Kamini : Opioid marketed under the guise of Ayurvedic preparation

Having grown up around the Indian culture and having had the privilege of studying the ancient language of Sanskrit, I have known and understood Ayurveda to be a traditional, herb based, non chemical, healing remedies derived from mother nature. The words that come to mind when I think Ayurveda are: tradition, wisdom, natural, safe.

So when I recently started work with people who are struggling with drug addiction and recurrent mention came up of this ‘Ayurvedic medicine’ Indian men are taking and which they have got dependent on, to the point of requiring assistance from specialist that provides assistance with heroin addiction, it caught me by surprise and intrigue.

Until a few weeks ago I had not heard or read anything about it. And suddenly I am seeing a whole lot of young migrant Indian men who are addicted to the drug. So much so that they are not able to function. They have given up their studies, work and their families are falling apart so what’s going on here?

This ‘Ayurvedic medicine’ is called Kamini. It’s available online and also under the counter at a few Indian food and grocery stores and is marketed as an aphrodisiac.

The label information reads as such:

Kamini vidrawan ras is one of the safest ayurvedic medicine with potent herbs and minerals, constituting a herbo-mineral ayurvedic drug having aphrodisiac effects on human health. It is available in the form of Tablets and also known as Kamini Tablets. It has excitement stimulating effects and properties, that is how Kamini vidrawan ras is helpful in improving sexual vigour,  cures erectile dysfunction and premature ejaculation. “(www.kaminividrawanras.com)

The catch is that when people start talking this ‘safe Ayurvedic medicine’ they report development of dependence quite quickly and it is similar to the pattern seen in heroin dependence.

And this is how easy it is to buy it:

I just hopped to the website whilst writing this and it took me less than a minute to get to this:

Shopping Cart

Price
Quantity

$52.75

Subtotal (1 item): $52.75

 

 2 clicks is all that it took and I could have placed the order from the convenience of my home. Or as my patients have advised me, I could try my local grocery store and make some discrete enquiries and can get a bottle for about 100 AUD.
This is very concerning.
It somehow gives the air that because its Ayurvedic medicine and is relatively easy to acquire it is safe which is absolutely not the case when you deal with people who have developed dependence after tasking these tablets.
I am using this platform to share information about this drug and its ill effects with a hope to raise as much awareness as possible. I have mentioned only Indian migrant men as main users but that is because I am an Indian medical professional who speaks a few dialects so attract these subgroups but there are other users as well – Australians, other Asian groups, women…
Drug dependence ruins lives – of users and of their loved ones. But fortunately an even stronger drug exists and that is the basic nature of us humans to never give up on each other. And on ourselves. And this quality will help us all to keep on our fight against illicit drugs, in our own special little ways –  creating more awareness and tolerance, one addict and one addiction at a time.

Short story: The answers

A short piece I wrote, loosely based on the story of a remarkable woman I had the privilege of knowing many moons ago. She led me to reflect on the intricacy and incredulity of our emotions and the effect they have in shaping our relation with self and with others. And a valuable lesson- about developing the beautiful ability to let go.                                                  As she lay on the bed, she drifted in and out of consciousness. She could hear the beeps of machines on the background of constant humming sound. What was this sound? Suddenly she was back in her childhood, and the humming sound was made by the drone flying out in the otherwise quiet and dark skies. Four people were sitting in the darkened basement awaiting sudden spray of bullets that had become the norm now that the Great War was drawing close to its end and just like a beast doing a final heart wrenching roar before its imminent demise, the war seemed to have become more deadly as it drew closer to its long awaited end.Even at the tender age, when the hardest task a child should be having to comprehend is how to read alphabets and count basic numbers, she understood that there were bad things happening around her and she could understand that these things should normally not happen. Otherwise why would mother keep cursing the wretched war and bemoaning her bad luck to be stuck with a husband at the war front and three young children to look after all on her own. She thought it was awfully nice of uncle Jack to be looking after their mum and comfort her when she was tired and sad. Just as the war had become a familiar noise and chaos in the background, having uncle Jack around the house became a way of life.

She couldn’t be too sure when uncle Jack metamorphed into dad but it remained a blur throughout the times when she was growing up. The toddler had craved a father so much that it was finally nice to have one and it didn’t really matter who or where he came from . She grew up to be a young lady and then a doting wife and then a proud mum and then a loving grandmother. She had a clean and comfortable town house with well-tended gardens and had her tea parties in the garden. She became a part of her local community, doing regular work as lollipop lady for the local school and also volunteering as part time canteen worker there. She loved being at school partly because, amongst many other things missed by her peers, regular school was a luxury denied to her generation. She would have loved to be a librarian but that would have required her to read fluently and it would have shamed her deeply if others could see that behind her carefully kept exterior she was just an illiterate person. She took great pride in her children’s literacy achievements and made it a point to display each and every certificate on display cupboard.

But then as her own old age crept on her, she found her mind playing games with her. Where was her real dad? Why did he never come back home? Had he died or had he simply abandoned her as it was the easier thing to do? Or perhaps the war messed his brain up and he couldn’t remember that he even had a family and especially a little girl who really wanted him to come back? Maybe he lived for many years trying to remember through the war riddled haze in his brain and had died, having met an agonizing end, tormented by these unanswered questions? Would things have been different if she had made some effort to connect with him? And then why had mother never spoken about this? Was she ashamed to have her little kids on her own? Was she not enough for her? Why did uncle Jack have to come into their lives and then become dad which he really wasn’t? She suddenly started feeling increasing more resentment towards her mother for putting her through this agony in her own old age and also rage against her father for not coming back home and not making any efforts to find her and explain things to her.

