The Lockerbie Bomber, cancer, handling pain

A large part of media analysis takes the view that most decisions made by people in power, turn out in hindsight, to be wrong. The families of the Lockerbie victims naturally want full justice to be done. Many of them are furious that Abdelbaset Ali al-Megrahi was allowed to go home to die with a prognosis of 3 months to live. What the media do not analysise is that by releasing him on compassionate grounds, the Scottish Government gave him something to live for. Had he stayed in prison he might well have lived for 3 months or so. Going home to a welcome from his family and the attention of people who cared for him as a person gave him hope, joy, and a future - all the qualities that enable the human race to survive against all odds.

Over the years a number of my patients have or have had cancer. One man who came to see me for an unusual muscle condition had prostrate cancer. He was not given long to life. Whether it was the treatment on the muscle condition, or of improving blood flow, his prostrate cancer incidentally made a dramatic improvement. The consultant told him that he was not going to die of the cancer, so he got married. He was 82 when he first came to me.
Another man had a terminal prognosis from a respiratory condition. He is still alive and kicking. He asked the consultant what was the longest someone had ever lived after being diagnosed with the condition. The consultant said, 14 years. This man has cheerfully decided that his life expectancy is 14 years less the time he has had it already.
People say to me, "You not only treat me but you give me hope." So often they go to see health professionals who say things like, "What do you expect? Its your age." "You'll be in a wheelchair if you try to have children", (that lady now has two healthy children). "Its arthritis, there is nothing you can do." "Stop going to the gym, its too dangerous to exercise" (that man is now training for tri-athlons)." Its a disc prolapse or collapse, we are not going to operate, there is nothing you can do." "It is a frozen shoulder, it will take 18 months to heal." All of phrases have been used by people many times. In most instances we have seen a return to good health in far shorter times than if they had accepted the bad news and resigned themselves to it. As health professionals we need to take care to avoid transferring our own frustrations onto the people who come to us for help and advice. Sun Simiao wrote in his Essential Prescriptions,
"Whenever a physician treats an illness, he must quiet his spirit and settle his will. He must be free of wants and desires, and he must first develop a heart full of great compassion and empathy."1

