boost to my morale, even though when I visited Brian in the evening he remarked that my bright pink nails made me look like a whore.

When my mother’s health was failing I discovered what a fine balance there can be between providing help and support that is appropriate to the patient’s needs, and seeming to be interfering with their independence and autonomy. Ideally it is best to check what the patient wants, rather than assuming you know what is good for them. But this does not always work, for sick people can make irrational choices, keep changing their minds, or be incapable of expressing their wishes, in which case the carers can only try to be tolerant.

While attention is focused on the patient, the carer’s vulnerability is not always appreciated, and I felt this a couple of times. A friend of the family sent two beautiful hand-painted cards, one for Brian and one for Clare, but did not send one to me nor mention my name on the messages inside. I did not blame her for leaving me out – I might well have done the same in the past – but, being at a very low ebb at the time, could not help feeling a twinge of self-pity. On another occasion, I phoned the hospital about 11 p.m. and asked to be put through to the ward where my mother was dying. The ward nurses had told me I could ring at any time, but the telephonist was reluctant to make the transfer, and sharply reprimanded me for calling after visiting hours.

Leaving these minor incidents aside, my relatives, friends and healthcare professionals were tremendously helpful to me both on practical and emotional levels. Research consistently shows that good social support is an important factor in buffering the adverse effects of life events, and my experience showed me that this is very true. I will always be grateful to those who took time to listen while I confided my troubles, brought meals to the house when I was too unwell to shop or cook, gave lifts to the hospital when I was too unwell to drive, or sent supportive emails from overseas.

My main confidant and support was Brian himself, and though we were close before his illness we have become even closer since. Finally, as an animal lover, I must also mention the comfort provided by the presence of our three cats.

Earthing; or, A virtual dog walk

~ Jennifer Barraclough ~ 4 Comments

Today I walked the length of Takapuna Beach without my shoes on. The sun was out, the tide was low, the sand was smooth and firm. Being near to such beautiful beaches is one of the best things about living in Auckland.

 Walking barefoot on grass or sand is a natural way of “earthing“. Apparently this practice causes a transfer of electrons into the body, thereby helping to neutralise free radicals and reduce inflammation, so bringing about improvements in physiology. Research is still in its early stages but there is some evidence that earthing can help with numerous conditions including pain, insomnia, hypertension, cardiac arrhythmias and autoimmune disease. Certainly I feel in better health when I walk on the beach regularly, and often get new ideas for writing while there.
For eight years I used to take this same walk once a week, rain or shine, accompanied by my mother and a dog called Khymer. Then Khymer and my mother both died, my husband and I were both ill, and I gave up doing it regularly. Now I am determined to resume the routine. Having Khymer with me only in spirit does have one advantage; I no longer have to start early in the morning to comply with local regulations about the times when dogs are allowed on the beach.

Stress and the heart

~ Jennifer Barraclough ~ 1 Comment

Although I used to work as a general hospital psychiatrist, I doubt if I fully appreciated the power of the mind-body connection till I became ill myself. Last year, during a prolonged period of anxiety and exhaustion due to my husband’s heart attack and cardiac surgery followed by my mother’s bowel obstruction and fatal stroke, I started to experience alarming episodes of fast irregular heartbeat, faintness and tightness in the chest, accompanied by high blood pressure. Other symptoms around this time included weight loss, insomnia, spells of fatigue, hot flushes and cold chills. Medical investigations showed a few minor abnormalities which were not regarded as very significant.

The episodes of tachycardia and hypertension continued to happen after everything else had settled down, as if they had taken on a life of their own. My husband, who has now made an excellent recovery himself, believes that being in the “front line” of so many traumatic events caused me to develop a variant of the condition described in the First World War as “shell shock” or “soldier’s heart”. Many other diagnostic labels were suggested from various sources: “broken heart syndrome” “post-traumatic stress disorder” “atypical depression” “autonomic neuropathy”. The diagnosis from a recent specialist consultation was “paroxysmal hypertension” also known as “pseudopheochromocytoma” and preventive treatment with beta-blocking and alpha-blocking drugs has been successful so far. From being barely able to cope with daily activities a few months ago I am now almost back to my usual self, but with an increased awareness of the fragility of life and health and the unpredictability of the future.

