Podcasts about cheyne stokes

2.16 Sleep Apnea Pulmonary system review for the USMLE Step 1 Exam Sleep apnea is the repeated severe decrease or cessation of airflow into the lungs for more than 10 seconds during sleep, which causes the person to stop breathing for more than 10 seconds while they're sleeping. There are two types of sleep apnea: obstructive sleep apnea and central sleep apnea. Obstructive sleep apnea occurs when the airway collapses during sleep, and it is more likely to be associated with snoring, gasping, and choking. Central sleep apnea occurs when breathing cessations are caused by decreased central nervous system respiratory drive, and it is more likely to be associated with Cheyne-Stokes respirations. Sleep apnea can cause hypertension, pulmonary hypertension, cardiac arrhythmias, and even sudden death. The most common symptom patients will present with is daytime sleepiness, and obesity is associated with obstructive sleep apnea. Diagnosis relies heavily on testing, and the gold standard for diagnosis of sleep apnea is a sleep study (a laboratory polysomnography).  

  Für Kollegen, die auf einer kardiologischen Intensivstation arbeiten, wird dieser Beitrag vermutlich nicht so viel neues bieten (ich hoffe natürlich trotzdem drauf). Alle anderen könnten überrascht werden, so wie es mir auch passiert ist. Wir hatten einen relativ jungen Patienten mit einer relativ schlechten Ejektionsfraktion in der Nacht aufgenommen. Wir reden hier < 20% … Weiterlesen

The Curious Clinicians examine why advanced systolic heart failure can induce the Cheyne-Stokes respiratory pattern. Check out the episode's show notes here. Don't forget to claim your CME/MOC credits, courtesy of VCU Health! Audio editing by Clair Morgan of Nodderly.com. 

When your loved one has a serious illness, the world feels a bit darker. But you shouldn't lose hope. In this episode, I talk to Cushla Young, my lifelong friend and the co-author of Relentless. This book recounts my mother's road to recovery despite seemingly insurmountable odds. Cushla and I talk about the challenges my family and I face to cope with my mum's sudden illness. You'll also hear a little from my mum and her experiences through this ordeal. Our circumstances didn't stop me from being relentless. My goal was for my mum to recover, despite the experts saying otherwise. I wanted to extend my mother's lifespan and give her the best quality of life I can. Throughout my mother's treatment and rehabilitation, I had to step up and take control. I managed to compartmentalise things before they got out of hand.  If you want to learn about my relentless effort to defy the odds, this episode is for you. You will gain insights into how I challenged myself to keep my family together in a time of crisis.    Get Customised Guidance for Your Genetic Make-Up For our epigenetics health program all about optimising your fitness, lifestyle, nutrition and mind performance to your particular genes, go to  https://www.lisatamati.com/page/epigenetics-and-health-coaching/.   Customised Online Coaching for Runners CUSTOMISED RUN COACHING PLANS — How to Run Faster, Be Stronger, Run Longer  Without Burnout & Injuries Have you struggled to fit in training in your busy life? Maybe you don't know where to start, or perhaps you have done a few races but keep having motivation or injury troubles? Do you want to beat last year's time or finish at the front of the pack? Want to run your first 5-km or run a 100-miler? ​​Do you want a holistic programme that is personalised & customised to your ability, your goals and your lifestyle?  Go to www.runninghotcoaching.com for our online run training coaching.   Health Optimisation and Life Coaching If you are struggling with a health issue and need people who look outside the square and are connected to some of the greatest science and health minds in the world, then reach out to us at support@lisatamati.com, we can jump on a call to see if we are a good fit for you. If you have a big challenge ahead, are dealing with adversity or are wanting to take your performance to the next level and want to learn how to increase your mental toughness, emotional resilience, foundational health and more, then contact us at support@lisatamati.com.   Order My Books My latest book Relentless chronicles the inspiring journey about how my mother and I defied the odds after an aneurysm left my mum Isobel with massive brain damage at age 74. The medical professionals told me there was absolutely no hope of any quality of life again, but I used every mindset tool, years of research and incredible tenacity to prove them wrong and bring my mother back to full health within 3 years. Get your copy here: https://shop.lisatamati.com/collections/books/products/relentless. For my other two best-selling books Running Hot and Running to Extremes chronicling my ultrarunning adventures and expeditions all around the world, go to https://shop.lisatamati.com/collections/books.   Lisa's Anti-Ageing and Longevity Supplements  NMN: Nicotinamide Mononucleotide, a NAD+ precursor Feel Healthier and Younger* Researchers have found that Nicotinamide Adenine Dinucleotide or NAD+, a master regulator of metabolism and a molecule essential for the functionality of all human cells, is being dramatically decreased over time. What is NMN? NMN Bio offers a cutting edge Vitamin B3 derivative named NMN (beta Nicotinamide Mononucleotide) that is capable of boosting the levels of NAD+ in muscle tissue and liver. Take charge of your energy levels, focus, metabolism and overall health so you can live a happy, fulfilling life. Founded by scientists, NMN Bio offers supplements that are of highest purity and rigorously tested by an independent, third party lab. Start your cellular rejuvenation journey today. Support Your Healthy Ageing We offer powerful, third party tested, NAD+ boosting supplements so you can start your healthy ageing journey today. Shop now: https://nmnbio.nz/collections/all NMN (beta Nicotinamide Mononucleotide) 250mg | 30 capsules NMN (beta Nicotinamide Mononucleotide) 500mg | 30 capsules 6 Bottles | NMN (beta Nicotinamide Mononucleotide) 250mg | 30 Capsules 6 Bottles | NMN (beta Nicotinamide Mononucleotide) 500mg | 30 Capsules Quality You Can Trust — NMN Our premium range of anti-ageing nutraceuticals (supplements that combine Mother Nature with cutting edge science) combat the effects of aging, while designed to boost NAD+ levels. Manufactured in an ISO9001 certified facility Boost Your NAD+ Levels — Healthy Ageing: Redefined Cellular Health Energy & Focus Bone Density Skin Elasticity DNA Repair Cardiovascular Health Brain Health  Metabolic Health   My  ‘Fierce' Sports Jewellery Collection For my gorgeous and inspiring sports jewellery collection ‘Fierce', go to https://shop.lisatamati.com/collections/lisa-tamati-bespoke-jewellery-collection.   Here are three reasons why you should listen to the full episode: Discover my relentless journey of helping my mother recover from aneurysm. Learn important lessons about the value of health and extending your loved ones' lifespan. Gain insights from how I maintained my composure and became the backbone of my family in these difficult times.   Resources Gain exclusive access and bonuses to Pushing the Limits Podcast by becoming a patron!  Relentless: How a mother and daughter defied the odds Listen to other Pushing the Limits Episodes: #71: Cushla Young- Seizing the Day in Paradise #183: Sirtuins and NAD Supplements for Longevity with Dr Elena Seranova #189: Understanding Autophagy and Increasing Your Longevity with Dr Elena Seranova   Episode Highlights [04:43] Cushla's Interview with Lisa's Mum, Isobel As an educator, Isobel shares that she felt terrible when the doctors told her about what she can't do after the aneurysm. Getting a driver's license boosted Isobel's confidence. Isobel advises people who are going through a rough time to hang in there and continue to fight. To maintain her health, Isobel is currently going to the gym, taking yoga, undergoing hyperbaric treatment and attending art classes. She feels amazing about herself. [14:04] How an Aneurysm Affected Isobel and the Family After the aneurysm, Isobel went from an active individual to someone who couldn't function. Lisa shares some medical mishaps on the day her mum was rushed to the hospital. These mishaps caused delays in Isobel's surgery. It took 18 hours for Isobel to be taken into surgery because she had to be airlifted to another hospital. The fear of death coming to her mum was a big wake up call for Lisa. [20:03] Lisa's Relentless Fight for Her Mum's Life In the initial phases, Lisa was in shock and was extremely terrified. After processing the situation, she was in a ‘mission mode'. Lisa's father came up to her, saying that they needed to plan the funeral despite Isobel still being alive. When people are in crisis, you need to take control and give them jobs, so they don't panic. Over the next few weeks, Lisa was relentless in organising her family and the logistics surrounding her mum's medical needs. [26:14] Sustaining Herself Throughout This Journey Lisa shares her experience crossing the Libyan desert with an abusive boyfriend. During that extreme situation, she learned to compartmentalise. She will fall apart, but not right now when there's something that needs to be done. Lisa and her family had to stay with Isobel in the hospital around the clock for she could go any moment. Lisa also had to learn a lot about aneurysms, medicine and rehabilitation.  Amidst all this, Lisa's dad experienced heart problems, so he had to go home. [32:17] The Importance of Self-Care Lisa knows the value of exercise and having fresh air from time to time.  She made sure to take at least half an hour to an hour for herself. When you're in stressful situations, you tend to put self-care aside. However, it's vital to have systems in place to manage the stress so that you're prepared to continue fighting. [35:02] Lisa's Family Lisa's brothers were very supportive throughout the whole process. Lisa's family trusted her and what she told them to do. Her father also stepped up to help. He was relentless in caring for and supporting his wife's recovery. [38:25] Coming Home from Wellington after the Surgery Lisa was happy that her mother was stable. But she is also worried during the flight because any dropping of pressure could cause Isobel's death. Lisa sneaked into the hospital to have a friend check her mother for sleep apnea. And the results confirmed her suspicions. She had to convince the medical staff to provide her mother with a C-pap machine. Her mother could breathe properly with the machine. [44:43] Moving Lisa's Ageing Mother Lisa shared how they came up against people who insisted on having her mother placed in a facility. A social worker was against them having a caregiver. Lisa shares that she had to fight for the resources she wanted for her mother. [46:08] Caring for Isobel at Home Lisa and her family were willing and able to care for Isobel in the comforts of their home. A social worker told her that they wouldn't be able to care for her mother adequately. But Lisa remained relentless in the face of all these judgements. She and her family wouldn't go down without a fight. [50:57] The Importance of Mindset Professionals show you statistics based on their knowledge and experience. Don't discount their expertise, but don't lose hope. How you approach things is critical. You have the power to control your health and well-being. Lisa brings her mum to the gym daily for this reason. Lisa wants Isobel surrounded by athletes pushing their limits. If you want to stay alive, you need to work hard to keep fit and healthy. [1:00:28] Living and Lasting Longer Living a relentless life means taking lots of small steps and letting them accumulate.  By being relentless, you'll find more fulfilment and last longer.  Lisa shares that she wants to push degeneration out for as long as possible. There's a lot of research now that helps you live longer and better. Don't feel guilty for investing in your health.  If you want to learn more about how Lisa takes care of her body and her family, tune in to the full episode. 7 Powerful Quotes from This Episode ‘She was really the rock of my world. And then that turned upside down very much overnight. And you go from being this adult kid to complete role reversal where you're now having to do everything for your mum.' ‘We need to set up systems and processes and understand our own bodies and how our bodies work so that we can manage the stress levels.' ‘What I want people to understand is you have to fight for the resources that you want for your loved one.' ‘I'm only ever going to listen to the ones that tell me I can do, not the ones that I tell me I can't do. They may be right. I'm not saying they're not right, but I'm gonna throw the book at this. I'm gonna do whatever it takes.' ‘They're (professionals) making educated guesses, based on the statistics of the past whatever and their experiences. And I get that. And we can't give people false hope. But we've also can't take away all hope.'   ‘The older you get, the more effort you have to put into [working hard] if you want to stay alive... If you still want to be alive and enjoy life, then you have to fight for it.' ‘If you have some self-care and take those small steps, whatever that may look like for you at the time of your life, then you are living a life that is relentless.'   About Cushla Cushla Young is a life-long friend of Lisa. They met in a running retreat they both participated in 7 to 8 years ago. She is also the co-author of Lisa's book, Relentless: How a mother and daughter defied the odds. Cushla is a teacher at the St. John Bosco School, New Plymouth. She is also a Trustee and Educational Coordinator at the Taranaki Gifted Community Trust. Having an interest in gifted education, Cushla provides intellectual and creative ways to support students with advanced and complex learning skills. The other things Cushla is passionate about are digital technology, literacy and pedagogy. Cushla currently lives in New Zealand with her family. If you want to reach out to Cushla, you can find her on Twitter.    Enjoyed This Podcast? If you did, be sure to subscribe and share it with your friends! Post a review and share it! If you enjoyed tuning in, then leave us a review. You can also share this with your family and friends so they can find comfort and hope in fighting for their loved ones' lives. Have any questions? You can contact me through email (support@lisatamati.com) or find me on Facebook, Twitter, Instagram and YouTube. For more episode updates, visit my website. You may also tune in on Apple Podcasts. To pushing the limits, Lisa   Full Transcript Of The Podcast Welcome to Pushing the Limits, the show that helps you reach your full potential. With your host Lisa Tamati, brought to you by lisatamati.com. Lisa Tamati: Hey everyone. And before we get on the way with the show today, I just want to remind you to check out all our great programs that we have. We have our www.runninghotcoaching.com, where you can find out all about our online run training system, we get video analysis, your customised personalised plan made specifically for you, and ongoing support and help and education around everything running. So check that out at runninghotcoaching.com.  We also have our flagship epigenetics program, which is all about optimising your genetics and making the best out of them and how to do that. Understanding what your genes are all about and how to get the right food, the right exercise, the right timings for everything. Understanding every aspect of your life, your place, your career, your social environment, all of these things, your predispositions and much more. So check that out. Go to lisatamati.com and hit the work with us button and you'll see our Peak Epigenetics program right there. Also a reminder to check out the longevity and anti-ageing supplement that I am now importing into New Zealand and Australia in conjunction with Dr Elena Seranova, a molecular biologist who is behind this product. Now this is all about the sirtuin genes basically, which are all your longevity genes. Now NMN is a precursor to something called NAD, nicotinamide adenine dinucleotide. And this is an absolutely essential compound for every in every single molecule— every single cell, I should say, of your body. It's very important in regards to ATP production, and in regards to metabolic health, in regards to autophagy, in regards to sirtuin genes and upregulating those. Make sure you check out the episodes that I did with Dr. Elena Seranova and head on over to www.nmnbio.nz if you want to find more about the science of that, and why I am super excited about this product, this longevity and anti ageing product, NMN.  Right. Now, today I have something very, very different. I've turned the tables on myself and I have a very dear friend interviewing me about our book that we wrote together. Cushla Young, she's a, got a master's in English and she is the person who helped me rescue my book when I had a hell of a mess, basically. So I hope you're gonna enjoy this interview. This is all about my mum's story. It's about mindset. It's about going up against all the odds, it's about going against the establishment. So it's a lot of things we cover in this interview. So you're also going to hear from my very special mummy. She's going to come to work and tell us a little bit before she heads off on her coffee date. So now over to the show with Cushla Young and Isobel.  Well hi, everybody. Welcome to Pushing the Limits. Today I am doing something very unusual. And so hi everybody in YouTube land who's listening to this as well. I want to introduce my best friend, Cushla Young. Cushla, welcome to the show.  Cushla Young: Thank you. Lisa: For starters. Now I'll give you guys a bit of background. Cushla and I have been friends for now, a decade or so. Cushla is the lady that helped me write this book. Without her it would not exist. It wouldn't have come out before Cushla came along. The book is Relentless: How A Mother and Daughter Defied the Odds. It's my latest book, and Cushla is the magic behind that book. What we're going to be doing today is talking about what the book is about, which is the story of bringing my mum back from a mess of aneurysm, major brain damage at the age of 74, when it was against all the odds, when the medical professionals were telling me the brain damage is so bad that she's never going to recover.  Being an athlete I went, ‘No that's not happening, and we'll find a way.' This is going to be all about that story. Now I'm going to hand over the reins to Krishna to actually interview me, but I've actually got a very, very special guest sitting here next to me, who is the actual star of the show. And so Cushla is going to, she's going to take off for a coffee date. So I'll have to let her come to work first. So I'm going to pass you over to my very special mummy. There she is, Isobel. And she's gonna talk to Cushla for a second so I'll just pass over the headphones. Cushla: Hand over the reins. Lisa: You're on, Isobel.  