The human spirit is far stronger, deeper and more creative than most of us can imagine. Some people survive the worst of experiences. Others succumb to the smallest accident. Dr Judith Trager wrote a book called, The Worst Is Over: What to Say When Every Moment Counts--Verbal First Aid to Calm, Relieve Pain, Promote Healing, and Save Lives She positively talked people in crisis into a process of healing. Through positive suggestion, people who were bleeding from an artery at a road accident could make their bodies bleed just enough to cleanse the wounds, then stop when they needed to preserve their blood.  They could focus their minds on the help that was going to come, not on the prospect of imminent death. When I came home after my own major accident I met someone called Simon. He too had a serious accident. The first thing that he told me was, "Healing starts in the mind. You tell yourself you are going to heal and you will." He had been hit by an articulated truck, broken numerous ribs and lost his spleen.
How to Handle Pain
When you are injured start by completely resting. Calm down your heart rate by controlling your breathing. Allow your mind to take on board where you are now and what tissues are injured. Examine yourself both physically and mentally. Imagine you are the doctor or paramedic. Ask yourself, Where does it hurt? What hurts? Does it feel like sort tissues or hard tissues?muscles, bones, organs, ligaments, nerves or connective tissues? Does the pain come and go? Does it lessen with painkillers or do they make no difference? Does stretching help or make it worse? Can you localise the pain by saying to yourself, "I am not in pain; the pain is in me. It is not going to last; it is temporary. Someone has had it before so they can help me. There was a time when I was not in pain, What has changed in my life to bring on the pain?
Now start to visualise what is happening in your body. The troops are arriving at the source of the pain. Special red blood cells called platelets plug the leaks. Special white blood cells called leukocytes and eosinophils arrive to fill up the area with healing chemicals such as bradykinins (they create inflammation). As the inflammation reaches a limit over 2 to 4 days the macrophages (lit. 'big eaters') arrive. They digest the toxins and by products of inflammation. Over a period of weeks the new collagen cells proliferate and remodel into scar tissue. The bones heal with a lump called callous. Skin cells recover with some scarring, muscles rebuild but not as elastic as before.
Chronic pain is harder to handle but you can develop strategies to manage it.
What slows down the healing process
Taking too many anti-inflammatories or steroids. These drugs mimic the body's response to stress but in much larger doses than we produce ourselves. Take only enough to see you through the worst of the pain. Omega 3 oils (DHA and EPA) have an anti-inflammatory effect (take 3 a day). Turmeric, chilli, fenugreek, bromelain (extract of pineapple core) are all anti-inflammatory.
Getting your joints manipulated in the first four days. In the first 4 days the tissues are repairing and almost plastic in their make up. Strong manipulation can be very harmful at this early stage. Gentle manipulation and lymphatic massage or acupuncture are very soothing and promote healing.
What speeds up the healing process
Use covered ice if the skin is not broken. Ice limits excessive inflammation and constricts the blood vessels. Later they dilate and improve blood flow. For small areas try rubbing an ice cube directly on the skin it until the cube melts. If the skin is broken you must concentrate on cleaning the wounds and possibly taking anti-biotics or using them directly on the skin. Grit, saliva and mud are all sources of infection.
Gently massaging around bruising but not directly over it clears the bruising. Blood in tissues is an irritant that slowly disperses through the lymphatic vessels. The lympathics link in chains back to the heart. Their main collection areas are the back of the ankles, the inside of the thighs and groins, under the diaphragm behind the oesophagus or food pipe, down the sides of the neck, under the armpits and alongside the breasts, then finally back into the venous return to the heart under the left collar bone. Massaging through lymph glands clears inflammation faster and promotes neutrophylls or white blood cells to detox the body.
Listening to music, unwind, do what you enjoy.
Take anti-oxidants and eat highly nutritious foods.
Rest then stretch and rest again.
Keep asking questions about your pain but don't assume that because someone is a professional they have the answers. Your own body has the answers and a treasure chest of healing chemicals to cope with emergencies.
Keep a positive attitude, you will heal, you will get better. Keep company with positive people and those who make you laugh when you yourself are healing. Watch anything that makes you laugh.
Go for massage, gentle manipulation, acupuncture or any other therapy that has helped you in the past.
Take up a new hobby, sport, or interest, get involved with others. It helps them and takes your mind off your self.

Increase your energy and integration through yoga breathing

Our yoga teacher Toby gave an interesting homily, or talk with a meaning, this evening. He talked about the word 'yoga' being related to the word for 'yoke'. A yoke implies being joined together, the union of two ideas, causes, souls or whatever, going in the same direction. Jesus Christ had the same idea when he said, "Come to me all you who are weary and heavy laden and I will give you rest. Take my yoke upon you, let me teach you because I am humble and gentle, and you will find rest for your souls."

B.K.S. Iyengar talks about yoga being the union of the individual self with the universal self. Carl Jung had the idea of a individual unconscious that connects with a collective unconscious mind through dreams, common experiences or tendencies to behave in a certain manner. These are called archetypes. Hinduism likens us to islands of ideas connected by a deep ocean.

When I commuted to London for 11 years I used to dream up inventions. It was not possible to fulfil them but slowly I saw some of them come to fruition by others who put their minds and resources into the ideas. From this experience I came to believe that there is a collective wisdom in humanity that some of us tap into. Foolishness is often an inability to listen to or act upon advice.

Toby felt that the role that yoga played for us was to unite the mind with the body. By bringing the mind and the physical practice in the body together we coud both focus and calm the mind. The force that links the two is the breath. The breath itself is under both voluntary and autonomic control. We have such a strong instinct to breathe that we do not need to think about it. However we can control the breath through pranayama or yoga breathing exercises. There is nothing strange about these exercises. They simply bring the body under the control of the mind. There is a simple exercise to let you practice in my video on the neck and the diaphragm.