While the type of stress-related syndrome described above is not life-threatening, there are more serious cardiovascular conditions that can be partly attributed to stress. I am not an expert in “psychocardiology”, but my experiences led me to look through the research literature and I found some well-established links. These probably stem from a complex interplay between biological and lifestyle factors: over-secretion of stress hormones such as adrenaline and cortisol, and lifestyle habits such as smoking, drinking too much alcohol, lack of exercise, lack of sleep, and general neglect of self-care. For example: Coronary heart disease, building up gradually over the years, is associated not only with the well-known physical risk factors such as hypertension and high cholesterol but with psychosocial ones: long term difficulties such as being unemployed, lonely, unhappy in marriage or at work, suffering from anxiety or depression and according to some studies the personality characteristics of impatience, competitiveness, hostility and suppression of emotion. Acute traumatic events, such as experiencing the death of a loved one or being involved in an accident, can precipitate angina, arrhythmias or heart attacks (myocardial infarction caused by coronary artery blockage) in predisposed people. The risk of death from heart disease  is increased during the first year of widow(er)hood. Those who survive a heart attack, and become anxious and depressed afterwards, have a worse medical prognosis than patients whose mental health is not so affected.

Mind-body connections, though widely accepted in theory, do not always have much impact on clinical practice. It is perhaps inevitable that, in the highly specialised world of hospital medicine and surgery, there tends to be a narrow focus on the diseased part rather than a more holistic view. Staff who are expert in technological procedures may not have the time or skill to deal with the lifestyle and psychological aspects of illness, for example many cases of depression and anxiety on cardiology wards are not recognised or treated.

Most cultures regard the heart as the seat of emotion, and in the energy medicine traditions of the East the “heart chakra” is associated with love, compassion, empathy and forgiveness. Can cultivating such qualities protect against heart disease? Not only are they difficult to measure, but most studies in medicine and psychology focus on negative factors rather than positive ones. However, there is evidence that life satisfaction, optimism, and happiness lower the risk. Owning a dog, which besides encouraging regular exercise provides a reliable source of unconditional love, is also conducive to heart health. Cats apparently have less cardioprotective effect, but they do know how to demonstrate the art of relaxation.

Homer supine

 

 

 

 

 

 

 

 

Frequent attenders

~ Jennifer Barraclough ~ 2 Comments

As a former doctor, I know that people who frequent medical settings are often regarded as a burden on the health service, and often attract negative labels such as “fat file patients” or “heartsink patients”. Now, after many years of being reasonably well and not taking any regular medication, I fear we are in danger of entering this category ourselves. As Brian remarked today, our lives have come to resemble a medical soap opera.

The latest episode began last Wednesday. My appointment in gynaecology outpatients at North Shore Hospital finished in time for me to go over to Auckland City for the evening’s choir practice. But just as we were about to start singing, Brian called my mobile phone. He had fallen over in the garden and hurt his leg. What would otherwise have been a fairly minor injury was potentially serious for someone on the anticoagulant drug warfarin, and his thigh was gradually swelling up. A kind neighbour drove him to North Shore Hospital and I set off at top speed to meet him there.

I have become very familiar with the hospital’s car parking system and bus services, and with the layout of the emergency department. The doctor who had seen me during my episode of hypertension and tachycardia last month greeted me warmly. I also recognised the doctor who had examined my mother prior to her emergency surgery for bowel prolapse.

Brian was assessed by a highly competent nurse specialist who, having discussed his case with the consultant on call, cleaned and bandaged his leg wound and recommended an overnight stay, with two-hourly neurological observations just in case there were any signs of bleeding into the brain. Luckily there weren’t.

After another largely sleepless night for us both, I drove back to the hospital to bring Brian home. For the rest of that day he could hardly walk and was in considerable pain, but since then has been gradually recovering from this latest setback. After review with his GP, we agreed that he could now stop taking warfarin, so that is one less drug for the twice-daily medication round.