Isobel: Okay. Cushla: Hi Isobel, morning.  Isobel: Good morning, Cushla. How are you?  Cushla: Taking off for a coffee date soon, are you? Isobel: Yes.  Cushla: So you are a guest of honor for a few minutes on this podcast. This is, I'm going to be a little bit different because I get to interview your daughter rather than her interview others today. Isobel: That's good. Cushla: So, but we'll start with you. So you have been on one heck of a journey over the last few years. Isobel: I sure have.  Cushla: So how can we start with how you're feeling now?  Isobel: I'm feeling good.  Cushla: You're looking great.  Isobel: I can go for a coffee and I can go walking on my own. And I can do almost anything.  Cushla: When Isobel left my house after a lovely glass of wine the other day, you didn't have one, but Lisa did. You drove, didn't you? You drove her home? Isobel: I did. Yes. I can drive now. That's good. Especially if Lisa's having a wine. Cushla: You get to be a mum.  Isobel: I do, I get, revert back to being mum. Yeah.  Cushla: Yeah, and that must have given you a lot of independence that you have lost for quite a few years.  Isobel: Yes. It's awesome. You don't realise how isolated people are. They haven't got— We all have a way of getting around here. It's isolating. Yeah.  Cushla: And can you tell us a bit about what you have been getting up to? I understand you've been doing some art classes with your sister. How's that going?  Isobel: Not as well as I would like to but it's, we're doing all right, you know?  Cushla: Yeah.  Isobel: I'd like the results to be a bit more spectacular. But—  Cushla: It must be nice to be creative.  Isobel: Oh it is. It's good, it does me good.  Cushla: Now, do you have much of a memory of the hospital time?  Isobel: No. Cushla: No. What's your first memory that you can recall?  Isobel: Probably where we went to a meeting with all the big guns— Lisa: At the hospital.  Isobel: At the hospital, and they wrote me off, really. Cushla: Did they? They underestimated you as well.  Isobel: I can remember saying— Lisa: I was feeling good. I was feeling good. Isobel: I was, I was feeling fine before this. Now. I'm feeling terrible. I have been demoted, I've been, lost my independence. Just because they were talking like they were, they shouldn't have done that.  Lisa: They took away all your confidence. And— Isobel: Yeah, they just. Cushla: And so your background is similar to mine. You're an educator.  Isobel: Yeah.  Cushla: Have been for decades and decades. You must understand how demotivating it is when somebody tells you what you can't do rather than what you can do. Isobel: Yeah, that's it exactly.  Cushla: So when did it change for you after that meeting? What were some of the first things that happened that gave you a bit more confidence? Lisa: Driving?  Isobel: Getting on a driver's license probably was a major breakthrough. Lisa took me down to the dam by the port and just— Lisa: It's been months. Isobel: Happier— Cushla: Round and round you. Isobel: You will, ‘now you drive.' I was totally gobsmacked. Cushla: But you did it.  Isobel: I did it.  Cushla: And I understand the doctor was utterly shocked—  Isobel: He was.  Cushla: —when you went in to get your medical for your license.  Isobel: Totally blown away. Cushla: Yeah.  Isobel: That was a blow away.  Cushla: It had probably been a while since the doctor had responded that way.  Isobel: Yeah, I think so. He was a nice doctor. So that was good. Cushla: So could you give some advice to someone who might be going through something pretty tough at the moment. What would you say to them?  Isobel: Just hang in there and— Lisa: Fight. Isobel: Fight hard. Yeah. Yeah. You've got to grit your teeth and just carry on, really. Yeah. Cushla: You're one tough lady, aren't you?  Isobel: I must be.  Cushla: Definitely.  Isobel: So that's what we did.  Cushla: Can you describe some of the routines of things that you do at the moment that keep you in such good health? Isobel: I go to the gym most days.  Lisa: Do weight training, cardio. Isobel: I do weights, I do cardio, I do walking on the treadmill, yoga. Cushla: And you still do your hyperbaric as well?  Isobel: Yes, every day at the moment. Cushla: Everyday? Wonderful. Still eat the smoothies that Lisa makes you in the mornings? Isobel: They're pretty terrible.  Cushla: But they're good for you, right?  Isobel: But they are good for me. Broccoli is not exciting, and it's sickening. Cushla: What we've noticed is, about over even the last six months, is how fit and agile and glowing that you are. That's amazing.  Isobel: It is amazing. It's amazing that you said that. I don't always feel it.  Cushla: Right.  Isobel: It's hard to know where you're at, so.  Cushla: Yeah, I think sometimes what you see is yourself reflected in others' eyes, and that's a really good indication of how far you've come.  Isobel: Yeah, and I have come a long way.  Cushla: Really. Isobel: Yeah, a really long way. Lisa: A bloody long way. All right, now you can go get coffee. Isobel: I'll pass you back to Lisa— Lisa: —and get yourself a coffee date. Cushla: Enjoy! Isobel: I will. Lisa: Thanks, Mummy.  Isobel: Okay.  Lisa: She's an absolute legend. Thanks, you have a nice coffee. We're now actually going to get into her backstory. Because, I would have done it the other way around and had her at the end of the show. But she needed to get to a coffee date. So she's just rolling. Yeah, we're rolling with the punches.  But Cushla, this— can you, I'm gonna pass the reins over to you fully. Because you know the story, you lived it with me, you helped me from the get-go pretty much. So over to you. Oh now I'm an interviewee. Cushla: Got you. We're flipping the tables, aren't we? Lisa: Yeah, we sure are. Cushla: To be interviewed for once, which is fabulous. So this has been a long journey for you and your mum and your family, and you're right. I was, I had known you for a few years before this happened. I think from my perspective, the thing that was so shocking about what originally, with the aneurysm, with your mum, was just how quick things changed overnight. I think we see Isobel now and— how old is mum?  Lisa: She's 79.  Cushla: 79. So we're going back quite a few years, and I used to often pop into the shop and see your mum, and just pop in and say hello. And she is now but she also was been a very intelligent, clear spoken woman that used to do acro-aerobics all the time, she was very fit and healthy, very independent, working still pretty much full-time. Lisa: Yeah, she was. Cushla: For somebody watching, to see overnight that she went from that, from a completely functioning full-time working adult, to just being, nothing was there. Overnight, the aneurysm took her from being completely functional to nothing. I think the shock in that first visit and I saw her quite a few weeks after the aneurysm, and you're back up to New Plymouth. You'd been in Wellington. The shock of seeing her lying there, she had aged a decade overnight.  Lisa: Yeah.  Cushla: It's hard. Hard to see. I think the shock of that must've ripped through your family quite viciously. You notice that change overnight. Lisa: It was huge. Yeah, to have growing up with mum being always the one supporting me. And the one that was there for me in all the phases of my crazy, upside down life that I've had, you know, with all my adventures supporting me with all lower— dramas and relationship breakups and divorces and business growing.  Cushla: Rooting for you at most of your races. Lisa: Oh, yes. Yeah. She'd seen, been there, done that with me, I can tell you that she had a hard life with me. She had a good life, she had exciting times with me. She was really the rock of my world. And then that turned upside down very much overnight. And, you know, you go from being this adult kid to a complete role reversal, where you're now you know, having to do everything for your mum, you are advocating, you're fighting, you grow up really quickly, even as a fully-grown adult. Obviously, I still am very much, when you've got a parent, you're still like a kid in a way to them. That is that was a biggest shocker for me I think was to be, no, now you are the one that's caring for your mum, and you are going to have to pull out all the stops to help her and it's you know, no longer about you being the selfish egotistical athlete, and there's nothing wrong with it, if you're an athlete, you have to be if you want to reach, know, do the stuff that I did. But that was a shocker. And then not, like the— we had medical research mishaps from the very get-go when mum had this aneurysm that happened early in the morning. And an ambulance driver came into the house, you know, they got her into the ambulance up to the hospital, he knew already that she was having a neurological event. And he told the doctor so much, and he just ignored it. He ignored it.  He said, ‘No, she's having a migraine, I think. So we'll just leave it for a few hours and observe her and give her some painkillers.' Well, you know, ‘Thanks very much for that.' The first six hours not knowing, and she was dying, basically. She was dying. And I knew she was in deep trouble. And I didn't know what to do. Because at that point in my life, I had no idea of anything like this. So I was never, you know, in a situation like this, I didn't know what was wrong with her. But I knew we were in trouble. And that was a very big wake up call. I actually got our mutual friend, Megan Stewart, who's a paramedic here and the head of the ambulance here. And she came up to the hospital at that time. She sort of rattled some bloody cages very quickly. And because she knew immediately what was happening, stroke or aneurysm or something neurological, migraines. She went and told this doctor what for. He then relented, and we got a CT scan. And that's when we saw the blood right throughout the brain. So that was a very big wake up call for me in a number of ways. Obviously, the shock of it happening to your mum, the fear of her dying, she's being very, very, very close to death at this point. And then realising that, you know, the medical system had not worked for us. And I'm not— you know, we're all human, and we all make mistakes and stuff. But that was a pretty big one. That was a pretty big one. Cushla: I think, in those situations, we want to trust the people that are— the medical professionals that are around us. For the most part in ED, they're an amazing group of people. But I think also there is a lot to be said for your mum. You knew what a migraine looked like, you should have before. And it's a matter of trusting yourself, isn't it, enough to then think, this isn't to your question what you're saying, and then fight as hard as you can for a different outcome. Because my understanding about aneurysm is there's a golden hour, or it's really important to be treated.  Lisa: Exactly.  Cushla: A short time.  Lisa: Surgery, that's the golden hour, they talk about getting you into surgery within the hour. It took 18 hours. 18 hours, because not only do we have the medical mishap and we also had the fact that we had to get to our Main Hospital down in Wellington, neurological. Living in a regional area, unfortunately, that's just the way it is. But we had to wait another 12 hours for the air ambulance to actually get to us, and when you're over 65, you're sort of bumped down the hierarchy, especially if you— if they don't think you're a good, you got good odds. So, you know, we— there were, at that time we had a baby that needed help, and that was more urgent than mum. They have to make those calls. I understand. I don't like it; I understand it. It's your loved one and you don't really give up. Cushla: Not at the time because you're also going through the shock of what's happening and trying to process that. In that moment, can you describe, I suppose I want to focus a little bit on what was happening to you and your body. Because I think the thing about this really, this story is that it's not just about a mum surviving an aneurysm, but it's also about you and your family and how you've managed to pull yourself back together as well.  So not just Isobel but yourself. I know that a lot of us, all of us will face a moment in our lives where we have to handle a bit of trauma.  Lisa: Yep.  Lisa: What was going on in your body and how did you cope so that you had the ability to fight for your mum? What are you doing in your mind? Lisa: So in the initial phases, Cushla, you know, you are in shock, you're out, you're terrified. But very, very quickly, oh, especially after the mishap, once I realised what had just happened and the ball's up that that was, and that it was likely going to cost your life. I just went into what I call mission mode. Like, ‘Okay, right, I am not going— I'm going to research the hell out of this. I'm going to learn everything I can. I'm going to be hypervigilant. I'm going to watch everything they do. I'm going to question everything they do. I'm going to get my family organised.' Because I had get them down to Wellington. My father was, of course, falling to pieces because it's the love of his life. He's been, you know, married to her for 55 years. He came up to me already in the ED and said, ‘We better start planning the funeral.' Because they were, you know, saying to us, she's like, unlikely to survive. And I'm like, ‘Dad, we're not even considering that. She's alive, she's still breathing, and we're gonna fight with everything we have. Here's a list of jobs to do: I want you to go ring so and so, organise this, get the boys down, my brothers down to Wellington, blah, blah, blah.' When people are in a crisis, you need to take control and give them jobs to do so that they, their, you know, their amygdala, that their permanent part of the brain doesn't go into complete full-blown panic, and which doesn't always work. And I'll relay a story a little bit later, where I did go into full blown panic. It's all very well and good to say this. But at that point in time, I was like, ‘Dad', I shook him, I grabbed him, I held him and I said, ‘No, you've got this and this job to do, we're going to do it, and follow me, dad. Follow me.' And that was basically how it was then for the next few years. Yeah. My brothers as well, they were very much, ‘What do we do?' I had no idea at the time, but I pretended like I did. Fake it till you make it. What we're doing this is how we're going to operate over the next few weeks. So it was being down on Wellington together, organising the family to be down there, all the logistics that go along with that, and your jobs and your, you know, partners and all the rest of it. And then a 24-hour watch over Mum, and being hypervigilant, explaining to the boys everything that I was learning medically, because I was like, studying forever, I was just going, going, heart out, trying to understand and get up to speed on something that I was completely not aware of prior to this, learning what an aneurysm does, what vasospasms are, what I've been looking for, what they— signs.  We were only in the neurological unit, we weren't in the ICU, which, looking back when I arrived, what the hell. When she got down to Wellington, they get straight into surgery, they started draining her blood off the brain. She started to— start to have that pressure released. But then we had to decide the next, in the next couple of days, though it had stopped bleeding at that point, but it was about to go out in time again, it could go at any moment. How do we clamp it? What do we do? Would we cut into her brain and put a physical clamp over the area? And it was a mess of aneurysm. Like we're talking a 16 millimeter huge aneurysm. We went up through the femoral artery, and we weighed up the pros and cons and you make that call. She's got a 50% chance of dying this way, she's got a 30% chance of dying that way, pretty much. So we'll take the lesser evil, but she was going to have to have two operations and in that way you know. So that was gonna be really touch and go, really touch and go. I remember them wheeling her off for that operation. I think it was on day two, through the doors, and you just don't know if it's the last time you're going to see them alive, and the whole just trying to hold your shit together. Cushla: I know that you're very good at compartmentalising parts of the— of something when it happens. What I remember you talking about when we were writing the book, was how you were able to put the jobs that needed to be done in that box. The research you were doing in this box, your family in that box, and probably, and I know this because we had phone calls and I was in touch with you at the time, your emotions and your shock and your trauma in this box. It was a matter of kind of keeping you know, all those juggling balls in the air at one time. But also, and importantly allowing you to have that emotional spot as well. And I know that you were very good at compartmentalising and giving yourself time to do that, but not letting it overtake you, letting you drop all the other balls at the time when you were dealing with the emotional side of it. I think that's really important because I know— so when Lisa and I first met, I was a bit of a Lisa Tamati fangirl, before we became friends, and I got to know you really well.  Lisa: And then realised, oh no. Cushla: Yeah. I mean, we just saw you as Wonder Woman. You know, there's tough, tough, you know, athlete. Then I got to know you, as a human being, of course, a woman, there's a vulnerable side to you. But what I think is really important at that time, an immediate trauma time, as you gave yourself time to release a bit of that stress and that trauma by leaning on your husband Haisley, by your phone calls to me. But also, like, I know that you went for some runs, went to get gym, threshed it out, you probably screamed at the ocean at one point. Do you know? That's also important, isn't it? It's not just— Lisa: If you want to sustain— we knew this was going to be a long, long, long battle. While we hoped it was going to be a long battle, a short option was not a good one. This is something that I've learned doing ultra marathons: is to— in particular in the Libyan desert crossing, where you have to read the book for the whole story. But I did an expedition across the Libyan desert with three other guys, one of them being this abusive boyfriend that I was with at the time. There was a very extreme situation that we were in, we needed two liters of water a day, etcetera. And I'm having this big domestic fight with the boyfriend right in the middle of the Libyan desert. Cushla: In the most extreme environment on the planet. Lisa: In the most extreme environment, walking 45 kilometers a day with 35-kilo backpacks and only two litres of water a day in a military bad zone, not a good time to breakup with a boyfriend of five years. And in that moment, when he left me and disappeared over the sand dunes, that was a turning point for me, and I fell apart initially. And I was like, ‘Oh, God,' started  crying in the rails. I can't afford to lose any more tears here. I've got to pull my shit together, because I cannot let the energy dissipate that at the rate of I want to actually survive. It was getting down to that sort of level of you know, you're going to survive this or not. And so I learned in that moment, really a very hard lesson in compartmentalising things in your brain. So like, ‘I'm going to fall apart, but not right now. I'm going to put that off right now because I have to focus on this, and getting through the desert and surviving.' That's been actually a really good lesson. It's never a pleasant one to actually have to instigate where you have to actually compartmentalise.  