Improve your neck and breathing


Most people who have asthma, IBS, acid reflux, hiatus hernia, gall bladder pain, or heart conditions have a shallow breathing technique. By steady practice you not only help your digestion but improve the oxygen levels in your muscles. I often see long distance cyclists who improve their stamina by breathing more deeply. Our other yoga teacher Andreas Wren puts it very clearly when he says that the first move we every make is an in-breath and the last move we ever make is an out-breath. Its what we make of our life in between that matters.

Living with Warfarin, INR,

 Before reading this please be aware that I am not a doctor. I am writing this because I have first hand experience of a heart condition that meant I had to be on warfarin for over a year. Please check any information or agree any changes to  medication with your doctor first.

If you have been affected by a blood clot, stroke, DVT (deep vein thrombosis), or heart arrythmia (irregular rhythm) or heart condition such as atrial fibrillation, you might be put onto warfarin (Coumadin). Irregular heart beats could produce turbulence and lead to bits of heart valves breaking into the bloodstream. Blood clots are formed when platelets get "stuck" in the capillary system or the arteries start to harden as they degenerate. Calcium is also needed for them to form.

Warfarin thins the blood by inhibiting the action of an enzyme that converts vitamin K to an active form.
It has a stronger action than aspirin or clopidogrel which inhibit platelet activity. Once you are put on warfarin the level in your bloodstream must be measured at least weekly until you are stable and know your own levels. Testing might then be reduced to fortnightly. The level must not be altered rapidly. It is a bit like steering a barge on the canal. The barge takes a while to respond, if you move the tiller too far it will hit the bank. Blood clotting rates are measured as an INR (Internation Normalised Ratio). A therapeutic dose is normally between 2 and 3, (or 4 if you are waiting for an operation).

Warfarin will have a stronger effect if you take non-steroidal anti-inflammatories like neurofen or aspirin. It might also have more effect if you are on metformin for diabetes. Some anti-biotics also reduce vitamin K levels in the blood. Bromelain which is extracted from pineapple core might increase its effect. Grapefruit or grapefruit juice is an active substance that can increase the effect of medication. High levels of anti-oxidants like vitamin C might affect the level.

More importantly, foods that contain vitamin K will reduce the effect of warfarin. If your diet regularly includes green leafy vegetables such as cabbage, broccoli, lettuce and spinach you might reach a stable level on warfarin without having to make changes, the dose will be higher. But if you change your diet frequently it will be harder to stabilise. Foods that are very high in vitamin K are alfalfa sprouts and watercress. There were times on warfarin that I simply had a craving and ate a whole bag of watercress. It is as if my body needed to stock up again. Green vegetables (and cauliflower, oranges, tahini and honey are also good sources of calcium). Calcium is needed for blood clotting and muscle function. You might be led to believe that you must not eat these foods at all. Taking these foods is not harmful, but stopping them or changing your diet might lead to a change in your INR levels.

Long Term Effects of Warfarin (Coumadin)
Tiredness is a common side effect. My suspicion is that it lowers calcium uptake and leads to energy loss in muscles. Frequent bruising at the slightest knock, break down of capillaries around the eyes and nose, in the legs and all signs of too high a dose for too long. Nose bleeds are another sign of capillary breakdown. A blow to the head could lead to a haemorrhagic stroke (a bleed in the brain). If you have a sudden severe "thunderclap" headache the physician must be informed that you have been on warfarin. The biggest long term risk is osteoporosis. I suspect that the increase in hip and other fractures from falls could correlate with increased numbers of elderly people on warfarin. As long ago as 1975 scientists isolated a substance called osteocalcium from the bones of chicks. Vitamin K acted as a catalyst to start bone formation around this protein framework.



Conclusion
Doctors have to weigh up the benefits of a mediation against the risks of its side effects. In my case I am glad that I took warfarin, unpleasant though it was. It enabled me to have numerous complex heart procedures that led to a great improvement in my energy levels. It is up to you, talk with your own GP or specialist physician.