Day after day, simple things in life, which she took for granted like getting up in the morning, taking a shower, dressing up, preparing food, cleaning the house, became increasingly difficult. Her husband started showing concerns that she has become more forgetful and seems weak and tired all the time. Slowly she started losing the joy she found in loving her family and tending to the well-kept home she had created. As the layers of her comfort fell away, she became increasingly withdrawn and the demons in her head kept soaring higher and higher asking the same questions until she could actually see these horrible thoughts in shapes of monsters sitting by her bedside and mocking her.

As she tried to fight them with words and her feeble body, her family decided that she she was going mad and tried to make her comfortable by doing things for her and asking her not to move as she was making herself prone to falls with sudden lunging movements as if in the motion of hitting or pushing someone away. These restrictions made her more uncomfortable because now these demonous thoughts, which had by now taken familiar shapes and facial expressions, could just get their own way of laughing in her face, making fun of seemingly full life she created for herself but which in fact was hollow because the very creator of her person had chosen to abandon her and the other one had kept her in dark without any explanation as to why this had happened. She felt inexplicable pain and agitation that they could just make these judgements about her and brush her whole life away as if she was inconsequential all along. She felt outraged that they could just mock her whole life as if it was all make believe act that she lived throughout her life to mask the hollowness of her existence.

Any further attempts on her part to fight these demons were met by the assessments done by cold stethoscopes and blood tests by her family doctor and giving her some sedatives to calm her down. Could they not see that there was no calming for her now that demons had taken hold of her and were mocking her whole life? As she made final attempt to fight these, the family decided that mum was too sick and bundled her to the big hospital in ambulance. She was too weak to protest. Her attempts to communicate her position in her fight with the demons of the past were labelled delirious babble by her loved ones as well as by the authoritative figures at hospital in their white coats.

And then her family was told that she had a rare brain condition which had caused her to have a stroke and hence this delirium. As she lay there with her eyes closed and her chest rising and falling in shallow tired breaths, she finally understood that there are are some questions in life which are beyond our comprehension and sometimes we don’t get answers even where they are well deserved. She understood now that as a two year old little girl she had no control over the decisions her father or mother made and she could finally see the difficulties her mother went through to raise her and the siblings in those hard times and she could comprehend the fright his father must have felt fighting from a disease and dead bodies ridden trench. She could finally forgive them. She could finally see that she actually had a very full life with a loving husband who stood by her through thick and thin and together they had beautiful children who still rallied around her and loved her for what she was and not for what she had been or where she came from. Her past was not shameful anymore. She could see the happy faces of all the little children of neighbourhood she had helped on the crossing and in the canteen and the lack of any judgement in their joyful faces. She could hear the laughter in her tea parties. There was joy and contentment all around and she had created that by being who she was. She understood that life is very complicated and yet very simple because you don’t need to have all the questions answered and things don’t always have to be correct. As long as you have joy, love and peacefulness around you, it’s enough. As if in a movie, she saw all the demons fall in front of her and then evaporate in thin smoke to be gone forever and she felt lighter and free. She longed more than ever to share this contentment with her husband and family. It was at this point that nurse in charge of ward noted that beeping sound on bed 5 had stopped and she said a silent prayer for bed 5 as she made emergency call for cardiac arrest team to attend.

Lifestyle choices: Happiness or Fulfillment

The most common causes of illness in modern age are diabetes, high blood pressure, heart disease, cancer, mental health. Almost all the research into these ailments points towards lifestyle as being a significant contributor. Lifestyle is a choice we make. So does this mean at times we are choosing illness?

It’s an unpleasant thought but worth pondering over.

The recommended lifestyle choices for health and wellness are:

  1. Eat healthy – daily portion of fruits and veggies, lots of water, reduced amounts of processed and sugar rich foods, consuming most of the diet in the first three-quarters of the day, avoiding eating large portions of meals and avoiding eating after 6pm, avoiding smoking and excess amounts of caffeine, alcohol or drugs.
  2. Regular exercise – recommended regime is moderate intensity exercise 4-5 times per week for 30-40 minutes.
  3. Relaxation – all work and no play makes Jack a dull boy – the proverb has been around since 1600s so no new brainwave here but the hectic lifestyle of modern days makes it all the more relevant. If we are not actively practicing it then it can be quite easy not to switch off at all in today’s whirlwind pace. De-stressing, mindfulness, yoga, pursuing favourite hobby – these are all the ways to practice it.

The general lifestyle choices we do make are:

  1. Eating – diet is rich in processed foods, based more on comfort, driven by busy lifestyles. We have become so busy creating “the lifestyle” that the very basis of a healthy lifestyle i.e. a good diet is the first casualty. Its much easier to find the exotic flowers or bushes in our boutique gardens than the basics of kitchen herbs as it’s not that much of a thing anymore.
  2. Exercise – the organs to get the most exercise in today’s world are the eyes, followed by the fingers as we spend a significant amount of times in front of our social media connector devices.
  3. Relaxation – well, all I can comment here is that this is a rarity nowadays. If you ever find yourself truly relaxed, cherish and relish the moment as it has perhaps become the most difficult to achieve out of all the lifestyle choices.