Just interrupting the program briefly to let you know that we have a new Patron program for the podcast. Now, if you enjoy Pushing the Limits, if you get great value out of it, we would love you to come and join our Patron membership program. 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Lisa: But in this in this situation where you're dealing with— you're having to study like really hard. And we have access now to the greatest minds on the world that come in, all those information about out there that you can study. So I was studying all the drugs that they had on, all the procedures they were doing, what is the normal plan, and what happens when you have an aneurysm, what are of the some of the dangers, or of the things that I should be looking out for, what are the signs in your body. You know, all of these types of things in the initial phase and then later on at it went into rehabilitation research and study. And so that was one aspect of it. And then we had a 24-hour clock system, much to the disgust of the people at the hospital because they didn't want us there 24 hours. They don't like that. There was no way I was leaving my mother when she could die at any minute alone. No way.  So I had massive battles with the hospital, for them to be able to allow us in. And then having to fight for that. So you're fighting on all these fronts, you're already fighting with— your mum's in deep, deep trouble, and then you're fighting against these systems. And they may have some good reasons for those systems. But there was no way I was leaving my mother alone when she could die any second. A family member had to be with her at all times. And I was very, very strict on that. We had some big blow-ups at the hospital. We got through really in the end. And we tried to be as unobtrusive as possible when we did what we were. And we picked up things that they missed, because she was on a neurological ward, they only come around a couple of hours into obviously, patients. But going back to the whole compartmentalising things. I know how to manage my body really well, and how to pace myself really well from doing ultra marathons and stuff, and expeditions. And so I knew that we were going to be in the for the long haul, I knew sleep deprivation was going to be a problem, I knew that the family dynamics were going to be a problem, that there was going to be fighting because of the stress there was it we were under, and we were all living in one motel unit. And that mum was in deep crap, we had my father to look after who was just, you know. Cushla: And he was down with you in the initial stage.  Lisa: He was here, he was; and he's very much, was a homebody. He didn't like to be out of his garden and sheep. So he was very, very stressed on that front, and of course his wife in such dire straits. He was, but he— so we managed to, had him to manage home because he started having heart problems. And so I had to eventually actually send my dad back home and actually lied to my dad that, ‘She's okay now, we've got her, Dad. She's all good.' Because I think that we're gonna lose him. I was making those sorts of decisions and just running the ship. Like you said, I know the importance of, for me, especially exercise and fresh air for my mental well-being, that if I was going to sustain it, I had to have at least half an hour to an hour every day out from this whole thing, where I just go and do a workout.  Again, all the fear, the cortisol, the adrenaline that's running through my body flat stuck and try to manage it, and making sure that she was looked after, and that time. You know, you feel guilty and everything for leaving the hospital all. But you had to do that after a few days. You know, just a couple of days, I didn't, but after that. It was— it's setting all these things in place. And we need to do that in our daily lives. We need to set up systems and processes and understand our own bodies and how our bodies work so that we can manage the stress levels and we can manage the movement that we need, the sunshine, and needs for sleep and recovery and all those aspects. And of course, in a situation like that, sleep deprivation was a massive, and there's not much you can do about that, you have to function at that level for as long as you have to.  Cushla: And I think a lot of people that are in stressful situations, whether or not it be something like what happened with your mum, or even at work or just in daily life, big stressful moments. A lot of people put the self-care to the side. And they just think, ‘Well, I'm not that— I don't have time for that,' or, ‘I shouldn't have time for that.' That's when the guilt that kicks in, and yet, it probably is one of the most important things to prioritise in terms of your day and compartmentalising your day through to handle stressful situations because it allows you to have the focus and the energy that you need and get back into the the stressful—  Lisa: Into the fight you're in. Yeah, absolutely. You need to be able to have that energy put back in. It might only be 10 minutes out in the bloody— you know, like when we, here's another situation which we'll probably get onto later with my dad. In his situation, in the hospital for 16 days, fighting for his life. It was sometimes 10 minutes in the waiting room doing press ups. That was all I could get before I went back into the battle zone if you like.   Cushla: Just to release that.  Lisa: Just to manage the cortisol. Reach, I call it discharge and recharge, and then reset. Come back into the moment. But yeah, it was a heck of a lot of lessons to be learned and then leading in a crisis situation. My brothers were amazing. They were very supportive, and they were, followed everything that I asked them to do, basically. Because I'm the study-er of the family, I'm the one that is into research and science and studies. They trusted me to do that thing. And they were like, ‘Well, you tell us what to do, we'll do it.' And that's really great. Because you've got your roles. That is, in having somebody lead the charge, so to speak, even though you don't know what you're doing, where you're going, and there's certainly no rehabilitation over the next years, because this process took years, having that person that's got that responsibility, got that, ‘This is what we're doing. This is how we're doing it, I just need you guys to do this bit and the other thing.' And my whole entire family were willing to do that. They were— my dad was just, jumping ahead in time, my dad was just amazing, how he stepped up to the mark. When he had a wife that had done everything for him pretty much. Cushla: He was, back when she came back to New Plymouth, he was cooking, and— Lisa: He was doing all the things.  Cushla: He was doing all the things, yeah.  Lisa: It was a shocker for him, but he stepped up to the mark to the best of his ability. He was the most wonderful, caring husband. He didn't give a— he didn't care that she— when she came back home for the first time, and we actually got her out of the hospital after three months. Now, I'm jumping ahead in time. But he didn't care that she had no function, basically. She was in a vegetative state who had a heartbeat. She was alive, and we were fighting. That was all he needed to know. He had his wife at home, she was alive, she's stabilised, we were fighting together, and we were on a mission. Every day he had his jobs to do and the things to do. He was just relentless in his love for her, stepping up.  Cushla: So going back to the moment where— so she's in Wellington, and you need to read the book to find out what went on in Wellington. The moment that she was transferred back to New Plymouth was a bittersweet moment, wasn't it? You were able to come home and be with Haisley and be back at home with the family and friends around that were helping. But you knew that the care that you would receive back in New Plymouth wasn't at the level that it would be in Wellington, basically just because Wellington is way more resourced. And fair enough, you can have a very small region. Taranaki here, you know, we're a little provincial spot in New Zealand. So we knew that we wouldn't get the care that you got in the big city. So talk us through how it was like to come home— Lisa: It was terrifying. I was happy for all those reasons, but at the same time, and I was happy that she's apparently stabilised. But she was in ICU for the good part of the two of the three weeks that she was in Wellington when she was in and out of coma. Once she'd gotten out of the coma, then they had to get the stent out of her heart, and she kept dropping. What happens when you take the stent out is that pressure can start rising in the brain again, and three times as they tried to take the stent out, the pressure went up. On the third time, they said, ‘Well, if it doesn't work, this time, I'm going to have to operate and put in a permanent one.' And the third time, it worked. But it only worked for the next 24 hours, and then they were like, ‘Right, she's not— her pressure's not going up. She's keeping consciousness, she's not falling back into the coma. She's good to go.' And I had researched, I knew that that was not the case, that she couldn't have— that pressure could go up over the next 70 days at any point, and if that pressure went up, it would happen very quickly, and she wouldn't— she could die.  So I knew that even though they weren't telling me that, she could still die in the next 70 days. If that happened in Wellington and the pressure started to go up, they were— they might be able to recognise that, they might be to go in and do something. They wouldn't be able to in New Plymouth. I was hypervigilant on trying to understand how I could notice if something in her consciousness was going down, right. All I could do was to understand some of the symptomatic things that she did which might exhibit if her pressure is starting to go up, because you wouldn't be able to communicate it to me, you wouldn't be able to see it, you would slowly lose more and more of a brain till it was gone basically. So that was a huge fear bringing her home, and of course putting her in an airplane with a pressure change. Yeah, I didn't know what it would do. In fact, it was nothing, but there wasn't a problem, really. But you know it this time you just— Cushla: You don't know.  Lisa: Yeah, so for the next 70 days, I'm like, hypervigilant. If I noticed something down on, I'll be like, ‘I think she's doing this and doing that.' Then they took her off the oxygen at the same time, and that was a big problem. They didn't see it as a problem that she was, ‘Her oxygen states are alright.' What they were forgetting was that she was sleeping 18, 20 hours a day. So when she was asleep, she wasn't breathing properly, and I believe she had sleep apnea. So I said to them, ‘I want a sleep apnea assessment.' They said, ‘No, she doesn't need that, why should she need that? Her oxygen stats are okay when she's awake, so why would she?' I knew about sleep apnea. So I got a friend of ours, he's actually a sleep apnea consultant, Jez Morris. I said, ‘Come into the hospital illegally, would you do that?' He said, ‘Yeah, I'll do that.' Well outside of rules actually, so not illegally, but you know.  We sneaked into the hospital at nighttime, put on these machines onto her, did an assessment overnight, because it had to be an overnight thing. We got the results, and when it came back, severe sleep apnea. Now, this is absolutely key. Like her oxygen levels were down at 70% SPO2. she was Cheyne-Stokes breathing, which is not a good thing. Probably going to be on your way out in the next couple of months. Her oxygen was so low that she was knocking off any brain cells that she has, the infections that are in her body were just going apeshit. So bacteria was exploding, and they're already known. That was actually the one of the signs that I picked up because I had done a lot of racing at altitude, and I was seeing a lot of the signs in her that I had at altitude when I had altitude sickness and things like that.  That was at first wind, because I had to convince the bloody staff that we needed to have the CPAP machine on here, and they weren't trained in CPAP machine, so they didn't want to do that. I'm telling what she needs, she's got this and you know, him being a sleep physiologist was able to convince them that okay, this is a good thing for her now. He said he'd been banging his head against the brick wall for decades, trying to get for stroke patients an assessment that is part of the process. Because very often, this happens that that part of the brain is damaged in the stroke or the aneurysm, and even in things like concussions, that you can have a change in your breathing situation. And that part of the brain that monitors that is not working properly. So it should be staying apart and perfect, and that's what I believe, and that's what he believes. So anyway, we got the CPAP machine. Initially started to have little bits of improvement, but we're already two months, three months, two and a half months or something into her time in the hospital and we're running out of time. But she's stable, nothing we can do with her, basically. She's pretty bad, and we've given paid lip service to some physio and some speech therapy and stuff, and now it's time to get you out of the system. Cushla: And I think at that point, I think they, if you saw Isobel at that moment in the hospital, you would see an old woman who was probably on her way out. You didn't see the vibrant person that we saw before the aneurysm, that was so independent, and so highly functioning. For the hospital, I think they just saw an older woman— Lisa: Another older woman.  Cushla: —another older woman, and a family that wasn't willing to accept the fact that they had an ageing mother. So there's that little bit of not understanding who she was before, and how abrupt this change was. We knew that if we could just get her back, even if it was a little bit back, then you could take her home and start working on rehab. Can you talk about how quickly they just wanted to move her into a home? Lisa: Oh yeah. And this is what happens very often when you're over 65 is the answer is get them out of our budget into someone else's budget. That means putting them into a hospital-level care facility. If you've got anything, that's the normal route that you go, and they will try and convince you of that route, at least in our situation. I can't speak for everybody obviously. We came up against a brick wall of this, especially the social worker who shall remain nameless, who just was totally against us being able to have the caregiver that I wanted, the caregiver for in the morning for an hour, and one in the evening for an hour, which is part of, they do provide the service and so on. But it costs more money, and you stay in the budget. That's the key point.  We were fighting over these resources. What I want people to understand is you have to fight for the resources that you want for your loved one. And we have limited resources, it's a fact of life. If you want to get some of those resources, and you think your loved one is worthwhile, worth it, because they've spent their entire lives paying taxes, being good citizens and have a right to have some of this, then you better be prepared for a fight because that's what you're in for. And we did have the fight. Cushla: And it was interesting that, because as a family, you were willing to bring her home and you're willing to do a lot of the care yourself. You didn't want to be taking up a resource in a care facility. You were prepared to do that yourselves, as a family, at home. So in a sense, there's a lot of money to be saved. Because I know how much you have given up and how much it costs the family to care for her at home. But that is what you wanted, and your family wanted was to just, to have her home. I remember in the book, you spoke about wanting Isobel to hear familiar sights, smells, sounds around her to aid her in her rehab. And that in having those, you felt that she was going to make more connections, neurological connections, because she was in her own home, with her own people around her, with her own sights and sounds and smells around her. Can you talk a little bit about how positive you felt that was? Lisa: Yeah, that's a huge piece of the puzzle. I had a friend's mum who actually worked in stroke rehabilitation. She really encouraged me to do that and said how important this was, and it just made total sense to me. I knew that when you're in the care of any facility, no matter how good they are, they can never provide the love and the attention that you can. Because they've got other people and you're just another patient and in— they provide a magnificent service and so on when this is absolutely necessary. But in this case, we had the willingness and the ability to do this. They said to me, the social worker said to me, ‘There is no way in hell you are going to cope with her. She's 24/7 around the clock care, two people at all times, there is no way you're going to cope with her.' I actually came and threw my books on his table one night, across the table at him. And I said, ‘Read these. This is who I am and my family are, and we are not giving up without a fight. We may go down fighting, but we're going to go down fighting, we're not going to go down and take the easy route out. It is not in our nature.'  It's a fundamental difference between a family that's a fighting family and a family that isn't. It's very much influenced by the people in power in these situations, the medical professionals, the people that are associated with all of it. And you have no confidence to stand up against all these professionals, usually. They're the ones that have been to medical school, they're the ones that have been to whatever, social work. Whatever the case may be, and you have a tendency to think, ‘Well, they know better than me.' But one thing they don't know is you. And they don't know how strong you are. They don't know the resources that you have. They don't know your mentality. And they don't know, really, they're all guessing as to what will actually happen based on their experiences. But that's what becomes partly a self-fulfilling prophecy. So when they say to you that there is no hope. No, that's their opinion that there's no hope.  