We have many more outpatient visits coming up in the next fortnight: pacemaker clinic and ECHO cardiology (Brian), abdominal CT and surgical review (my mother), hypertension clinic (me). I have also booked a session of energy healing for myself. I hope I can keep the morning free for that appointment and that it will help with my episodes of fluctuating blood pressure, heart rate and body temperature which are presumably stress-induced. Meanwhile lying on the grass with one of the cats, in this case Leo, is the best way to relax.

IMG_0661

The long and winding road to recovery

~ Jennifer Barraclough ~ 4 Comments

Today is a Sunday, and also All Saints Day. After many weeks of absence, I’d been looking forward to returning to St Patrick’s Cathedral to sing in the choir at 11 a.m. Mass, always an uplifting experience. But I didn’t make it. With our various family health issues still ongoing, dealing with domestic practicalities and medical appointments leaves little time or energy for anything else.

Although life is still not easy, there are plenty of good things to be thankful for. Brian is making a splendid recovery from his cardiac surgery five weeks ago – though an atheist, he talks of a “miracle”. He can go for long walks on the beach; climb up and down the steep hills around our house; and do some work in the garden. The limiting factor is that he cannot yet lift heavy weights, because it will be three months before his divided sternum will be fully healed. Nor, because of the pacemaker insertion, can he raise his left arm above shoulder level. His mood is cheerful, and there is no sign of the cognitive impairment which he feared might follow such a massive operation. Having reached the age of 82 without being on any regular medication, he is now on five different drugs, which are presumably necessary at present though we hope some of them can be discontinued in future.

Meanwhile, the health of my 91-year-old mother has become the main focus of care and concern. Now home from hospital following emergency abdominal surgery, she is making a good recovery from the operation itself, and striving with great determination to cope with independent life again. But there are problems with managing her ileostomy and I only hope a satisfactory system can be worked out, and that it will be possible to reverse the procedure in a few months time.

My own symptoms continue on and off, and while further investigations are in progress I try not to worry about them too much. Friends and family continue to be wonderfully supportive and we have greatly appreciated all the messages of support, the lifts to hospitals, and the gifts of food and flowers including this lovely bouquet from the Cathedral Choir.

Flowers from choir

Why troubles never come singly

~ Jennifer Barraclough ~ 4 Comments

Just as our lives were beginning to settle down, with Brian recovering from his heart surgery and its subsequent complications, our household was hit by another health crisis. A few days ago Clare, my 91-year old mother who lives next door, developed acute abdominal symptoms. For the third time in recent weeks I called the emergency ambulance, and for the third time spent most of the night helplessly keeping watch by the hospital bedside of a desperately ill relative. The surgeons were doubtful whether Clare could withstand the operation which would be necessary to save her life. I pressed them to try, for the alternative would be an agonising and undignified death, but they were reluctant to attempt such a major procedure in the middle of the night. Meanwhile repeated large doses of morphine and other drugs were failing to control Clare’s pain, nausea and distress, though eventually the anaesthetists performed an epidural which brought her some relief.

There was better news next morning. The surgeons did decide to operate, and Clare survived the removal of large sections of necrotic bowel. So far – though it is very early days – she is making good progress in hospital.

It seems incredible that our lives, so contented and well-ordered for the last few years, have been suddenly disturbed by this sequence of traumas. Sayings such as “troubles never come singly” “it never rains but it pours” and “bad things come in threes” suggest that negative events do have a tendency to cluster in time. I noticed this when I carried out my own research study to investigate “Life events and breast cancer prognosis” which involved repeated interviews with over 200 women over a three year followup. While some of these women reported very few happenings during the study period, there were others who experienced a whole series of disasters. Sometimes it was possible to identify a chain of events leading on from one another. Sometimes all the events seemed to stem from one single cause, which in some cases appeared to involve the personality and behaviour of the person concerned. Few of the events could be considered totally independent from those who experienced them.