So this is a quick snapshot of what we need to be doing and what we are actually doing. Why this imbalance?

Surely we are smarter than the last generations and have more intelligence and knowledge than our predecessors so logically should have figured it all by now about the lifestyle choices thing but it’s clearly become our biggest problem so what’s gone wrong?

What drives our lifestyle choices? I like to think that positive drivers by far outweigh the negative drivers.

The biggest positive drivers of lifestyle choices are happiness and fulfilment.

At first glance both seem to indicate the one and the same thing but they are actually very different. Happiness is an instant emotion – of momentary gratification. Eating a chocolate makes me happy but does this fulfil my life? Eating healthy for the whole day, exercising adequately and finding time to relax makes me feel fulfilled but doesn’t necessarily make me happy – I can’t remember feeling the same happiness whilst eating berries as that felt whilst tucking into an ice cream Sunday!

So what is more important – happiness or fulfilment?

I’m sure I’m not the first to stumble upon this philosophical thought. Lifestyle is a choice. A choice driven by our quest for happiness and fulfilment. Whichever emotion is more important to us will dictate what lifestyle choices we make. And our lifestyle choices have a significant bearing on the state of our health and wellness. Choose well.

 

Finding the balance in life

I was talking to someone yesterday and I was asked the question yet again – how do you find the balance? Its quite often working mums ,and an occasional dad, who asks this question as they find themselves struggling to find the balance in building a successful career, looking after self and simultaneously creating a content family life.

Well my answer on this occasion, as always, is that I can’t.

I can’t find the balancing act if I try to do it all by myself. For me to have the ability to find the balance I have to rely on the village that goes into building me and providing me the stability to finding it.

They say that behind every successful man there’s a woman. All I can say to that is that men seem to have got themselves an incredible deal as behind every successful woman there is not only a man but a whole team.

The team members can be different people and sometimes even things (like a tennis racket in my case as you’ll see).

So, my team members are:

  1. My partner. He is a big help as he treats me as a human being, without compartmentalising me and my role in our relationship into that of a woman.He doesn’t expect me to ‘be the woman’ and doesn’t burden me with the traditional expectations of my role in our family unit. I try my best to be the woman as I quite like it but I don’t have to tow any lines of expectations. In return I don’t expect him to ‘man up’ on all occasions. We both try and work on our strengths and try to respect each other as much as possible within the confines of emotional ups and downs of a relationship as delicate and strong as that of a married couple.
  2. My work colleagues and staff. I rely a lot on their support. I’m the first one to admit that if not for an efficient staff, my best efforts will not yield any meaningful outcomes as most work will quickly become disorganised, less efficient and will loose longitudinal productivity. We are all very different personalities but we try to keep the focus on work and mutually agreed outcomes so that even if there are disagreements along the way, we keep the ultimate focus in view and not allow any disagreements become personal. Mutual respect, tolerance and regular evaluations of expected outcomes help to maintain a healthy relationship.
  3. My family and friends. These are people such as my parents, siblings and other people that I have emotional attachments with. These are people that I don’t interact with on daily basis but they are always there in the background, ready to lend a sympathetic ear or even an occasional hand when I need help. I make a conscious effort to be mindful of how much I ask from a relationship and try my best to give back in equal measure so that the emotional state of the relationship stays balanced and healthy so either sides don’t get drained from strains which are inevitable from time to time. In this rapidly shrinking world that is incredibly well connected by social media, we are actually becoming poorer in human connection. I use the social media as much as I need to but my focus stays on human connection and this is the section of my team where I put most efforts in maintaining it.
  4. My dog and tennis coach. Between the two of them, these guys make sure that I get 30-45 minutes of decent intensity exercise at least 4-5 times per week. Tennis is almost like meditation for me. I held a tennis racket for the first time in my life last year although I grew up on the staple diet of badminton as an Army kid but can now have a half decent game of tennis with my unforgiving coach who doesn’t care what kind of day I’ve had and always expects high standards from me on the court which needs undivided attention. My dog is not much more lenient either and expects her exercise no matter what my own circumstances are. Tired? Tough. Pick up the lead and let’s go. I have a whole heap of running and sniffing to do for the next 45 minutes so cut the slack please.
  5. Last but not the least – the integral part of my success story are the people I work most closely with – my patients. I have no qualms about bragging and saying that I’ve had the privilege of looking after some of the best personalities ever! My patients enrich my life experiences everyday. People constantly talk about their quest for good doctors. Well here’s a secret – doctors hope for good patients too. And I have had the incredible luck where every single patient I’ve interacted with has enriched me in some way. And some have touched my life at a much deeper level than they will ever realise and they’ve done so by making me work harder at finding solutions to there problems, challenging me to keep up-skilling myself to meet their health needs, reflecting on deeper issues in life to incorporate that into my medical training to manage health holistically.

I will not be able to have any conversation about being a success if not for any of these team members. Even if I am having a bad day or an endless moment of self doubt , one of my trusted team members is there to pick me up – sometimes knowingly but mostly without having any awareness of doing so. These beautiful moments have instilled the character trait of reciprocating and lending a helpful ear or a hand, saying kind words as you never know which word or gesture might end up impacting someone’s life significantly, or at least making their day easier.