I had time and time again, people telling me, ‘There is no hope, there is no hope, she's 74, her brain damage is so massive, it cannot be that she would ever.' I was like, ‘We'll see.' I'm only ever going to listen to the ones that tell me I can do, not the ones that I tell me I can't do. They may be right. I'm not saying they're not right, but I'm gonna throw the book at this. I'm gonna do whatever it takes. And it's all about attitude and effort and grinding it out then I'll take that one any day, I'll take that option. I'm a fighter. I'm a worker. And my family is too, and we're not going to go down without a fight. I've seen lots of— I saw lots of other families going through the same process, because this thing's happening every day in every hospital around the world, right? It is very much, ‘Well, statistically, this person's not a good bet. Therefore we'll just go through the standard of care, we'll be the— do the humane thing, we'll do all this— tick all the boxes or do it all right.' But the anomaly cases, the cases like mum's, why is nobody coming to say to me, why do I get— no, I'm out there telling everybody that story. That's why I've written the book is to empower other people in these types of situations, even different ones. But why is nobody asking me, ‘Well, what did you do?'  Cushla: What did you do to get there? Lisa: They've been— I'll let you know, when they mum here today, talking and walking and going off for coffee and driving up to see her friends, you would have no idea that she ever had anything.  Cushla: No.  Lisa: She's just completely normal again. But I was told that was an impossibility. How many people are told, you have a terminal illness, you are going to die of this thing? When you plant this sort of stuff, they're making educated guesses based on the statistics of the past whatever and their experiences, and I get that. We can't give people false hope, but we've also can't take away all hope. Cushla: No. That's a really powerful message, I think. I was talking to a friend of mine who is battling with cancer at the moment. She has the most amazing mindset, her mindset. So she's— you know, she was told she had three months to live, that was, I think, six months ago. Her mindset— and she's just been through some chemo and the tumors have shrunk. Her mindset, basically, is that cancer is not welcome back. It's just not. I'm going off to live my life. If I die of it, well, okay, I die of it. But in the meantime, I'm living my life, and I'm— it's not welcome back. She is charging in life and sure, she has her rough days. I really love how you said, it's— there's a responsibility for them not to give false hope, but at the same time not to take away. similar situation with my father, he has myeloma, so cancer of the blood. I think at the time, the doctors said, ‘After this treatment, you have between five and fifteen.' He immediately said, ‘I'll take the 15, thanks.' Because it puts them at that, at the point that it would have taken them to 85, and he was quite happy with it, because at the time he was 69. I love that. And we're six years down now. And I think mindset is huge—  Lisa: Oh, yeah.  Cushla: —in the way that you approach things. Because, sure, we might, I might die by being run over by a bus today. But if you don't live life thinking that things are going to get better, that you have the power to do, to have control over your health and your well-being, the way that you deal with these traumas, if you don't have that mindset—  Lisa: You're definitely not going to—  Cushla: — you're definitely not, you're going to roll up in a corner. As my friend with cancer said when she went to hospital, she's like, ‘Oh, I'm surrounded by all these sick people.' Which I loved. Because she didn't see herself in that. Lisa: That's one of the reasons I take mum to the gym every day.  Cushla: Exactly.  Lisa: I don't take her, I didn't take her, we did go to the physio program at the hospital. Don't get me started on that. But it was dreadful, it was shocking. The story's in the book, if you want to read that one, that is a real battle. But they— I like her to be surrounded by athletes going for it. Because that rubs off on her. She's not a patient, she's an athlete. She's training for her Olympics. That is the attitude we take every single day. And I make no concessions that she is 79 years old, and, ‘Oh, isn't it time for her to relax?' No, it isn't time for her to relax. It's time for her to work harder. It's time to go harder and the older you get, the more effort you have to put into, if you want to stay alive. That is the key.  When you stop wanting to be alive, then yes, sit on the couch and do nothing. Because it's what that will lead to. If you still want to be alive and enjoy life, then you have to fight for it. This goes whether you're bloody 10 years old, or 95 years old, or 105 years old. If you give into the easy way, if you go, ‘I don't feel like training today.' I don't feel like training most days. But most days I train. Because it keeps me healthy, fit, and I'm being prevented. That's what I'm all about now is being in the prevention space, and then helping people who are in dire need navigate the waters of into connecting people to the right doctors in the right studies and the right information and the right books and all of that sort of jazz. Cushla: When I was in the depths of my training for a marathon, I remember that exact conversation with a friend. She said, ‘I can't—' You kno at the end of the day, I go for a run. And she's like, ‘You've just worked a full day.' And I'm like, ‘Yeah, And I'm tired. But I'm going to go do it because you never regret it when you finish it.' At the end of that 10k, you've never thought, ‘I really shouldn't have gone for that run.' You don't. You come back thinking, ‘That was awesome.' Sure you're tired, but you were tired before you went out for the run. So you actually end up more energised.  Lisa: You mean that will energise your cortisol in—  Cushla: My muscles might be tired, but you're energised.  Lisa: And you're getting stronger. Cushla: Yeah, I think that's a really good message, that you don't regret it once you get out. It's always just those first, first few five minutes, or I always say the first 4k of any round was always more difficult than the rest. Lisa: 20 minutes is all it is.  Cushla: Yeah, it is. It's always shit.  Lisa: So same for me. And if I warm up properly, then it's only shit. If I'm in a hurry, and I run out the door, and I don't, then it's gonna be more shit, warm up quickly.  Cushla: The more experience you have with training, or with whatever it is that you're doing for self-care, understanding that the first little bit is always tough. And the more that you experience it, the more you know to expect it, then you know that you're going to get the buzz at the end and you start looking forward to that. Lisa: Yeah, yeah, I had that conversation with my brother yesterday, because I've been telling him, he's very funny. He does a lot. He's amazing, boaties, he does weight training. He's a surfer, and he surfs sometimes six hours a day, but he doesn't do cardio. And, you know, I monitor his blood, and his health and his everything. ‘You've got to do some cardio, we've got some issues here, we need some cardio please.' And he's like, ‘I hate cardio, I don't want to do  cardio.' And then we'll do five minutes, and he's like, ‘I don't want any—'  and I said, ‘It's about pushing through that barrier. It's the same as if you tell me, why aren't you going surfing anymore? And I'm like, “Oh, because it's so hard, and I don't want to get hit by the waves and get smashed around.' And he's like, ‘what are you talking about? It's awesome.”' As long as you go through that barrier. Pushed enough, long enough to get through that, and I'm having to go through that.  It's always that initial adaptation phase, that time when you're not fitting, you're not good at the surfing or the running, or the whenever, when it's shit. Let's be honest. But if you hang in there long enough, if you stay with the tension long enough, th

It started with one of the worst nights of sleep I have ever experienced. The sweats, nausea, headaches, constant vivid nightmares (mad shit about guides, sherpas, mountain life, permits and not getting kicked off the mountain), diarrhea, and lastly, Cheyne - Stokes breathing. This is basically where you stop breathing momentarily mid-sleep. A disconcerting way to wake yourself up. A tough night on the mountain for Damian. Subscribe now, so as not to miss an episode.

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This week, Drewby and Yergy review the mysterious case of Gloria Ramirez, a cervical cancer victim, whose brief but dramatic emergency room stay  in Riverside, California and untimely death baffled the medical community in the mid 90's due to medical workers falling very ill just by being in the presence of her and her body, prompting concern that her body had turned into a chemical weapon, and this was further highlighted as a possibility due to her alleged self-administration of Dimethyl sulfoxide (DMSO). Later the county health department attempted to make the claim that the whole thing was simply a case of mass hysteria, as many of the workers who fell ill were women. The case was further complicated due to multiple autopsies with the majority done after her body had already badly decomposed. Several conspiracy theories have since arisen. We also discuss the need for continued funding to clinics that specialize in reproductive health in order to detect, treat, and eradicate diseases such as cervical cancer and HPV, the leading cause of this fairly preventable disease.  Join Our Facebook Group to Request a Topic: https://t.co/DeSZIIMgXs?amp=1 Support Our Patreon For More Unreleased Content: https://www.patreon.com/themiserymachine PayPal: https://www.paypal.me/themiserymachine Instagram: miserymachinepodcast Twitter: misery_podcast Discord: https://discord.gg/kCCzjZM #podcast #documentary #truecrime  Source Material: https://www.rxlist.com/dmso_dimethylsulfoxide/supplements.htm https://en.wikipedia.org/wiki/Cheyne-Stokes_respiration https://en.wikipedia.org/wiki/Death_of_Gloria_Ramirez https://www.discovermagazine.com/health/analysis-of-a-toxic-death

  This weekly addition to the PAINE Podcast is a quick review and history of medical eponyms  

Commentary by Dr. Valentin Fuster

In this interview Lisa interviews Jez Morris, a clinical sleep physiologist on everything sleep apnoea and also cardiac testing. They do a deep dive into the symptoms and treatments and consequences of not picking up sleep apnoea.   Lisa has a personal interest in this as it pertains to brain function and rehabilitation and it was one of the key factors in saving her mum Isobel's life after a major aneurysm and stroke.  Jez explains the different types of sleep apnoea and co morbidities and risk factors.   You can visit Jez and his team at Fast Paced Solutions www.fastpacedsolutions.co.nz    About Fast Pace Solutions It was a common belief in the need for equitable health care – and improved accessibility for all – that led to three healthcare professionals joining forces to provide primary-based diagnostic services to GPs, specialists and concerned patients themselves. Fast Pace Solutions offers a range of cardiorespiratory diagnostic tests aimed at early and fast diagnosis of heart, lung and sleep-related complaints. Working closely with a range of health professionals and operating out of their new premises in the Strandon Professionals Centre, Michael Maxim, Jez Morris, and Alan Thomson want to encourage more people who have issues with breathing, dizziness, palpitations or sleep to get themselves checked out. Visit them at www.fastpacedsolutions.co.nz  Ambulatory Blood Pressure Monitoring Ambulatory blood pressure monitoring (ABPM) is concerned solely with detecting problems related to high blood pressure – a hugely significant health risk which is currently on the rise. Blood pressure monitoring involves wearing a cuff linked to a small device which measures your blood pressure every half hour (or hourly during the night) over a 24-hour period, while you go about your day. Many studies have confirmed this method is superior to clinic blood pressure testing in predicting future cardiovascular events and targeting organ damage. This means your doctor can provide a much more accurate diagnosis and effective management plan Holter Monitoring A Holter monitor is a small, lightweight heart rate monitor that measures the rhythm as well as the rate of your heart for a continuous period of 24 or 48 hours. The monitor has three leads which are attached to your chest via ECG electrodes. The Holter monitor's primary purpose is to correlate symptoms such as heart palpitations, rapid breathing or dizziness with the ECG (see below) and rule in or out any abnormal rhythm activity. The patient is required to document all symptoms in a diary. 24 Hour Holter Monitor Exercise Tolerance Testing An exercise tolerance test (or ETT) requires a patient to exercise on a treadmill in the clinic while being monitored by a 12-lead ECG (electrocardiogram) and blood pressure machine and is often used if we don't pick anything up on a Holter heart monitor. The ETT replicates how your body behaves under stress and can pick up issues such as angina and demonstrate how adequate your heart function is as well as your exercise tolerance. Chest pain and shortness of breath while exercising are common indicators for this test. Cardiac Event Monitoring Similar to a Holter monitor, but worn for a full week, cardiac event monitors (or cardiac event recorders) are used to correlate a patient's heart rate and rhythm to their ECG (electrocardiogram) over a period of 7 days. A cardiac event recorder is preferred when symptoms are less frequent and allows a patient to activate an "Event" button to snapshot a rhythm when they experience any abnormal symptoms. It is often used for younger patients. 7 Day Holter ECG and Oximetry An electrocardiogram (ECG) measures the electrical activity of your heart via 12 leads attached to your chest and body. It takes only a few minutes and records your heart's rhythm, checking for abnormal activity which may indicate damage to your heart or blood vessels caused by high blood pressure. An ECG can detect problems long before they become significant issues. In fact, everyone over the age of 45 should have an ECG. Oximetry measures your oxygen levels while you sleep, or for selected hours of the day. Resting ECG Sleep Studies Getting enough quality sleep at the right times can help protect your mental health, physical health, quality of life, and safety. Snoring is one of the most under-acknowledged symptoms in the management of health. Although often seen as a benign problem, it can cause disharmony in relationships as well as significant disruption to sleep. Ongoing sleep deficiency can raise your risk for some chronic health problems such as high blood pressure, heart failure, diabetes and many breathing disorders – sleep apnoea is a major cause of cardiac and respiratory issues. We offer an advanced at home sleep study to assess the severity of snoring/sleep apnoea and impact of cardiac and respiratory health. Level 3 Sleep Study Level 4a Sleep Study (Oximetry)   We would like to thank our sponsors for this show: For more information on Lisa Tamati's programs, books and documentaries please visit www.lisatamati.com   For Lisa's online run training coaching go to https://www.lisatamati.com/page/runni... Join hundreds of athletes from all over the world and all levels smashing their running goals while staying healthy in mind and body.   Lisa's Epigenetics Testing Program https://www.lisatamati.com/page/epige... measurement and lifestyle stress data, that can all be captured from the comfort of your own home   For Lisa's Mental Toughness online course visit: https://www.lisatamati.com/page/minds...   Lisa's third book has just been released. It's titled "Relentless - How A Mother And Daughter Defied The Odds" Visit: https://relentlessbook.lisatamati.com/ for more Information   ABOUT THE BOOK: When extreme endurance athlete, Lisa Tamati, was confronted with the hardest challenge of her life, she fought with everything she had. Her beloved mother, Isobel, had suffered a huge aneurysm and stroke and was left with massive brain damage; she was like a baby in a woman's body. The prognosis was dire. There was very little hope that she would ever have any quality of life again. But Lisa is a fighter and stubborn. She absolutely refused to accept the words of the medical fraternity and instead decided that she was going to get her mother back or die trying. This book tells of the horrors, despair, hope, love, and incredible experiences and insights of that journey. It shares the difficulties of going against a medical system that has major problems and limitations. Amongst the darkest times were moments of great laughter and joy. Relentless will not only take the reader on a journey from despair to hope and joy, but it also provides information on the treatments used, expert advice and key principles to overcoming obstacles and winning in all of life's challenges. It will inspire and guide anyone who wants to achieve their goals in life, overcome massive obstacles or limiting beliefs. It's for those who are facing terrible odds, for those who can't see light at the end of the tunnel. It's about courage, self-belief, and mental toughness. And it's also about vulnerability... it's real, raw, and genuine. This is not just a story about the love and dedication between a mother and a daughter. It is about beating the odds, never giving up hope, doing whatever it takes, and what it means to go 'all in'. Isobel's miraculous recovery is a true tale of what can be accomplished when love is the motivating factor and when being relentless is the only option.   Here's What NY Times Best Selling author and Nobel Prize Winner Author says of The Book: "There is nothing more powerful than overcoming physical illness when doctors don't have answers and the odds are stacked against you. This is a fiercely inspiring journey of a mother and daughter that never give up. It's a powerful example for all of us." —Dr. Bill Andrews, Nobel Prize Winner, author of Curing Aging and Telomere Lengthening.   "A hero is someone that refuses to let anything stand in her way, and Lisa Tamati is such an individual. Faced with the insurmountable challenge of bringing her ailing mother back to health, Lisa harnessed a deeper strength to overcome impossible odds. Her story is gritty, genuine and raw, but ultimately uplifting and endearing. If you want to harness the power of hope and conviction to overcome the obstacles in your life, Lisa's inspiring story will show you the path." —Dean Karnazes, New York Times best selling author and Extreme Endurance Athlete.   