Were the recent misfortunes of our own family linked, part of a cascade of events beginning with Brian’s heart attack? I have always tended to be sceptical of the theory that most illness is due to “stress” (the results of my own study, cited above, gave no support to the popular notion that stressful life events promote the growth of breast cancer). But there is no doubt that psychological stress can lead directly to imbalances of the body’s neurological, endocrine and immune systems, as well as to impaired self care due to missed meals and lack of sleep. I have no doubt that anxiety, overwork and exhaustion since Brian became ill have contributed to my own recent health problems of high blood pressure, sinus tachycardia, a posterior vitreous detachment of the eye, and delayed healing of biopsy wounds.

“Stress” is not the only possible explanation for the clustering of events, and maybe there are also metaphysical causes. According to the Law of Attraction, negative thoughts and feelings in response to adversity are likely to result in more of the same. And an astrologer friend, who like me was born under the sign of Aquarius, has cited “the ghastly Saturn square Pluto events which have befallen Aquarians of late”. I am trying to “take one day at a time” and appreciate good things like the spring roses blooming in our garden.

big pink rose

My husband’s heart Part 3: Cardiac rehabilitation

~ Jennifer Barraclough ~ 1 Comment

Over two weeks have gone by since Brian had his open heart surgery, and it is one week since he was discharged from inpatient care.

We are both very happy that he is back home, though there continue to be ups and downs in his condition. During good periods he is able to walk short distances both inside and outside the house, and to eat reasonably well. However he has relapsed into atrial fibrillation on several occasions, and a recent blood test showed him to be anaemic. At times he feels weak and breathless and is unable to get warm. Formerly an avid reader, he has no interest in books at present, though he does follow the news on his computer.

We were advised that recovery from such a huge operation takes about three months, so perhaps cannot expect too much too soon. His medication – currently including amiodarone, warfarin, aspirin, an occasional beta blocker – will be reviewed by the cardiologist next week.

After the previous month of acute anxiety combined with frantic activity – travelling to and from the hospitals to visit Brian every day while managing practical, legal and financial affairs at home and dealing with medical appointments for myself – my own life has entered a quieter domestic phase. My role as nurse-housekeeper is not unduly arduous, so I am catching up on lost rest and sleep. Brian and I have time to spend together in a relaxed way talking, listening to music, or watching the four cats in the garden.

Daisy with flowersLeo on gatepostMagic on plum tree best photohomer at feijoa tree

All the regular engagements which once provided structure to my weeks – singing with St Patrick’s choir, volunteering at Auckland SPCA, attending Auckland Film Society, dog walking on Takapuna beach, coffee dates with friends in the city, yoga class – have been cancelled for the time being. The activity which means the most to me, creative writing, is also on hold. Apart from this blog and emails to friends I have written nothing for six weeks, but look forward to getting back to editing my new novel soon.

My husband’s heart Part 2: Auckland City Hospital

~ Jennifer Barraclough ~ 3 Comments

Following on from my previous post: Brian spent 18 days in the cardiology unit of North Shore Hospital. On 23 September came the long-awaited news that a place for him was available at Auckland City Hospital. Accompanied by a nurse carrying a defibrillator, he was transferred by ambulance across the Harbour Bridge, and admitted to the cardiothoracic surgery ward in preparation for a five hour procedure to bypass his left coronary artery, replace his aortic valve, and repair the aneurysm of his ascending aorta.

We kissed farewell as he was wheeled through the doors of the operating theatre next day, and then for the first time since it all began I broke down in tears. Fortunately a close friend was available to take me out for coffee and listen to the story of our recent woes.

When the surgeon phoned me that afternoon to say that the procedure had gone well my relief was enormous. But when I arrived to visit Brian in the intensive care unit later on, I was told that he had had a stormy few hours. A group of doctors and nurses were gathered round his bedside. He was deeply unconscious and blood was flowing out through the drains in his chest.

Despite repeated transfusions of blood and blood products, his condition did not improve and shortly before midnight the decision was made to recall the surgical team and take him back to theatre. I was trembling with fear and distress, and very thankful that family members had come in to sit with me and then drive me home.

After the second operation, which involved the removal of blood clots and fluids, Brian began to get better. By next morning his vital signs were stable, and I was present to watch him being awakened from his drug-induced coma.