How do you know if you’ve got the balance thing right? If you wake up with a light heart, decide to be the architect of your day, get ready to go to work with excitement and come home to smiling faces then definitely you’re doing something right and you have your team working just right.

Its no fun, and in fact not possible, to do it all by yourself. Get your team and make it work for you. But keep in mind that you’re part of other people’s teams too and have to pull your weight in making it work for them. I have the village working to make me a success but I am not the village. I am a part of the village, lending myself to others in the village and we all try to make it the best village ever!

 #healthandwellness

Early Pregnancy Loss

Experiencing a miscarriage can be very difficult. As a health care professional, whenever I sit with a patient or a couple going through early pregnancy loss, I get a glimpse of the turmoil they experience as they process the medical information given to them about miscarriage.

It’s not unusual to get a sense of failure, particularly when the pregnancy was planned and quite wanted. Quite often the women experiencing miscarriage will feel helpless or angry with themselves for not being able to hold the pregnancy and sometimes there can even be frustration directed at medical profession for not being able to offer any help in avoiding this unfortunate incident.

But rarely do I hear a woman say that she has heard of this happening to someone she knows or any such recollection about hearing the experience touching the life of someone else in their social circle. This makes it even harder for people to process this sad event as they go through it. There’s a sentiment that other people try for pregnancy and seem to get pregnant so why couldn’t they do it too?

The reality in answering these questions is that early pregnancy miscarriage is quite common. As common as 1 in every 5 pregnancies.

So obviously if people aren’t hearing about it as much in their personal environment then its likely that people deal with their loss at personal level but they aren’t talking about it.

So when it does happen to someone they can feel quite isolated in their experience.

Some of us prefer to deal with our losses in private and that’s fine but the kind of silence I am talking about is when we do want to talk about or discuss our loss to make some sense of it but just don’t feel comfortable enough doing so as it hasn’t been brought up in a conversation sort of way.

Talking about lived experiences normalises things in a way which makes it easier for people when they are living through those experiences themselves or if they find themselves in a supportive role for someone else living through it.

The first question that comes to a woman’s or couple’s mind as they face early pregnancy loss is why? Why did it happen? And why did it happen to me?

So lets discuss the most common causes of miscarriage:

  1. Chromosomal abnormalitis : This is the most common cause – about 80% of all cases. Just as a house is made with bricks, our basic structural foundations come from chromosomes which hold our genetic make up together. To make a sturdy house, the bricks have to be good quality and laid in a perfect manner, without any gaps or slants. Otherwise the building is not strong and will get damaged quite quickly. Similarly, to make a perfect baby, the genetic material has to come from mother and father and has to meet together in a required manner to make a healthy baby. Nature tries it every time but things don’t quite work out perfectly each time. Our bodies are clever enough to recognise the mistake when its made and sets the wheels in motion for damage control by not letting this pregnancy grow any further as the imperfections in genetic sequencing mean that such pregnancy will give rise to baby with physical or mental disabilities. Nothing you have done or not done is responsible for this. It just happens by chance.
  2. Mother’s health and age : If mother has other health issues such as undiagnosed or poorly treated diabetes, high blood pressure, thyroid disease, anaemia etc then these can interfere with growth of a pregnancy in early as well as later stages. So it’s a good idea to attend for a pre pregnancy consultation with your health care provider when you’re thinking about having a baby. Advancing maternal age also plays a role in the rate of chromosomal anomalies and the related higher rate of miscarriages in early pregnancy.
  3. Smoking, alcohol, drug use: All these factors play a significant role in rates of early pregnancy loss. Abstinence is the best advice but even if you feel you can’t quit completely, it’s always worth discussing to see what steps you can take to minimise any harm.
  4. Previous history of miscarriages: If you’ve had three miscarriages, particularly with no normal pregnancies in between, then it’s quite suggestive of an underlying health issue which may be making it difficult for the pregnancy to grow and definitely warrants further investigations under specialist care for such possible causes.

So the take home message with miscarriages is that they are common – as common as 1 in 5. Don’t stress too much if you’ve had 1 or even 2 miscarriages as they are very likely related to a chance chromosomal problem and is not likely to happen again. It’s not your fault as foods you eat, usual chores or work you do, continuing gym exercises doesn’t cause miscarriage except in some rare circumstances. Don’t hesitate to talk about it if you feel it may help you feel better. Offer positive support to anyone you think might benefit from it to make the experience bit easier for them. If possible plan your pregnancy, seek advice from your health care professional before you start trying so that they can help you start the process in a healthy state. Keep positive. It’s good to know your facts and be aware that early pregnancy miscarriage rate is high but for each miscarriage there are four healthy pregnancies coming to a happier and far more desirable end:)

Problems in life

Problems. Life. Two separate things which are generally running together and at certain times the former seems to take over the latter.

The key thing is that problems may be a part of life but problems are not life.

Think of a rose bush.

The plant itself is the life.

The beautiful fragrant flowers are the things going well, the good experiences.

The dried up, droopy and stenchy flowers and leaves are the problems.

Nature has made the rose bush in such a way that it will always have the rotting bits but the bush will drop them off and allow the new ones to bloom, keeping its beauty and appeal to the eye.