Transcript of the Podcast: Speaker 1: (00:01) Welcome to pushing the limits, the show that helps you reach your full potential with your host, Lisa Tamati, brought to you by LisaTamati.com. Speaker 2: (00:12) Welcome back to the show. This week I have an exciting episode with a clinical sleep physiologist. Jeez Morris, who's been a friend of the family for years and we've actually been in business together. We had a hyperbaric oxygen therapy clinic, but today we're going to be talking about sleep apnea, what it is, what the risks are involved when you have sleep apnea, how to assess it. The symptoms and sinuses are really, really important topic. It's so important that, you know, I don't believe that my mum would be alive if we hadn't picked up that she had sleep apnea. So it's a very interesting episode to learn all about sleep, what it does for your body, and it's a really fantastic interview. So I hope you enjoy the show with, jeez Morris. Um, just a reminder to I have my new book relentless out, which is available on my website. Speaker 2: (01:03) Um, it tells a story and part of that story, uh, from bringing her back, uh, from a major aneurism, a part of that rehabilitation journey was, uh, diagnosing her with sleep apnea in dealing with that. So it's really pertinent to today's topic. Um, I am currently working on a brain rehabilitation course that I'm going to be offering to people since the release of my mom's book and the story of her, um, incredible, amazing comeback journey, um, from being not much over a vegetative state to being now fully functioning again, um, fully healthy. Um, I have been inundated with requests for people wanting help with brain rehabilitation, whether it's strokes, dementia, Alzheimer's, uh, TBIs, concussions and so on. So I'm in that, in the throws of making that course because, uh, you know, I just can't deal with so many one-on-one. Um, so look out for that. It's going to be available hopefully within the next couple of months if I can get my energy. Um, and really looking forward to sharing that with the world as well on the back of this book. So right now let's go over to James Morris and learn all about sleep apnea. Speaker 2: (02:16) Well, hi everyone. Lisa Tamati here. and pushing the limits. So thank you for being with me again today. I have a friend of mine who is a sleep physiologist, a clinical sleep physiologist. Jeez Morris, how are you doing? Geez. Oh, very, very good now. Um, jeez and I have a bit of a history together. Um, I'm uh, he, when my mum had a stroke and everyone knows that she had an aneurysm and a stroke a few years ago, um, and I was doing better with the hospital because I wanted the sleep apnea test done and I couldn't get one done. Um, saved for going to my friend dues who is asleep physiologists and saying, geez, can you come and help me please? Can we do a test? Um, we did that um, slightly against the roles Speaker 3: (03:00) at the hospital at the time, wasn't that, uh, we came back with severe sleep apnea with oxygen and then was at the worst point at around 70% during the night, which is pretty disastrous. So I'm going to talk to you today with uh, jeez about, um, sleep apnea, what it is, what you need to be aware of. And we're also going to go into a new cardiac system that is, that got there. That's going to be really interesting. So jeez, firstly, thank you for helping me back then. My pleasure. I don't know if my mum would be sitting here today. I'm healthy and well, if it wasn't for you coming in and doing a stake assessment, it's that important and this is why the subject is really important to me to get out there and to let people know about this. So just can you just tell me a little bit your background, um, and then you know, what is sleep apnea? Speaker 3: (03:52) Okay. My background is actually an anesthetic technology. I used to work as an anesthetic technician here at base. Um, and as the years went by I got approached by a colleague of mine yeah. And T surgeon David Tolbert who was on a real interest in sleep, Mmm. Apnea because of the upper airway and asked me if I could help him with regards to treatment. And that the relationship developed and I got really interested in this area because it's so fascinating that eventually we set up I primary based sleep clinic that then sort of spread a bit and there's quite a few around the country. Um, because sleep is something we all take for granted in some respects, but it actually has a significant role within normal health. Hmm. So that, that's, that's how I started in this field. I'm still doing it 18 years later. Speaker 3: (04:47) Yep. And you've, so you've had a series of clinics throughout New Zealand at one stage and um, yeah, sleep apnea is what is it defined as specific place? So w w how, you know, people hear this word but they don't often know what the heck it means. Okay. So sleep apnea is a condition that has pretty sure, I realize it basically pauses in breathing during sleep, uh, for a number of reasons. Um, it affects about two to 7% of the population. However, that's with moderate to severe. Um, basically, but what we talk about now is sleep disordered breathing because we know there's a range of respiratory sleep issues affecting the patient. So sleep apnea itself is fundamentally, you can tell, cause if you've got obstructive sleep apnea, which is the main one [inaudible] it's a classic symptom. So all sleep obstructive sleep apnea, but not everybody who shores has obstructive sleep apnea. Speaker 3: (05:56) Okay. So that's key. So snoring is, is like, um, a pain in a joint. If we are a runner or sports person, if you get pain in your neck, you don't tend to ignore it. Yeah. You want to know what's happening because it's an abnormal process, right? Shoring is an app, normal process. And as a symptom of something, it could be benign, it may not. So we actually say that up to about 20% of the population will suffer from pathological or issues related to snoring. And that's the key here. So if you snore to start, you really should just get it checked out. We know that snoring gives you a higher chance of developing high blood pressure. Hmm. Um, from there, high blood pressure can lead to other cardiac and physiological issues. Absolutely. Yeah. So that's, that's where we start. Okay. The most common is obstructive sleep apnea. Speaker 3: (06:57) Then we move into things like central sleep apnea. That's what mum has. Yeah. Because basically if we see these conditions, there's lots of reasons why we'll see central sweep here. We see it in severe cardiac problems and basically it's a miscommunication where you just physically stopped breathing. So obstructive apnea is the, is the airwaves physically shutting off? Yeah. So you get this jerky movement of patients who have got it until they breathe. Central sleep apnea is a pause, just a stop in breathing. Wow. So they will be breathing quite normally. Then they stop, go silent. There's no effort to breathe nothing. Um, and you can see it for a number of reasons. In your mom's case, it was due to a stroke, uh, that caused her to stop breathing. But we see it in neurological conditions. We see it in change. Stokes breathing is a common cause of central apnea change. Speaker 3: (07:58) Stokes is a word that sort of worries me when I heard that. It's what we tend to see in the pre pre mortal issue. So just before people die, they go into this change. However, there's 31 reasons we see more, more that we can see, change, dehydration, heart conditions, all sorts of things because there's not, it's a metabolic condition. It's why we get changed up. So anything that can cause a metabolic issue can cause change steps. Yup. And this is this waxing and waning of, of the respiratory pattern. The center of a nice smooth process. This is what got a particular sound to it. Speaker 3: (08:48) It's usually, it's, it's a form of hyperventilation. She'll see the patient sort of get deeper and deeper, deeper, and then weighing off again and then flat. So people refer to it sometimes as like a death rattle. Yep. Okay. Yeah. Yeah. And there's a scary, scary way. And so that's, and so that's happens when you've got a central problem that can happen. Central sleep apnea can be caused by different Cheyne Stokes is one pot, one tile of central apnea. Some people just physiologically stop breathing. Yeah. Because of a stroke or a head injury, a neurological condition. Something in the brain that's been affected by the strokes, our blood supply to a particular gland or a particular part of, uh, of the primary. Primarily. Yeah. Neurological. Yeah. Primarily. Yeah. Okay. Um, all right, so that's two of them. Is there a, is there a third variation? There's a few other ones. Speaker 3: (09:50) We've got hyperventilation, which is, um, a reduction of breathing of at least 50% in the, in the volume of breath, but taking with a subsequent, um, reaction. So in other words, you know, your oxygen level starts to drop or you physiologically wake up. Yeah. Uh, hyperventilation in itself, I mean, everyone will stop breathing and the brief assert, so about two, about five times out, we're not going to stress too much about it from a risk perspective, but hyperventilation, we're seeing more and more because like obstructive sleep apnea, one of the main cause of that is weight. Obesity is, is, you know what I mean? Again, within healthcare, I know that people feel that we pushed away question a lot, but obesity with good is a significant health issue that we're not, we don't seem to be successfully addressing. Yep. So you've then got hyperventilation syndromes, you've got obesity hyperventilation syndrome that can be significant, uh, detrimental to long term health. Speaker 3: (11:01) Yeah. Okay. And this has seen a bit of a, um, you know, a circle because what's your, what's your obese and then you have this, then you'll get more obese because there's, there's a big, big connection between things like leptin levels and stuff that control appetite, especially in fragmentation. Yeah. So theoretically you mean the worst you sleep the hungry you are. Because at the end of the day, that's how we function as, as a survival mechanism, as a building. Yet, if we're feeling low on energy, we tend to eat to get fuel to feel energetic. Unfortunately, a lot of the foods that we might grate to when we're feeling like that tend to be the highest fat snacky type foods. So in a lot of cases, people who are, who are significantly overweight may not eat big meals, but they eat are very, but a lot of very small, high fat milk, which compounds the issue. Yeah. Speaker 2: (12:01) And that's done in Graham on as being a part of that equation. Yeah. So your satiation mechanisms aren't quite as good and of course when you, when you're not sleeping well, I mean there's, there is a whole lot of knock on effects, which I've talked about on a couple of episodes on the podcast. So it all starts to tie into to each other and has huge impacts on your, your mental health, your physical health, your brain, you know, mission, everything. Speaker 3: (12:29) Yeah. Well what we tend to see in people who to be, cause that's what we're really pushing her obstructive sleep apnea. These patients will first of all go to bed. They'll then start to sleep, start to snore. So sleep in itself. It's a very complex process. People always think you're awake, you're asleep. That's it. It's not. We talk, we talk in w we talk about sleep architecture, how your sleep is structured. So for the first seven minutes or so stage one sleep, that's the time you're getting comfortable, your eyes are closed. It's not true sleep. It's that like pre sweet sort of process. Then then we're supposed to drop into stage two, which is what we define as true sleep is when you actually go to sleep physiologically things start to settle down. You're hearing still going so you can still be erased at that stage and we spend 20 to 25 minutes there and then we move into what we call Delta wave sleep stages for him. When the brain goes into that slow wavy pattern, so you've basically got an inactive mind instill a veritable active body so you can still Twitch and stop after about 90 minutes of these processes you then stack and drop into what is REM sleep, Speaker 2: (13:44) which is that Speaker 3: (13:46) dream fell asleep. Yeah. Which is very, very important within a human, so like, and then we just cycle through that every 90 minutes or so. So you get to have about five, six, seven periods of REM during the night. What we tend to see in people with obstructive sleep apnea is that they'll start to snore at stage one too. Stages three four they'll start to obstruct. Once they stopped breathing, about six seconds later, their oxygen levels start to drop. We then get this sympathetic nerve activation that causes them to physiologically wake up to their heart, beats faster, that blood pressure goes up. Um, and it brings them back to a stage where the obstruction disappears, which may be level one, level two, but that Reiki did deep sleep. And then a lot of cases that these patients don't get true REM periods, pure sleep architecture. Speaker 3: (14:43) It's completely fragmented. And we're talking, and we, I've seen people stop breathing, I mean over a hundred times an hour, which means is that our heart rate variability is phenomenal during the night. So in effect, these people are working harder to sleep, to stay awake. So of course, but the body's a learning mechanism, it starts to say, well, I'm burning more energy doing this than I am by just staying awake. So people tend to start to develop this really bad sleep pattern where they can't get to sleep properly or they wake up frequently during the night. So you mean, you mean sleep is really important for things like growth hormone production, cortisol productions, all of these things. Your adrenals have hormones. They have very poor short term memory, their fatigue, blood pressure tends to be high and you mean eventually things are going to shut off. Speaker 3: (15:40) Yeah. And, and your health is going to seriously be a farrier, right? Absolutely. Yeah. And this is, this is so it's so important and just not, you know, all the sort of stuff needs to be taught at school. So what happens in the sleep process? Cause we all just fake. We go to bed and we go to sleep. You know, we don't know about deep sleep and REM sleep and in the life stages of sleep and how it, how it actually affects our physiology the next day and how our brain function isn't going to work. And what about the, I read a study recently on the brainwashing. Yeah. Function that happens when we're in asleep and that the brain shrinks. You're talking about, yeah. You're talking about amyloid. Cool. Yeah. Yep. Yep. Speaker 3: (16:24) Which is good when we're young because I think, I mean, this is getting into real neurophysiology. So, excuse me. So basically when you're growing or developing synopsis, it sits with that neuro logical function. Mmm. It's a, it's a byproduct of metabolism, of neurophysiological by metabolism and needs to be washed out. Um, which tends to happen during sleep while you were asleep and we beat her is dispersed ready for the next day. So it washes out the break. Yeah. Yep. It's a brainwash. That's what they're calling it. Yeah. They flush it out. Yep. And is it important a protein, but it flushes out all the and the rent. However, what we find sleep apnea patients or insomnia patients and where is that? I don't fully do they, that's why they wake up feeling groggy. Yeah. Yeah. Confused sometimes. Um, we noticed in outside of ms patients that there is a significant higher level within Sam or in place. Yeah. Yeah, yeah. So yeah, that is an important function as well. And we can see that not just in sleep pattern. We can see that in insomniacs and people. Wow. Wow. That is fascinating because if we not washing out those plaques every day and getting rid of them as that cause they build up when we're awake, from what I understand, we're functioning. Yeah. It starts to up over time. And this, Speaker 2: (17:50) you know, over a period of 20 years can lead to where they're suggesting it can lead to Alzheimer's. Early onset Alzheimer's. Yeah. Yeah. It's a long side process. So if we can get it early, we can, we can stop that process happening. Um, and this is really, this is the whole point of this conversation is, is to get people to be aware of what are the signs of sleep apnea, what are the things that are going to happen when you're asleep as off. Um, and what we can do about it. Um, uh, you know, we referred, um, just a bit earlier to mum's story. Um, and mum was in the hospital, excuse me, um, for three months and she'd been in Wellington, uh, in the acute phase and the ICU and then in the neurological ward down the air and she'd been on supplemental oxygen. Speaker 2: (18:36) Um, when, when she came back through to new Poloma, she was taken off of supplemental oxygen cause she was now stabilized if you like. Um, and I noticed that she was gone from terrible to really, really terrible. Like there was hardly any higher function going on at all. Um, and that's when my brain started to tick over and you know, my history with, you know, um, training at altitude and data races at altitude and I'd seen like things like she had a bacteria in the mouth that was just doing gross, horrible things. Yeah. And that was a really a signal to me like, Hmm. Bacteria, lack of oxygen. Uh, jeez. Sleep apnea basically was the connection that I made there. Um, oxygen in the body, you know, and lack of oxygen causes bacteria to spread and, and proliferate. Um, so it's really, really important that we, we address this. This is not something we should be putting off. So you is inherit in your clinics, you would do the sleep assessment on people, which is an overnight procedure or a test. Speaker 2: (19:44) Then if someone comes back with sleep apnea, they get a C-PAP machine? Well, it depends, right? So first of all, the key to anyone as to acknowledge that they have sleep patient. So the reason we can tell people who have sleep issues is people always say, you're mean I have sleep problem, but during the day they still function. Normally people with a true sleep problem don't function so well. So that constantly fatigued. Yeah. Tired, short term memory, it's usually quite poor because they're not dreaming. And part of the process of dreaming is the burn information to a hard drive if you like. So if you're not dreaming, you're not retain that information. So short term memory tends to disappear. There's petite. Quite often they're slightly on the higher. So those are the key things. Now I definitely, yeah, if you're not snoring, it's not obstructive sleep