Two days later he was moved out of the intensive care unit into a four-bedded ward, where he stayed for over a week. On some days he made rapid progress, and on some days his condition caused concern. On two occasions he went back into rapid atrial fibrillation and required intravenous amiodarone to restore sinus rhythm. At other times his heart rate became too slow, and a week after the first surgery he had a pacemaker fitted. He had some brief spells of anger and despair, but overall remained remarkably positive.

Brian in Wd 42 after heart op.jpg

 

For myself, the physical and emotional demands have felt almost overwhelming, and I developed several apparently unrelated medical problems during the month that Brian was in hospital. These included an episode of hypertension and tachycardia beginning on the same night that, unknown to me, Brian’s recurrent arrhythmia was causing great concern. Anxiety and exhaustion were the obvious triggers for my own symptoms and, despite having done so much clinical and research work in the field of mind-body medicine, this was my first significant personal experience of stress-related illness. If I had had such an experience before my retirement I think I would have been a better doctor.

Brian has now been discharged from hospital, and although life may not be easy during the projected recovery period of three months, we are both happy and relieved that he is home again. Through this whole saga I have been tremendously grateful for the skill and kindness of the hospital staff; the marvels of modern medicine and surgery; the practical support, good wishes and prayers of family and friends; and the comforting presence of our three cats.

My husband’s heart Part 1: North Shore Hospital

~ Jennifer Barraclough ~ 1 Comment

It is over thirty years since my husband Brian started feeling breathless after walking up long flights of stairs. He was found to have aortic stenosis and an aneurysm of the ascending aorta. As time went by, occasional repeat investigations showed this pathology gradually getting worse, and several specialists advised cardiac surgery to prevent the risks – including sudden death – associated with his condition. He declined, on the grounds that his symptoms were not too severe and that the operation itself could be fatal or cause some intellectual impairment. His diagnosis was one factor in our joint decision to leave our medical careers in the UK and go to live in Auckland, New Zealand, where Brian had been born and brought up. That was fifteen years ago and over most of this time Brian has continued in good shape – even walking the Milford Track.

on milford track

He continued adamant that he did not want surgery. He asked me and our family doctor not to send him to hospital if the aneurysm burst, but to give him morphine and let him die at home.

In July this year, soon after his 82nd birthday, Brian had a bad attack of flu and we attributed his continued lethargy and reduced exercise tolerance to the aftermath of that. He did seem to be getting better. Then on 4th September, on the way back from an enjoyable evening at the ballet, he said he did not feel well. He refused to let me call for help. Somehow I managed to support him on the walk home, but as soon as I opened our front door he collapsed in the hall. At that point I went against his wishes and rang 111. Time will tell whether I did the right thing.

A skilled ambulance crew arrived promptly, and did an ECG which showed atrial fibrillation with a pulse rate of 160-170 per minute. They started intravenous amiodarone and advised that Brian was likely to die unless he went to hospital. With a little persuasion he agreed to go. After many hours of investigation and treatment in the resuscitation unit of North Shore Hospital he was admitted to a ward and at 4 a.m. I took a taxi home.

The immediate cause of the collapse was not a ruptured aortic aneurysm, but a 70% blockage of the main stem of the left coronary artery. With excellent medical treatment and nursing care, Brian’s condition improved greatly over the next few days, but he was presented with a stark choice – go back home with probably just a few months to live, or undergo surgery which carried a 20% operative mortality but if successful could give him many more years of good quality life. Brian decided to “cooperate with the inevitable” and accept the operation that he had been refusing for so long.

He stayed three weeks attached to monitors in the cardiology centre, not allowed to leave the ward although he was feeling fairly well. Every day we anxiously awaited the news that a place had become available on the surgical unit at Auckland Hospital. On several occasions the proposed transfer nearly happened but was then cancelled – later we would come to understand all too clearly the reasons for this. Brian appeared to benefit from the long rest, and remained in good spirits. He spent much of his time exercising in the corridor, or with his laptop computer composing a self-written obituary for Munk’s Roll.

There is much more to the story, but to avoid making this post too long I will continue next time. Please sign up in the box if you would like to receive future episodes by email. I should add that I am publishing this with Brian’s full knowledge and consent.