Life is the same. It can sometimes have so many complications and problems that the life itself seems lost in them, but it will always have an underlying beauty and the promise., provided you give it a chance.

Just as the rose bush will thrive better with regular pruning and some regular watering and tending, our life benefits from regular reflections and tidying up and organising of the thoughts and some regular dose of loving care and kindness to ourselves.

What do I mean from tidying up of thoughts?

It’s taking stock of what our problems are. Choose top 2 on your list and then think them through. Are they really a problem or are you perceiving it as being a far bigger issue than it actually is?

Then break it down.

Every single problem can be dealt in 4 possible ways:

  1. Has a tangible solution. Act and solve it so it stops being a problem.
  2. Doesn’t have a solution and doesn’t have to remain a part of life. Let go of it. 
  3. Doesn’t have a solution but has to remain a part of life. Accept it and see how you can find a way to live with it. I’ll give a personal example here. I have chosen a slightly bigger and loftier problem but it can be of any level. I see poverty and its effect on children as being a big problem and it’s a social issue that affects me. I like my material comforts but having this sentiment makes me feel guilty of enjoying them while there are people out there suffering at extreme levels. This conflict has the potential to make me feel disillusioned and discontent which can take my mojo in life away. I also know I can’t change the situation. But I have to find a way to live with it. I have done it by adopting a child and a family. It’s not changing the world but there is a family that I am lending a helping hand to through their tough times and there is child who is getting meals on time, adequate clothes and shoes and is attending school, all of which wouldn’t have been possible otherwise. I understand that I’m not getting rid of the problem of poverty and it will still be here long after I am gone but I feel satisfied that I’m doing what I can at this stage in life and the conscientiousness of looking out for community events and helping out now and again has given me the ability to deal with the problem and accept it, without it having an ongoing impact on me psychologically.
  4. Has a solution. But there’s not much you can do about it at present. There’s a possibility you may be able to do something about it in the future so you accept the problem as part of your life – but not forever. The ultimate outcome is either reaching a solution or reaching the point of admitting that nothing more can be done and the problem needs to be allowed to let go. Keep the solution in focus, decide how far you are willing to go to put up with the problem and where are you going to draw the line – be clear about this specific point. I’ll again take a personal example here to illustrate this approach to problem solving. When I am talking to a drug or alcohol user who is not yet ready to quit, despite it being the best solution to their problem, my focus changes from harm elimination to harm reduction. I stop talking about giving up drugs (although I keep bringing it up at regular intervals) and start talking about using clean syringes to reduce the risk of acquiring and then spreading blood borne infections such as HIV and Hepatitis C, steering clear of unlawful activities, engaging with the available social services they can use. Some may argue about the righteousness of using tax payers money but I don’t think any of those arguing would want to be the next person whose house or car gets broken into by a drug user. The shattering effect of living through this experience is becoming all too commonplace . I’ve sat with patients and watched them transform from well functioning, hard working people to paranoid and traumatised people who are struggling to get through even the most basic of life functions, simply from having a mere few minutes experience of having their personal space violently invaded by someone who doesn’t even have the clarity of thought to know clearly what they are doing or to care about the consequences of their actions. I still keep my focus on the ultimate aim of them quitting drugs and become a functioning and useful part of society again but I’ll continue to manage their drug use related problems until that time comes. To minimise the wider ill effects of their drug use. But this is where the element of drawing a line comes in . If this drug user then starts creating problems in the waiting room for other patients or the staff, asks for scripts for prescription medications, steals or forges scripts etc then I accept that there’s nothing more I can do about the problem here and have to let go.

These four breakdowns of problems work every single time for me – from something as simple as doing the laundry becoming a problem to much bigger personal dilemmas such as employment, traumatic life experiences, perceived challenging behaviours from significant others.

The key is to not to do anything about a problem. That’s when it starts to overtake our lives and starts being the life itself. Separate. Problems. and Life.

A season of sore throats

It’s that time of the year again – cold weather full of sniffles, sore throats, congested noses and general misery.

It’s also one of the busiest times of the year for the family doctors as we see huge numbers of patients with these symptoms to seek some sort of medical advice and to enquire whether antibiotics are indicated.

First I want to talk about the cold and sore throat that seem to linger for days and days or tends to come back very quickly.

Quite a lot of my patients get surprised to learn that not every cold like symptom is an infection, let alone a serious bacterial one needing antibiotics.

Quite significant proportions of these colds are related to weather or environment related sensitivity. In the spring season, this association is more typical and more widely recognised and appreciated. It’s in relation to the response of the upper airways (nose and throat area) to pollen and is commonly known as hay fever. It’s easy to recognise with the hallmark nose running like a tap, puffy and itchy watery eyes and series of sneezing fits.

But this type of allergy is not necessarily limited to a particular season or allergen. It can last through different seasons and even through the whole year and it can be to all sorts of different elements in our environment such as grass, dust mite, pet dander to name a few. And it may present in completely different manner of congested or blocked nose, throat irritation and cough.