apnea, but it could be upper airways resistance syndrome or something like that. So in other words, you're having difficulty breathing during the night. Speaker 3: (20:47) People often wake up for headaches. They often wake up during the night, Speaker 3: (20:51) um, maybe once or twice. Um, so these are the common symptoms we see meet. But 70% of most GP consults will involve the word fatigue. Tired, no energy. Yeah. So that should be your key. If you're feeling tired during the day, most people come by their GPS because the GPS are becoming more and more aware of sleep specific. Um, because we spend one third of the day doing it. Yeah. Um, we would then go through a simple questionnaire like you're tired and scale Epworth sleepiness score is that, is that common tired and scale that we use to address how try it or how it affected people. And this involves eight simple questions about the ability to fall asleep doing certain things. And I would have run this through with Uma and basically it's things like if you sat reading a book, what's your chance of falling asleep? Yeah. Not possible. Moderate be high or high or sitting at traffic lights. Um, you mean what's the chances of you falling asleep? And believe it or not, there are people who want to positively, hi. Oh God. Every question. I remember one person telling me in Oxford, he said, I said, yeah, I mean, it's not very good if you're falling asleep at traffic lights. And he said, yeah, we can, we can sit for 20 minutes to traffic lights. So maybe we need to readdress it so that we're sleeping. Speaker 3: (22:17) Then we would probably carry out for most people who complain of sleep. The first thing I think to do would be to carry out a very simple respiratory sleep study and there's a couple of types you can do at home. There's all this imagery which surely looks up to gin levels during your sleep and that's a little clip that you wear on your finger, touched with a little monitor, some of wireless, they go on the watches and that's the simplest way and it has a very good correlation to sleep apnea so we can use it as a very simple cheap test. Yeah. As an a level three sleep study, which looks at as a thoracic efforts. So we're looking for specific obstructive central events or under breathing with a nasal cannula, an oxygen saturation monitor, and they can be done at home. Yeah, every simple test I can give us really detailed information, but level two sleep studies is when you're getting into neurophysiology side of sleep. Speaker 3: (23:16) Now 96% of sleep disorders. Alright. There were spiritually, mostly the very small percentage are the neurological disorders that we see that REM behavior disorders, the narcolepsy's, all of those more complex disease States that really require much higher levels of Oh, acuity and testing. Right. But the majority, and that's a medicine what we're supposed to address, the majority of patients can be, can be looked at from a respiratory. Yep. Um, once we get a test, we can then identify the severity of any underlying respiratory problem. No. Talk about sleep. Obstructive sleep apnea, which is where we get airway physically closes during the night. Yep. We talk about mild, moderate, severe. Yeah. Mine is any and vent above five to 15 events. Then we talk about moderate, which is 15 to 30 events an hour and anything over 30 we talk about severe. Yeah. This scale is really more focused on funding of therapies. Speaker 3: (24:27) Yeah. It's on impact of disease. That's terrible. Well, we know that people with certain tend to have a higher risk morbidity, mortality, but we also know that people with moderate with other pathology, awesome have significant risks. But more and more evidence is saying that if you don't treat the mild, they will become exactly there. Related to it is at the bottom of the cleft problem that we have. It's like fun. It always comes down to funding not how healthy you're going to be, but you'll be basically that's sleep apnea. Yep. Obstructive sleep apnea, obstructive sleep apnea can't be treated. Yeah. That's the good thing. What we talk about is things like conservative measures. Conservative measures are always going weight loss. Yeah. Fitness levels. Yep. Cause obviously the fitter you are just sending you out in the majority of cases. Yes. Um, so those are, those are simple things you can do to help. Speaker 3: (25:40) However the research is not green. Yup. Yup. For ag. And then we're moving more into the surgical options. Obviously you've got the weight related surgery, which is very difficult. Very Patrick. Yeah. To get, quite often we look at the upper airway as being part of dish mechanism that's causing the issue finish things like the obvious nasal deviations that we can. But you can see the obvious ones from rugby Plains, but obviously there are also, there's also subtle deviations. Then there's things within the knees or pathway that can cause problems. Their adenoids leaving you. Now tonsils is a controversial area in the area of sleep medicine. Yep. Because tonsils or something that's roughly what disappears. We get, Oh yeah, yeah. Um, however, saying that it would be the conversations I have with GPS about this is quite interesting because being in this, but I look at tonsils and everybody, well look at the back of the throat cause I'm looking at what we call a modern putty index, which is how far back the larynx and the size of the tongue. Speaker 3: (26:54) Um, but also I'm looking at tonsils and quite frequently you'll see extremely large asymptomatic in males predominantly. Wow. So if you've got tonsils that are kissing but asymptomatic, which means you don't get tonsillitis as such, then they're going to be causing an issue. Yeah, sometimes. Yep. Yes. Well in children now for sleep disorders. Um, the first line of therapy, children who might snort snoring to all the parents out there in children is not, it's not cute. It's not cute. And noise from a child while they sleep, um, is not cute cause they're supposed to be perfect breathers. Yup. But the first line of therapy, now children, but snoring or anything like that, just taking out there, don't bother with sleep studies. They just take out the tonsils and the admins, which in a significant number of cases can improve it. And there was a study out of the States where they took, uh, patients, children diagnosed with ADHD, trying to remember the study. Speaker 3: (27:56) Yep. And what they did was, uh, they took this group of patients were all treated, remove tonsils and adenoids. And what they found was that 50% of them, I think it was 50% ended up being taken off that Ritalin medication because it was hype. Children react differently to tiredness than adults. We get, we get authentic, we get children get hyperactive when they're tired. And we've seen that because everyone who knows your kids and then they crash. Yeah, exactly. Cause what they are is tired. Yeah. So when they get tired they send them like they run around. Speaker 3: (28:33) So surgery, surgery can help in some cases with obvious deformities. Um, success rate surgery for sleep apnea in the mild to moderate, probably about 63%. Wow. And surgery like anything carries Chris from an aesthetics from the surgery itself. So it's not a guaranteed cure. Then we're moving into things like most guides, uh, mandibular splints that designed the whole, the jewel in a prominent position pulling the, pulling the tunnel way from the back of the throat because as you fall asleep, nobody can physically swallow that up. Yeah. But their tonnes can drop back and include the airway. That's why in recess we pull the jaw forward. If you pull the jaw forward, your pull the tongue away from the back of the truck making that larger space. Monday splints can work very well. Um, there's different types of over the cancer, not so successful, but one is designed by a specialist orthodontist of which there are a number now in the country, um, can have an 80 plus percent success rate. Speaker 3: (29:39) That can be very good, but I probably won't be able to do that work very well. Okay. Yeah. Um, for more mild cases and some moderates, there's a thing called microvalve, Serafin therapies, Sarah events. These are the things you stick a little plastic over your nose and what they do is you breathe in normally through lots of holes, but as you breathe through your nose, lots of the valves closed down and one valve remains open. So you get like a, what we call a valve silver effect, like blowing through your nose and that back pressure keeps the airway splinted open. Wow. So it's a physiological form of C-PAP, which is what, yeah. Yeah. What's his, what mom's got like a sticking plaster that you see some athletes or is it on the inside? The strips on the outside. I for anatomical for collapse where the AOS actually collapse. Speaker 3: (30:45) So those things pull the nose. I was slightly out. These things stick over the, there's over the holes here. Oh yeah. That there. Interesting to work with. Very interesting feeling. But they can work. Probably don't use that run ongoing costs. You've got to use them every day. If you don't use them, it comes back. Yeah. So they're quite expensive. Right. But as an alternative to seatbelt, there's also this tummy device that don't think we turn the stabilizing device, the TST, very bizarre looking device that basically works upon the fact that if your tongue falls back, you pull your tongue forward. Now in the old days, very old days of anesthesia, we used to have a thing called a tongue clip, but we could collect the tongue, pull it out to open up the airway. Um, we've moved on from there. This is a TSD is like a suction device that you squeeze, stick your tongue in and it sucks your tongue forward. Speaker 3: (31:47) Yup. They read it to be cheap. Some people swear by them. I've tried most of these things. I couldn't sleep with it. This is the, it isn't, but it is an option. It is an option to try the only thing guaranteed to reverse sleep apnea. Yeah. Or it is what we call continuous positive airway pressure. Yup. And basically in simple terms is a pneumatic splint, so it blows air into the airway via either a nasal mask or a full face mask. Yup. While you're asleep, um, you can get very little cushions now that you wear like oxygen, things that can also be used for this machine. Um, and that blows air in. So when you breathe, you're breathing out against pressure so that then hold the airway open. Yeah. It's a new magic process. So you breathe in and out again to this flow or like that if you can wear it is guaranteed to reverse obstructive sleep apnea. Speaker 3: (32:55) Yeah, it's gold standard for therapy. And interestingly enough, it's only been around since about 1982 so relatively new therapy, but is now widely used worldwide for, that's the one that mum's got. Um, and she has to wear it every night and all night. Um, and you know, it's quite an invasive thing to have on. It's not pleasant for her. Um, having the central, uh, sleep apnea is guaranteed in that case? Like with obstructive or is it a bit, a bit more, it really depends upon that the, the, the reasoning behind the central event. Yeah. Um, in most cases it can improve it to an extent that it's okay. Um, in some cases it doesn't, but we stop an obstructive component. It proves your physiology changed to make the change they him and go away. There are some machines that are specifically designed to treat certain types of breathing, like Cheyne Stokes, the ASB system. Speaker 3: (34:03) Yeah. That can only be used. There are certain, a very small group of patients who can't use ASP because there's a higher risk of problems. Right. Like with any therapy, there's always risks. CPR tends to be generally safe if used appropriately in the right patients. And there are then machines that will provide backup. Correct. So if the machine senses that you're not breathing, it doesn't ventilate you, but it reminds you to take a breath. Yep. So we can use things called by levels or bilateral S T's with, with a minimum respiratory REM required. Yeah. So it will, it will. If you stop breathing, it will cook you with air to say take a breath. Is it the machine that mum's got? You know, because it regulates when she's breathing it's, yeah, yeah, yeah. Then when she stops breathing or you hear the machine crank up, yeah, you might, your mom's on auto type ventilate auto sheet. We'll have backup, right? Yeah. Right. And this is similar to what I've been delayed heroes in the hospital and not flight. Speaker 3: (35:17) C-PAP is not ventilation. C-PAP. C-PAP is stopping a reverse vacuum cleaner to your nose and away you go. It's, it's, it's helping. It's not breathing for you. It's like a walking stick. It's making your breathing more effective than if you weren't using it. I know ventilator is physically breathing for you. Now there are two types of ventilator says invasive ventilation. Well there's noninvasive ventilation. Noninvasive ventilation is legacy pap, but basically that the pressures are split. So you breathe in at one pressure and you breathe out at another pressure. Yep. And there is a, that can be a backup rate added to that. So that's, that's term. There's noninvasive ventilation. Those are the ones we tend to see used on patients with hyperventilation syndrome or severely large patient who cannot tolerate time levels of C-PAP. Breathing against the pressure of 10 centimeters may not be as bad, but the minute you start to get to 60 18 prep coming sent to me is a pressure that's a hurricane blowing, you know, so then we need to look at how we change. So we have an inspiratory pressure pressure, noninvasive ventilation. So in any form of respiratory failure, which is the end game of some disease States, they work really, really well. And it's becoming more and more used as opposed to inter invasive ventilation in a lot of cases. Now I've just read some reports out covert, they're starting to look at noninvasive ventilation as an alternative, right? Probably with noninvasive ventilation. Speaker 3: (37:04) Oh yeah. So you've gotta be really tough and the other ventilator, no, see, perhaps not recommended covert patients anyway, even though it's starting to be used as an alternative, but needs to be used very carefully. And we've got, um, uh, I've been looking at the research. Of course, Jason and I had a hyperbaric oxygen clinic, which we opened up to mum's story. Um, but the hyperbaric and covert, um, it's showing promising results. Uh, I, I saw, I saw that, yeah. The issue with coach, we're in the infancy of a disease state. We don't know what the longterm benefits, risks, outcomes next 10 years, 20 years of research is going to be around the last three. But hell's happened to us. So we keep on sleep apnea. Speaker 3: (38:07) Yeah, very true. But yeah, so, so, so treatment for sleep apnea with with C-PAP is very, very common. It's effective. Um, we really started to look at muscle diseases well because what we noticed with patients with mild disease, so they can still suffer all the same as severe disease. They can still be cycling, hypertensive or control. They can still be difficult to control diabetics. They can still suffer extreme daytime tiredness, um, and things like that. So, so C-PAP can be used as a management tool from mold too severe. Yep. So we were one of the first groups that probably made it more available to the mind. Yeah. Cases because in our opinion, the benefits fired out, weighed and the risks associated with treatment and at the end of the day, every therapy of any kind should be the decision that the patient not absolutely. Speaker 3: (39:10) Depending on what that treatment is, of course, and something like that. I don't see very low risk with a high reward in medicine. That's what we're looking. Is there any difference between when you were, say I'm now reading a sleep thing study last week is sleeping on your side versus sleeping on your back and can you actually sleep, and this is a question after I read that I was on your back all the time because of the sleep app machine. Is she actually able to sleep on the side? Yeah, of course she is. The machine she has got will automatically adjust for any change impression, so it will go up or down as required. Yeah. That's the benefits of that type of machine that that algorithm look. Positional sleep. Yes. You can talk to any partner who has suffered a partner who snores after a glass of wine or beer or whatever. Speaker 3: (40:05) We always poke them to roll them onto their site. Positional treatment for snoring can work and it's one of the conservative methods we recommend you. I mean there are very fancy machines are designed to be worn around the neck. Um, tell it when you were starting to. Sure. And then it plus as you would look for the electric shops to turn you on your side. Wow. The, the, the most practical tool you've got for positional sleep apnea is what your grandmother would have said, which is show up button in the back of your pajamas or get a tennis ball with a loop of elastic. Thread it through. I'm wearing like a backpack and that physiologically keep you on your side. There's no doubt that we can see. So obviously Pat on the back because all this depression is pushing down on their side. All that is moved away from, especially on the left side. Wow. If you turn onto your left, it's easier to breathe. That's why in the recovery position we turn people to their left. Wow. Speaker 3: (41:09) Pressure on their, on their venous return helps improve blood pressure, but it also moves and everything away from, from where your track here. So, um, you know, I, I sleep on my side but when I sleep on my left I can always feel my own heartbeat and then I always get worried. I'm putting pressure on my heart on the other side. If anything, if anything, probably be more on the right cause that's why we talk about pregnant women with debt gravid uterus. If you, if you lay on your side, that weight comes on to the vena cave on the right side. So actually restricts blood flow, especially return. Yeah. So your blood pressure theoretically needs to be higher. So in medicine we tend to turn people onto their left side and especially pregnant, when will we say light his left side. Great tap. Positional sleep can work very, very well in those people who are purely shorts. Speaker 3: (42:09) Yep. Yeah. It makes slightly improved sleep apnea, but because of all the other factors involved, it's not always there. Okay. But a sleep study, you can tell us that because part of the sleep study told us which side the patient is sleeping on when is happening. Yep. And we can, we can see that so we can recommend position therapy. What about like, um, I know it was several and you probably have a, have a crack at me for talking about him on the phone. Guys. I, he, he sits on his back and he sleeps on the couch. He wants to sit. I sit him up higher with pillows, um, in behind them and then a snoring is a lot less. Yeah, if you laying flat, yeah, it's okay to raise the head of the bedside. If you get a raise, the head of the bed, it's always been to put a pillow under the mattress as opposed to empty your head because the biggest problem is it a head forward and you make this more obstructive. Oh, if you want to put it in the yourself and put it in the shoulders, your headsets slightly flat or sniffing the morning air. This is the position we used to call it an anesthesia. So their head is flushed back, straightens the airway and it's easier to temporary sleeping in a chair. It's not a cool thing because you're not going to, you're not going to sleep, you're not going to sleep as well. Especially in patients who let's say have respiratory problems COPT they've got what we call overlap syndrome, so they've got sleep apnea. Speaker 3: (43:42) They tend to sleep in chess cause they feel they can breathe each year. The problem is is it's not very good for you from a health perspective and sleeping setup because of venous return, pressure on the kidneys and the heart. Other things probably blood flow to the brain. Yeah. Yeah. So if, if people are sleeping checks because we find it easier to sleep than they really need to be assessed to find out. I've got another fatal on my hands coming up. I can say yes for a number of reasons. Sleep apnea. Interestingly enough, we talked about it being related to obesity and other disease States, but it's also predominantly higher in men than women until about the age of 50. So postmenopausal women trach it to men very fast and it tends to be the effects of, it tends to be than what we see on men. Speaker 3: (44:33) Um, is that the weight gain side of what happens is because of the loss of certain hormones in postmenopausal women, especially around respiratory issues, um, we tend to see more in Mali, men especially but also higher percentage. So there is a ethnic link, we're not sure if that's because of body habitus to that. So the shape of the body and the upper airway rather than that, it just isn't working out, whether it's the increased weight, shorter neck, things like that. So yeah, so you mean there is, there should be a definite and I think there is a definite push within modem to check sleep apnea. If you've ever been onto a Mariah, not a pilot in a positive way. So you want me to probably one of the best places to have a sleep person would be on my mind very quickly identify and this is why, you know, sharing this sort of information so that people can directly, because it's with all, you know, all the health stuff that I talk about. Speaker 3: (45:40) Um, you know, it's being informed. It's knowing that the stuff is out there. It's being aware that there is a, perhaps a problem that needs to be checked as the first line of getting people in the door. You mean if you want to look statistically around research, you know what I mean? You ask three times more likely to have a stroke. If you have sleep pap, you're three times more likely to die. If you have sleep apnea, you're significantly more likely to develop diabetes. If you have sleep or especially what we call uncontrolled diabetes, you're more likely to develop heart problems, more likely to develop respiratory problems. I mean, we're talking significant percentages. If you look at something like what we call label hypertension, so blood pressure that is difficult to control. 80% of patients with difficult to control blood pressure will have some varying levels of sleep. Speaker 3: (46:29) Disordered breathing. Yup. 55% of cardiac patients, especially at S patients will have a compending or causative sleep disordered breathing. Yep. So the numbers start to stack up more and more and more. We're looking at nighttime physiology as a D as a predictor for daytime, especially around things like blood pressure. 24 hour blood pressure now is something that's becoming standard practice because we've historically treated blood pressure on one off. Yeah. Precious. Yeah. When we're noticing that nocturnal hypertension is a better predictor of cardiovascular mortality and morbidity than daytime blood pressure. Wow. So more and more GPS now are moving towards 24 hour blood pressure. You know, you go to your GP and he asked for it. Speaker 3: (47:23) Yet there's a few GPS in town who will do 24 hours. Most of the GPS will refer into somewhere like this where we were doing quite a few 24 hour blood pressures and Holter monitoring. Because my area of special interest has always been the impact of sleep on cardiovascular disease or on on cardiac health, which was why I've sort of moved into that sideways, into more cardio-respiratory physiology than I was sleep. So tell us about, a little bit about the clinic that you're in now. Fast based solutions, which is based in your Plymouth. If anybody wants to talk to jazz and come and see you guys. What is it that you do? You showed me a machine before that you can actually wear. Yeah. So basically we moved sideways and I teamed up with two other guys. Mike Maxim is a cardiac physiologist and Alan Thompson, who's a, who's an anesthetic technologist, we looked at what we could provide to primary care as a, as a midway step between primary medical care and secondary medical care. Speaker 3: (48:26) So we sort of set out to say, wow, we can bride these tests a lot faster probably because we have less restrictive process. Yep. Um, and so we're doing things like Holter monitoring. Holter monitoring is monitoring the heart over 24, 48, seven day period depending on, on what we're looking for and basically monitors cardiac speak to the variation. So it's great for identifying an arrhythmias. This is ASA Fletcher, all of those conditions. Uh, atrial fibrillation is something we're seeing more and more, um, potentially a significantly life threatening condition if not picked up and manage because of the increased risk of stroke and things. Um, so we brought in more and also we're seeing a higher demand from people wearing wearable technology who have started to notice that happy changing, going faster, slightly out to be, yeah, because they're exerting and it causes concern. And part of medicine is to address concerns and fear. Speaker 3: (49:38) So we do, we do Holter monitoring. So we're using small halted co monitors that allow us to monitor patients in a more free fashion. The old ones used to have lots of wires that restrict things. These things you can run cycle. So they're great for people who are active because that's where they notice the problem. So we can monitor the patient in the situation in which they noticed that problem. It's a lot more effective. The older, bigger ones are cumbersome. So you can't run in them cycles when you can with these. Yep. So it allows us to monitor patients or effectively, and we can even do cardiac ones on there so we can get really tiny patches. So we do those, we do exercise tolerance testing to check for narrowing the vessels. So it's a a test that you run on a treadmill and we'd look at your ECG 12 lead ECG. So quite in depth in ECG while you're doing it. Um, would you ambulatory blood pressure, 24 hour monitoring spiral Metairie cause that forms part of the cardiac paradox. You know what I mean? You talk about cardio respiratory disease cause they both obviously work together and they affect each other. Yeah. So that's what we're doing here. We're doing more direct to patient management. Speaker 2: (50:58) Are you working with athletes? Speaker 3: (51:03) We get a lot of athletes come through because they're the ones who, who noticed a change. Yeah. And they just want to be reassured that what they're feeling is not a problem, which is fine. Yeah. Optimize performance. Yeah. Speaker 2: (51:21) Yeah. A lot of, um, uh, I've got a few colleagues, you know, I've been doing, you know, ultra marathon stuff for years and they've got Speaker 3: (51:29) over-sized carts, um, as a result. Okay. Yeah. That's exercise induced cardiomyopathy. Yeah. Um, it's not very common, but we do see it and some patients who've been exercising to an extremist for long periods, any muscle that you can overwork can become hypertrophic. You know what I mean? That's the whole point of bodybuilding damaging tear muscle to develop definition. And we see that in things like guilt, um, and insomniacs would that, but their cortisol, they're a highly stressed person who can get adrenal atrophy, atrophy, hypertrophy from that because you're constantly kicking out high levels of cortisol. Why they can't sleep and it's all at the wrong time of day. So you mean that's, yeah. Exercise-induced Caribbean cardiac conditions. They're not common, but there's some that we can check for. Yeah. Probably more common amongst people are hanging out with, Speaker 2: (52:39) you know, it's not common. I don't have it. Um, but I, yeah, my wife's husband used to have that problem. Um, been exercising for just, you know, huge amounts for many, many years. Um, and it's mostly mean isn't it? Then Speaker 3: (52:53) it is mostly men, mostly men that they're giving. It's like with rugby players in that it'd be interesting to look at their sleep at the same time. Yeah. Because that's why we've moved this way. Cause sleep hearts, lungs all work together for good or a bad reason. Speaker 2: (53:11) Yeah. I mean this is something that I've been trying to educate people on. You know, the difference between um, you know, like functional medicine and naturopathic medicine and the need for more integrated as it were, more integrated. Look at the whole person and not just, we here in lines near in the hat near you, study the brain and study the kidneys. But having people make can look at the whole sort of system or systems within the body that can really take a more holistic or overlooking approach. Speaker 3: (53:41) Yeah. Look, I think you mean one of the issues we face in any form of health care is the fragmentation of the system. And that we are so busy these days that predominantly we only look at the field in which we are so much. Whereas you, I mean you sit at the GP level, you've got to try and work out. So you're a policeman if you like, or a police person trying to work out which way you need to go. So it's very difficult when you send someone, let's say for a heart test because you think it's a cardiac issue and the test comes back, not a cardiac issue, but that doesn't help you. All it's told you is what we're trying to develop probably more so here is to look at the patient that's been referred for a heart problem and maybe just looking a bit wider and saying, well look, if it's, if it's not your heart, we should be looking at your sleep or if it's not your sleep, we should be looking at other physiology. Um, and trying to give a more packaged answer to provide the same. Well, Nope, we've done a Holter. It's fine. However they mentioned they should and we noticed that they have. Speaker 2: (54:52) Yep. Sort of overview a little bit wider. I mean obviously you can't be an expert in the mechanics of the feet at the same time as being doing what you're doing, but you know it, Speaker 3: (55:05) it's similar. It used to occur I think long time ago when we run much smaller population, people could have more time as a specialist to look at all areas healthcare, but obviously as, as the health system that was invented back then didn't take into account that would be a population of 5 million with significant ability to study more areas of healthcare. So a lot of the people who are in specialties are just overwhelmed with that specialty. And what we'll probably need to be doing more of is having a step that allows people to look more broadly house. And that may include, as you said, homeopathic or alternate providers because my treatment to just purely disease, most practitioners I think health or otherwise would agree with that, that everything should be more patient focused as opposed to outcome. Speaker 2: (56:03) It's really important to have educational programs like this one because it does take the pressure off the GP knowing everything about everything. If you're aware of what's out there, what could possibly be going on and some of the, you know, sort of just, um, you know, comorbidities that can exist. You know, like I'm doing a brain radio rehabilitation course I'm doing at the moment, um, to help people. And the, the, the interrelatedness from whether it's looking, it's not a good word, but you know what I mean. Um, from brain injury and hormones or adrenal insufficiency and hypertrophy, tourism and thyroids, um, they can all really be affected through brain injury. Um, and then, um, the knock on effects of those and the signs and symptoms and things that I always look at within the course. I'm building out what's the foundational aspects of good health, you know, some of the basics around hydration and nutrition and, um, sleep. Um, and then looking at the next layer to be introduced because there's no use me giving you or giving you, uh, telling you to go and have a hyperbaric session, Speaker 3: (57:15) which will help your brain, Speaker 2: (57:16) which we know has beneficial things for neurological problems when you're eating fish and chips every night. [inaudible] you know, got, I've got some underlying other problems and not exercising and not doing the other pieces of the puzzle. So we need to have, um, an approach that looks at how do I build some foundation with health basics for status as well as the dressing, the actual no problem Speaker 3: (57:40) that we've got on top of that. Yeah. Yeah. You mean, I think you mean if I can say that it's a key to what we've been talking about is, is, is we take what happens during the day very seriously, but health should be a wider conversation. Human sleep is important. Not every reason you can sleep is insomnia. Yeah. So tablets don't always fix sleep issues. They're a great tool and it can actually be more problematic than the issue. So that's the main thing. It's the snoring is not good. If I could get that point across. Yes. And if, if you don't think you sleep well, which is probably majority of population, just check it out. Speaker 3: (58:28) I'm sorry, I probably sounded a bit garbled. But sleep is such a few, Gerry, to try and look at sleep in its entirety is, is quite a difficult area. I mean, the simple ones are asleep, happier snoring, tiredness during the day, no matter how old you ask, snoring is not good. Yeah. As a matter whether you're male, female, adult kids, get it checked. And it's a simple case of just talking to your, your practitioner, especially if you've got chronic conditions. Um, and, and, and look at your sleep health as, as importantly as you do your daytime health. That's probably a key. Speaker 2: (59:07) That's a key takeaway. And I think, you know, go and get yourself a seat. Go and find out if you, if you think you have a problem, uh, if someone, you know, has had a stroke. Um, I mean, I, I, I think it should be standard practice for everybody who's had a injury to get some sort of sleep assessment done at some level. Um, you know, I'm, I'm absolutely convinced my mum would, wouldn't be here if we hadn't done that. And then subsequently also hyperbaric was a key factor in her success. Um, so obviously very passionate about sharing this message today. Um, jeez, just as we wrap up, um, so we've talked, we've given people a couple of takeaways, you know, and if they're snoring through something about it, if you, if you're feeling absolutely in the gutter, uh, and not get a good night's sleep, if you are waking up a number of times, uh, we've seen about sleeping on the side, it's on the left side is, is, is really ideal. Speaker 2: (59:59) Weight loss is really important. If you're obese, you need to be taking this seriously. Seriously. There's a lot of comorbidities that they come along with having sleep apnea and it can be a bit of a, what do you call it, a circle that leaves a vicious circle that leads into each other. Um, so I think that's some really, really key takeaways. And from the cardiac perspective, I'm very keen to come and check out what, what you guys are doing there. It's a new clinic. Um, and um, relay that back as well. Um, I think, uh, having these new facilities and this new technology available to us is just absolutely awesome. Um, and there's so many great things happening in so many different areas of medicine that we, you know, just sharing a bit of information about it is really key. So if anybody wants to reach out to you at the clinic, we can, they find you guys. Speaker 3: (01:00:52) Okay. So, yeah, I mean you can do the usual webpage, www fast pace solutions.co. Dot. NZ. Um, you can call it, we do have a phone number, but as you notice that, Speaker 2: (01:01:06) so I'll put that in the, in the show notes so people can reach out. Speaker 3: (01:01:10) We're available on Google. Most of the GPS in turn know where we are as do the specialists at the hospital because we're obviously working very closely with the hospital supporting us. So that's really good. Um, with regards to your mom, I just like to say, I mean from a medical perspective, I'm pretty stunned at the way your mom's recovering. I, I, I have to sort of put my hand on my heart as a medical person when I first went through with your eyes. Yeah. I wasn't positive, but it's not purely that the sleep, why does he like that? I've got to acknowledge that what you and your family put in to that was phenomenal. Yeah, it really works. Um, and I think you need to take a little bit more credit with you and your boys, your brothers. It gave you that a reason to come and do my garden, which was awesome. Excellent. I tell him to give me a call anytime. Look. Yeah. So do, do take some credit for that. It wasn't a medical outcome. It was Speaker 2: (01:02:15) faceted approach. And you know, I always look at the silver linings and things. Geez. And when I, when I went through this horrible situation with mum, there are people like you and others who came out of the woodwork and all gave me their expertise in that area that I was searching and I was hungry for help and information. And that having that open mindedness and being able to research and I continue to do it has now lead to a complete new profession. You know, um, it's interesting where you end up in a, in a book that I hope is gonna, uh, empower other people to fight like crazy. I mean there was, you know, we weren't given no hope from, from the hospital. We would tell her, put he

Chris and Mark talk about strokes! They cover everything from bleeds to blockage and how to fix it all. An important message about how to recognize a stroke is also delivered. Chris annoyingly flaunts finally being right about something, while our listeners pointed out that we were both wrong about two things: Mark meant to say Billy Squire instead of Billy Idol. 2) Mark mistakenly stated Kussmauls instead of Cheyne-Stokes respiration with Cushings Triad. Chris then celebrated Mark's usage of big words.