When such a sensitivity is present in us, it can make our airways inflamed as they try to fight off the irritation caused by the allergen. We experience this inflammation as runny or stuffed nose, tickly throat, dry cough, fullness in the areas of cheeks and temple, blocked and itchy ears. The tickly throat and the cough are related as they are caused by dripping of the fluid, produced as a result of this inflammation, through the back of the nose down to the throat. It’s not uncommon to wake up with quite sore throat as a result of this process and to bring up chunks of gunky phlegm first thing in the morning which quite commonly worries people regarding the possibility of an infection causing all this trouble. The blocked ears are caused by the same fluid condensing in the little alleyway connecting our ear, nose and throat. The fullness in the face and head is due to the same fluid from the inflammation getting accumulated in normally air filled spaces in our face and head called sinuses. One very typical sign of sinus congestion is that leaning forward whilst sitting up in a chair will worsen the congestion or the headache.

Another quite common reason of sore throats in winter tends to be the dry air. Loss of humidity, accompanied with a blocked nose makes it necessary for us to breathe through our mouths, drying up our throat and making it scratchy and painful as breathing through nose naturally moisturises the air we are breathing. Using a humidifier may help here.

Quite a few cultural groups firmly believe that eating or drinking cold stuff can give you a cold. They might be onto something with this as consuming cold stuff does indeed increase your chances of getting sore throat, although not a cold. This is due to the fact that cold foods cause congestion of the upper airway lining, making it bit inflamed in a similar fashion to response to an allergen and the swelling weakens its natural defence mechanisms, thus making it easier for the omnipotent viruses to attack and get hold.

So in response to one of the most commonly asked question about whether cold foods can give you cold, the answer is no but it can definitely predispose you to catch one.

So the above mentioned cause of sore throats is allergy/ sensitivity related and its incidence is about 30% amongst causes of sore throats. It’s incidence is unfortunately even higher in Melbourne due to the environmental conditions we have here.

It obviously doesn’t need treatment with antibiotics or even with cold and flu measures but with anti allergy medications such as antihistamine – in form of tablets or nasal spray. Antihistamine or decongestant nasal sprays are effective and quick acting relief remedies but due to their side effects their use should be limited to about 5 days at a time. If the symptoms come back quite quickly after stopping these medications then steroid nasal sprays can be used safely and effectively to control the symptoms. A key with using nasal sprays effectively is knowing the correct technique so make sure you ask your health care provider or pharmacist for a demonstration when you are a first time user.

If an episode of sore throat is associated with fever, body aches and muscle pains, and swollen neck glands then it’s highly likely to be an infectious bout. Overwhelmingly vast majority of these cases tend to be either viral or mild bacterial infections which our bodies are capable of flighting quite well with some simple support such as plenty of warm fluids, throat lozenges, over the counter cough syrup, panadol, salt water gargles, lemon and honey drinks, plenty of rest and if possible home made mum’s recipe chicken soup – the last one is definitely one of the best remedy for most of the ailments known to mankind!

The warning signs which indicate that a trip to the doctors is indicated for a review or a reassessment are high fevers not responding to simple temperature control measures such as panadol and or nurofen, significantly troublesome sore throat causing difficulty swallowing, sufficiently tender glands in the neck and the most reliable of all signs – a feeling of being sick as the best expert on you is you and no one knows better than yourself when you are ill.

Glandular fever quite often mimics bacterial tonsillitis and make you feel quite sick for about a week but your health care provider should be able to make the clinical judgement about differentiating the two as the former, although quite distressing, doesn’t require any antibiotics and tends to get better with some tender loving and care whilst the latter may require antibiotics. When the antibiotics seem indicated then your health care provider may take a throat swab, give you a script for antibiotics with instructions to start if either you feel any worse or it you get a phone call in 24-48 hours about the swab result.

Another common cause of feeling quite ill with high fevers, generalised body aches, fatigue, loss of appetite, sore throat and congestion is influenza. It is different from cold due to the severity of symptoms it causes. Antibiotics do not work for this either and the best remedy is getting a flu shot well in advance of the season and to pay attention to simple hygiene measures such as covering mouth and nose with a tissue or hanky (I can’t believe I just wrote that! Does anyone still call them that or uses one?!) and hand washing with soap and water after coming back from outside, before eating etc.

So on the whole, you may notice that not all sore throats are infections and not all infections are bacterial. I am not drawing on any firm statistics here (although there are plenty available nowadays) but for every 20-25 cases of sore throats I see, maybe about 1 needs antibiotics but all 25 need clear advice and explanation about what they have, what are the things they can do to help themselves, including use of over the counter medications or home remedies, and clear instructions about what warning signs they should look out for indicating a need for review.

 

Shining a little light into a dark corner

Yet another knock on the door from a young migrant woman who came in to discuss about her period problems. At the end of the consult she hesitantly mentioned the difficulty she had experienced in managing her stress – for the last four- five years. I contemplated for a moment to ask her to make another appointment as the problem had been there for years and as I looked at the watch I saw that I was already running late by about two hours but instinctively decided to let her tell her story. As she spoke about her problem the guilt was palpable – concerned about taking up her doctor’s time, ashamed of feeling this way as her parents back home have huge expectations from her, embarrassed that she is unable to find happiness with her husband, worried that she’s not enjoying the work she desperately needs to hold down for financial reasons, annoyed with herself for not being able to share any of this with her friends and family; and helpless for feeling exhausted and down in this way when all seems to be okay on the surface. It took us about twenty minutes to work out that she’s actually been suffering with clinically severe depression and anxiety – unexplored and unreported by the patient for years. The conversation set me further back with mounting waiting times but I’m so grateful that the patient felt safe enough to talk about the issue and plucked enough confidence in herself to commit herself to a treatment journey with help from her health care worker. Day’s work done. But how many more people are out there who haven’t yet recognised that there’s a problem or who haven’t yet worked up the courage to talk about it and decided to take control? And who still feel that their mental health is somehow their fault, something to be embarrassed about and to be dealt with on their own? How many more feel so hesitant talking about it that they make an appointment about more validated physical health issues and only bring mental health up if they feel comfortable as the consult goes on and they sense that they will not be turned away? Let’s get talking. I’m not talking patient to doctor. I’m talking person to person. You just never know which gesture or remark will give the other person courage to speak up and share their problems. A little kindness and empathy goes a long way in shining much needed light into someone’s darkness. Keep shining it – you just never know how and where it might hit someone’s dark corner and show them the way out of it.

A story of emotions

Emotions are intriguing and mysterious. And they are open to interpretation – depending on whose point of view is taken into consideration – the emoter or the interpreter. When you are the emoter then you are said to be in an emotional state. When you are the interpreter you are said to be empathic. When you are the emoter and the interpreter then you are said to be self evolved. Can’t pretend emotions can always be understood or expressed adequately or as intended but they do add little something to our lives which we all seem to value incredibly.

During my days as wide eyed undergraduate I found my psychiatry lessons interesting but I somehow imagined that the subject will always remain in the sidelines as I manage the other real stuff like diabetes, heart disease, kidney problems, and all such pizzazz. Not saying that I didn’t appreciate the significance of mental health but I imagined that knowing my depressions from my anxieties and knowing my psychosis from neurosis will equip me well enough to deal with all that my patients will need from me.

But I have learnt slowly that the psychiatry lessons never stop for a general practitioner and the greatest teachers are the patients. They are way more complex… or perhaps far simpler… than I initially thought, all depending on how I choose to look at them or relate to them.

They have taught me that it’s not possible to put every mental health problem in a few well labelled boxes I brought to the table. In fact I’m finding out that these neat boxes are only the tip of the iceberg in a far more scattered and confusing sea of dysthymias, adjustment disorders, interpersonal issues, personality problems, anger and emotion dysregulation, substance use which are present everywhere around us, sometimes glaring and commanding attention but generally much meeker and quieter and hiding under the layers of  physical health issues which don’t seem to shy away from attention as much as the mental health ones.

Over the years my patients have gently but firmly guided me to strive to gain better understanding of their emotions, making quite clear that unless I understand their emotions I am going to struggle to get best outcomes in managing their health. It’s driven home the fact that I’d read hundreds of times before – chronic and longitudinal care. The relevance of what a GP does for a patient in comparison to 10 other health care professionals involved in their care makes sense now. Every health care worker’s contribution is significant and irreplaceable but it takes the bond of the patient with the GP to keep it all tied together.

I’ve learnt this from the silence I have heard from my diabetic patient who just never seemed to be able to regulate his sugar levels, no matter how hard his GP, endocrinologist, diabetic educator tried. I heard about his non verbally communicated struggles of not being able to control his emotions and the related comfort eating and the seeming non caring for his own health. In the noise of his behavioural problems, I also heard the silent plight of his feelings of guilt and inadequacy in relation to the impact of his poor health on his family and his worry about his ability to continue providing for them. I was at the receiving end of his external frustration which seemed to be directed at everything and everyone but himself. But because he didn’t press all the keys needed to unlock the codes of various mental health boxes I had lined up on consulting table, he kind of just hovered over the boxes, not getting the permission to enter any but refusing to let go either.

This situation seemed to repeat itself with all the health care professionals he came in contact with in his pursuit to achieve better health. It sometimes made him short tempered and angry, acquiring him the label of rude and aggressive patient. This also frustrated his health care professionals as despite their best efforts he just seemed to be help seeking with poor self motivation.

So what’s not working out in this situation? Is it the patient who has been equipped with all the help he needs in managing his health but doesn’t seem to be able to do so? Or is it the health care professionals who can perhaps sense that this is not a happy individual who is not being able to exercise enough will power or restrain in helping himself and there’s little they can do as on more occasions than not they have waiting rooms full of similar patients demanding their time and attention, leaving them under serious time constraints and then they just deal with the superficial layers of physical health issues, hoping that the person will sort out their emotions in due course. Or if they get worse enough then they can be put into a mental health box which then makes it bit less chaotic to deal with the problem.

The patient can generally sense when his health care professionals are getting tired of his confusing and disorganised emotions and behavioural problems with constant and recurring inability to help himself. I regularly come across a number of patients who report judgement from their health care professionals when it comes to confrontation with their out of the box mental health issues.

As time is going by, the only constant I am learning is that emotions are complex, they are individual and hard to be understood in their entirety. But there’s also another constant truth that generally people just want to feel happy and normal, howsoever they interpret normal to be. They don’t want to self harm, take drugs, treat their bodies badly by abusing them with unhealthy diet, lack of exercise and relaxation and general loss of purpose and motivation in their life. If they are doing all these things then they need a friend and guide and not judgement.

And health care professionals are in a fortunate and privileged position to be able to be there for them. People generally figure things out themselves, all they need is some validation and guidance.