El trauma a la cabeza, o lesión cerebral traumática, ocurre cuando el sistema nervioso central se afecta debido a un trauma cerrado o abierto. Las lesiones a la piel, aunque sean en la cabeza, no implican lesión al sistema nervioso central. Muchas veces decimos "trauma a la cabeza" cuando en realidad deberíamos ser más específicos... lesión cerebral traumática, o trauma craneoencefálico. Para entender la solución, hay que entender el problema primero. El problema del trauma craneoencefálico es que la presión intracranial aumenta y el cerebro deja de recibir flujo de sangre (disminuye la perfusión cerebral). El curso de Prehospital Trauma Life Support (PHTLS) enseña el manejo y resucitación de este paciente. Presión intracranial El cráneo es una bóveda cerrada. No se expande cuando la presión interna aumenta. Cualquier lesión que provoque un efecto de masa dentro del cráneo va a provocar comenzar a hacer presión a las estructuras internas, que incluyen el cerebro, el líquido cerebroespinal y los vasos sanguíneos. El aumento en la presión intracranial va a provocar una disminución en el espacio que tienen los vasos sanguíneos para fluir sangre... es decir, disminuye la perfusión cerebral. A esto se le conoce como la doctrina Monroe-Kellie. Presión de perfusión cerebral = (presión arterial) - (presión intracranial) Si usted entiende esta fórmula, entiende el concepto básico del trauma a la cabeza. En palabras simples, la presión de perfusión cerebral es la presión que tiene que tener la tubería para que haya flujo de sangre al cerebro. Este número siempre tiene que ser positivo. Si la presión de perfusión cerebral baja a cero, perdimos al paciente porque no hay perfusión cerebral. La presión de perfusión cerebral se basa solamente en dos factores: presión arterial y la presión intracranial. La presión arterial es la fuerza del flujo hacia el cerebro. La presión intracranial se opone al flujo. Para que el resultado sea un valor positivo, la presión arterial tiene que ser un valor mayor, y la presión intracranial tiene que ser un valor pequeño. Si la presión intracranial aumenta, matemáticamente hablando, la presión de perfusión cerebral va a disminuir. El único mecanismo que tiene el cuerpo para evitar que esto ocurra es el aumentar la presión arterial. Cuando esto ocurra, el flujo hacia el cerebro debe mejorar. El problema es que si hay una lesión cerebral con un sangrado activo, entonces el restablecimiento del flujo cerebral implica que el sangrado va a continuar. Si el sangrado continua, sigue aumentando la presión intracranial. El aumento en la presión intracranial va a provocar mayor aumento en la presión sanguínea, tal y como está descrito arriba. Esto va a ocurrir hasta que el cuerpo no pueda compensar más. Herniación cerebral El único escape, como parte de la progresión natural de la enfermedad, a una presión intracranial insostenible, es la herniación cerebral. La herniación cerebral ocurre cuando el tallo cerebral intenta salir por el foramen magno hacia el cordón espinal. Este proceso provoca daño en las estructuras cerebrales. El tallo cerebral y el cerebelo son las dos partes más cercanas al foramen magno y tendrán serios daños si el cerebro se hernia. Dos de las funciones más importantes que se afectan son el sistema de activación reticular y el centro de control de la respiración. Esto significa que el paciente gradualmente pierde la consciencia y deja de respirar en la medida en que el cerebro se va presionando hacia el punto de herniación. https://youtu.be/bA1OOQ4gkdc Hipoventilación provoca vasodilatación Los niveles de CO2 alteran la circulación cerebral. Si el CO2 aumenta, la vasculatura cerebral se dilata. Viceversa, si el CO2 disminuye, la circulación cerebral se contrae. Si el paciente deja de respirar efectivamente (no se deshace del CO2 que tiene acumulado), el nivel de CO2 aumenta dentro del cuerpo. El aumento en CO2 provoca vasodilatación, y esto a su vez provoca un mayor aumento en la presión intracranial. Mayor aumento en la presión intracranial provoca mayor herniación, que a su vez provoca más presión sobre el centro de control de la respiración, que a su vez provoca menor capacidad de ventilar, que a su vez provoca mayor vasodilatación, que a su vez provoca mayor sangrado, que a su vez provoca mayor presión intracranial, que a su vez... provoca un ciclo sin fin que termina en la muerte cerebral. ¿Cómo se vería el paciente? En base a esto, podemos predecir la presentación del paciente que se está herniando. Alteración en nivel de consciencia (inconsciente probablemente) Hipertensión Patrón respiratorio alterado Bradicardia Ya hemos explicado por qué se afecta la consciencia (debido al efecto de la presión sobre el sistema de activación reticular). También hemos explicado por qué ocurre la hipertensión, como mecanismo de defensa para mantener la presión de perfusión cerebral. La bradicardida ocurre porque los baroreceptores en la aorta y la carótida sienten el aumento en la presión sanguínea y estimulan el corazón a latir más lento como medida compensatoria. Patrón respiratorio alterado de Cheyne-Stokes El fallo del centro de control de la respiración se manifiesta en la forma de patrones de respiración alterados. Uno de los patrones posibles en este caso se llama Cheyne-Stokes. El patrón de Cheyne-Stokes es un patrón de dificultad respiratoria que va progresivamente aumentando hasta que se va en apnea, y se repite de forma indefinida. https://youtu.be/eAx4fxy7WbA https://youtu.be/VkuxP7iChYY Triada de Cushing El neurocirujano Harvey Cushing describió en el 1901 su famosa triada de signos que sugieren una herniación inminente. Su descripción fue: Hipertensión Bradicardia Respiraciones irregulares ¿Lesiones visibles? La lesión cerebral traumática puede no necesariamente ser aparente a simple vista. Los traumas abiertos a la cabeza producen sangre visible y esta puede ser la alerta al personal para que evalúe la probabilidad de que haya lesión al cerebro. Algunos traumas cerrados pueden producir signos visibles. Por ejemplo, las fracturas de la base de cráneo pueden producir hematomas alrededor de la base del cráneo que pueden ser observables desde afuera en el área retroauricular (signo de Battle) y como periocular (signo de mapache). https://youtu.be/yRg6IbwuytE https://youtu.be/MjYXoWHWQWk No todas las lesiones cerebrales traumáticas producen fractura en la base del cráneo. Por lo tanto, estos signos solo ocurren en la población que sí haya tenido este tipo de trauma. El paciente con aumento en la presión intracranial va a tener múltiples amenazas a la vida identificables en el tradicional A-B-C de trauma, por lo tanto, la evaluación del paciente no varía. La alteración en el estado de consciencia va a provocar que no pueda proteger su propia vía aérea. Si el paciente tiene un estado mental severamente deteriorado, es probable que se decida proteger la vía aérea. Fundamentos del tratamiento CPP = MAP - ICP Esa es la fórmula mágica para entender el problema y entender el tratamiento. Veamos cada componente por separado. ICP - Presión intracranial elevada El tratamiento definitivo es reducir el aumento en la presión intracranial. Una de las formas para hacer esto es drenar el sangrado dentro del quirófano. Si el paciente no está en un hospital con capacidad de neurocirugía, ¿qué pasa que no está en movimiento hacia allá? Si el paciente está aún fuera del hospital, es importante que se inicie el transporte de inmediato. Probablemente está solamente en las manos del neurocirujano el control definitivo del sangrado y de la presión intracranial. Pero lo que sí está en el control del proveedor a nivel PHTLS y ATLS el evitar que aumente más. El mannitol o la salina hipertónica (NaCl 3%) puede ser una opción para ayudar a drenar el edema asociado al trauma que contribuye al aumento en la presión intracranial. De más está decir que no se debe permitir nada que aumente la presión intracranial. Por ejemplo, un aumento en el hematoma intracranial seguramente aumentará la presión intracranial. Por ende, es sumamente importante que llegue a la facilidad adecuada para que puedan identificar la fuente del sangrado y controlarlo. Otra causa común de aumento en presión intracranial es las convulsiones asociadas al mismo aumento en la presión intracranial. Las benzodiazepinas pueden ayudar a aumentar el umbral de inicio de las convulsiones y disminuir la probabilidad de que ocurran. Durante la intubación endotraqueal, las fasciculaciones por usar succinilcolina, o la laringoscopía en un paciente que no está completamente inconsciente y relajado, puede aumentar la presión intracranial. Este paciente no debe ir a cualquier hospital. Debe ir a un centro de trauma con capacidad de intervención neuroquirúrgica. Desafortunadamente a veces estas facilidades pueden quedar algo distantes por lo que se hace ideal el transporte aeromédico. Los pacientes con trauma a la cabeza deben ser aerotransportados lo más cerca posible a la altura del nivel del mar. La altura puede aumentar la presión intracranial. Presión sanguínea La presión sanguínea está protegiendo el paciente. Si perdemos la presión sanguínea, perdemos el cerebro. Por lo tanto, es importante evitar cualquier evento que disminuya la presión sanguínea. Tenga mucho cuidado a la hora de seleccionar agentes de inducción para manejar la vía aérea que puedan causar hipotensión. Controle cualquier sangrado activo. Lesión primaria y ¿secundaria? La lesión primaria es el trauma ocurrido al momento. Por ejemplo, es el sangrado epidural que está creando efecto de masa y aumento en la presión intracranial. La lesión secundaria es todo aquello que agrave la lesión primaria. Es decir, todo lo que disminuya la presión sanguínea o aumente la presión intracranial. Evaluación primaria: ¿Qué puede complicar el paciente? La evaluación del paciente comienza con el ABC (vía aérea, respiración y circulación). El manejo inicial del paciente con trauma a la cabeza requiere que se controle cualquier amenaza al ABC ya que estas son causas proximales de muerte. Vía aérea La profunda alteración en el estado de consciencia de este paciente progresivamente provocará una pérdida del control autónomo de la vía aérea. Como dijimos anteriormente, el aumento en el CO2 va a provocar vasodilatación. El no manejar la vía aérea a tiempo va a ser causa del deterioro agudo de este paciente. Ahora bien, los detalles son importantes. Aunque el manejo de este paciente pueda requerir la eventual intubación endotraqueal, es importante evitar que el intento por intubar el paciente no provoque complicaciones. Algunas de las complicaciones asociadas a la intubación endotraqueal son: Hipoxia Hipercarbia Hipotensión La intubación en secuencia rápida (la administración simultánea de un agente de inducción + un bloqueador neuromuscular despolarizante o no-despolarizante para inducir inconsciencia flácida) es probablemente tanto la forma correcta como la forma en que se puede causar los efectos antes mencionados si no se realiza correctamente. Ventilaciones La pérdida del control de la respiración provocará un pobre intercambio de gases. La pérdida de la respiración provocará más disminución en el O2 y un aumento en el CO2. La falla en corregir esto va a provocar mayor aumento en la presión intracranial y por ende la muerte del paciente. La ventilación, ya sea manual o mecánica, debe mantener el CO2 entre 35-40 mmHg. La disminución por debajo de 35 mmHg indica hiperventilación. La hiperventilación provoca vasoconstricción cerebral. La vasoconstricción que se provoca al hiperventilar al paciente es bueno por un lado pero muy malo por otro. En teoría, la vasoconstricción puede ayudar a disminuir el sangrado, y por ende, disminuir el aumento en la presión intracranial. El problema es que la vasoconstricción provoca isquemia especialmente en áreas que no están directamente afectadas. La vasoconstricción puede provocar un aumento en el daño en las partes no directamente afectadas. Por lo tanto, inicialmente no se recomienda la hiperventilación controlada. Sin embargo, si el paciente muestra signos de herniación, la hiperventilación puede ser una medida transitoria para arrestar la progresión del aumento en la presión intracranial. Usted sabe que está llevando a cabo una hiperventilación controlada si obtiene niveles de EtCO2 entre 30 y 35 mmHg. Circulación Es importante recordar que la perfusión cerebral se está manteniendo gracias al aumento en la presión sanguínea. Si se pierde la presión sanguínea, automáticamente se pierde la perfusión cerebral en la simple ecuación descrita arriba. Las guías más recientes de la Brain Trauma Foundation recomiendan un mínimo de presión sistólica de 110 mmHg en pacientes entre 15 y 49 años de edad (o más de 70), al menos 100 mmHg para pacientes entre 50 y 69 años de edad. Esta es una nueva recomendación diferente a lo que antes se recomendaba de mínimo 90 mmHg. Por lo tanto es importante controlar todo sangrado de forma rápida. Un paciente con trauma a la cabeza y signos de shock está sangrando por otro lugar que no es la cabeza (hasta que se demuestre lo contrario). Aunque un sangrado del cuero cabelludo puede ser, en algunos casos, significativo, los sangrados intracraniales no producen shock hipovolémico. Por ende es importante buscar otros posibles sangrados activos tales como el torso, pélvis, y/o múltiples huesos largos. Métodos de monitoreo El monitoreo invasivo de la presión intracranial probablemente es una de las formas más fáciles de monitoreo continuo, para el proveedor que puede hacerlo. https://youtu.be/q7nJEMyqWwo La alteración en el estado de consciencia es el signo más temprano de aumento en la presión intracranial. Es por esta razón que el PHTLS recomienda el monitoreo continuo del nivel de consciencia (inicialmente con la escala AVDI y/o con la Escala de Coma de Glasgow) para detectar los signos iniciales de deterioro. Una disminución de menos de 2 puntos o más en la Escala de Coma de Glasgow sugiere un aumento significativo en la presión intracranial. Una disminución de 2 puntos o más, partiendo de una puntuación inicial de 8 o menos, sugiere inicios de herniación. Conclusión La fórmula de CPP = MAP - ICP y la Doctrina Monroe-Kellie explican la fisiopatología del trauma craneoencefálico. La evaluación inicial y resucitación que enseña el PHTLS presenta el mejor abordaje inicial para este tipo de paciente críticamente lesionado. Referencias Brain Trauma Foundation PHTLS

Recognize and manage end of life symptoms with competence and confidence. In this extensive discussion with Dr. Brooke Worster, Assistant Professor of Medicine at Sydney Kimmel Medical College and Medical Director, of the Palliative Care Service at Thomas Jefferson University Hospitals we discuss scripts for having difficult conversations, managing patient/family expectations, what comes in the hospice “E” kit, terminal delirium, the “death rattle”, air hunger, and more. Full show notes available at http://thecurbsiders.com Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 03:10 Rapid fire questions 08:33 Defining hospice and palliative care 11:28 Case discussion 21:28 Gunderson, MI and Respecting Choices 24:25 How to counsel patients about home hospice? 37:10 Hospice “E” kit and how to use it 42:09 Air hunger, terminal delirium, death rattle, and Cheyne Stokes breathing 52:48 What is the PCM’s role while patient is on hospice? 58:19 Cancer survivorship and palliative care 60:33 Take home points 62:20 Outro Tags: assistant, care, doctor, end, education, family, foam, foamed, health, hospice, hospitalist, hospital, internal, internist, life, nurse, medicine, medical, palliative, physician, practitioner, primary, resident, student, symptom