The day I stopped telling my patient what to do to manage his health better and started listening without judgement I learnt about the difficult childhood he had growing up in the shadow of a dominant and alcoholic father. As he spoke some more, I quietly put the mental health boxes away and stopped worrying about which one to put him into. We then spoke some more and discussed about how does he ever see himself moving forward, towards better health and he told me that he’d already done this. He’s opened up to his GP about issues that he’d bottled up for 45 years. He had finally accepted what he couldn’t change and decided to change what he could, one small step at a time. He wanted to do this for his children so they don’t go through the same cycle that he did. He reported that he was ready to take some control back.

Obstructive Sleep Apnea

  1. Do you snore?
  2. Do you persistently feel tired and sleepy in the daytime?

If you’ve answered yes to these questions then there is a good chance that you’re experiencing a form of sleep disorder called sleep apnea.

Whenever I mention this term to the patients, they almost always seem to have heard of it but almost equally tend to have very little understanding of what it means.

The reason more people are hearing about it is because the rates of it are going up. Statistics show that about 25% of Australian men and about 9% women tend to have clinically significant OSA. Out of these, about 4% will have symptomatically significant OSA. It is relevant and important as it leads to an increase in death rate by about 2.5 folds. People with OSA are 7 times more likely to develop heart disease, weight gain, have decreased levels of concentration and mental sharpness or alertness and up to 9 times more likely to have motor vehicle accidents.

So let’s talk and learn a bit more about it. Apnea comes from Ancient Greek word: a = absence, pnein = to breathe.

So the basic pathology in OSA is a blockage in the upper respiratory tract during sleep that leads to recurrent stops or pauses in breathing.

Now lets explore this blockage business a little bit further. During sleep the air enters through our nostrils and passes via the throat, down into the lungs. Our clever bodies have evolved in a way that allows the muscles at the back of the throat to relax a bit as we are breathing in, to allow this air transition to occur without us having any awareness of it. So if all is going well then you’ll either hear no sound coming from the person sleeping next to you or it may be a gentle and quiet rhythmic sound of deep breathing.

But in individuals with problems in the area, these muscles may relax a bit too much, gradually narrowing the passageway of the air and you may hear the person lying next to you breathe quite noisily and start snoring and the intensity of the snores may keep going up in a crescendo rhythm (partners have described it as the sound of a train approaching the station – gradually getting louder and louder). The over-relaxed muscles at the back of the throat eventually collapse down, completely clogging up the path of the air getting into the lungs and the breathing stops – at this stage you suddenly hear….nothing. This is where the apnea or absence of breathing happens. Then the reflexes of the body kick in, causing the person to gasp for air, which you may hear as a gurgle or startled breathing sound coming from them which then again settles into a gradually increasing intensity of snores and the whole cycle carries on throughout the night.

Quite often the person who is going through it will have almost no recollection or recognition of these events as it is happening in the unconscious state of sleep, albeit the quality of sleep is affected, unbeknownst to the sufferer. It is not unusual for the spouses to come to doctors with the problem with a disgruntled partner who can’t see what the fuss is all about!

So, the above explains what it is and how it manifests but it still doesn’t explain how it can make the sufferer feel so tired and sleepy in the daytime that it has become almost the hallmark of sleep apnea presentation. The tiredness can be explained with the changes in sleep cycle.

During a normal sleep cycle we transition from awake state to drowsiness and then to unconscious state. In medical terms we call these cycles NREM and REM. The Non Rapid Eye Movement state has 4 stages : 1 to 4 and we move from NREM stage 1 (‘light sleep’ stage – even a slight noise can wake us up) to stage 4 (‘deep sleep’ stage ) in about 60-90 minutes and then transition to REM sleep which lasts a few minutes, although as night goes on REM periods get longer. We dream and are in a physiologically aroused state during REM sleep whereas NREM, particularly after stage 2 is associated with all the benefits known to come from good sleep – boosting of our natural defences and metabolism, repair of our body and release of growth hormones. In a healthy sleep cycle we should be spending about 75-80% of the time in NREM sleep and the rest in REM.

In sleep apnea this beautiful sleep cycle is disrupted which results in lot more of REM sleep associated with increase in blood pressure, heart rate, vivid dreams, restlessness. During apneic episode the body goes into fight and flight mode and this continuous stress is not good for the body. So even though a person with OSA would have slept the whole night, snoring away, but the quality of their sleep tends to be much lower and they tend to have far lower levels of oxygen saturation as compared to normal circumstances. This chronic stress on their body results in tiredness and the need for body to rest during the day. Some people tend to have ‘micro sleeps’ in the daytime, sometimes even without knowing. Such a micronap during driving can have disastrous effects and is probably the greatest worry for someone with OSA.

As I have mentioned a few times already, most of the times the people with OSA don’t tend to know it and may not think that there is a problem. But if they are displaying any symptoms then it’s important to alert them of this possibility and encourage them to discuss it with their GP as there are simple tests such as sleep study to diagnose it and to assess the severity of it. There are also various methods of treatment, again depending on the specific nature of problem causing snoring and the degree of severity of sleep apnea.

Amongst the lifestyle factors which can have a positive impact on management of it is limiting intake of alcoholic beverages, particularly of amounts exceeding the daily recommended limits (as alcohol aids the already over relaxed muscles at the back of the throat to relax further – that’s why people tend to snore more after having a few drinks); smoking cessation; weight control and inculcating the habit of sleeping on side and not on the back.