40 - Dr Boon Lim - autonomic dysfunction, the heart & Long Covid

Episode 40 of the Long Covid Podcast is a chat with the wonderful Dr Boon Lim. We talk about the heart and how it's connected to the rest of the body, what can go wrong when something like Long Covid affects the body and how we can help ourselves and get better (what more could we want?!)

I have already listened to this episode several times myself and actually felt instantly slightly better after hearing it! It's quite a long listen but it's really worth getting to the end, even if you need to take a break.

Keeping your heart healthy by Dr Boon Lim 

https://stopfainting.com/long-covid-resources/ 

Suzy Bolt - 360 Mind Body Soul

ENO breathe

UK PoTS resource – PoTS UK.org 

Dr Boom Lim & Suzy Bolt in conversation about how Dysautonomia can affect the body 

Dr Boon Lim discussing recovery with his patient Natalie

https://stopfainting.com/breathe-yourself-better/

https://stopfainting.com/wp-content/uploads/2021/03/Long-Covid-Autonomic-Dysfunction-Patient-Sheet.pdf

Autonomic dysfunction in LC, rationale for treatment & management for LC – Paper Jan 2021


~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
The Long Covid Podcast is self-produced & self funded. If you enjoy what you hear and are able to, please Buy me a coffee or purchase a mug to help cover costs.

Share the podcast, website & blog: www.LongCovidPodcast.com
Facebook @LongCovidPodcast
Instagram & Twitter @LongCovidPod
Facebook Support Group
Subscribe to mailing list

Please get in touch with feedback and suggestions or just how you're doing - I'd love to hear from you! You can get in touch via the social media links or at LongCovidPodcast@gmail.com

For more information about Long Covid Breathing courses & workshops, please check out LongCovidBreathing.com

(music credit - Brock Hewitt, Rule of Life)

Transcript

Copy Transcript Copied

Jackie Baxter  0:00  
Hello and welcome to this episode of the long COVID Podcast. I am delighted to introduce my guest today, Dr. Boon Lim, who is the clinical lead of the Imperial syncope diagnostic unit at Hammersmith hospital, cardiologist and electrophysiologist at Imperial College London, and one Welbeck heart health, creator of www.stopfainting.com and author of Keeping your heart healthy. So we're going to talk about all things about the heart and long COVID. So, welcome to the podcast.

Boon Lim  0:36  
Good morning, Jackie. What a glorious morning. And thank you for having me.

Jackie Baxter  0:41  
Thank you so much for being here. So to start with, I mean, I've just said quite a lot. But would you just briefly introduce sort of what it is that you do?

Boon Lim  0:51  
Sure. So I'm a cardiologist. And my day to day practice involves seeing patients in clinic but also doing operations on patients. Because I'm also an electrician of the heart, let's say, where we try and fix heart rhythm abnormalities such as atrial fibrillation or slow heart rates by putting in pacemakers. But the thing that is relevant to this podcast is that I also run one of the largest Tilt Table testing services in London, which is the Imperial syncope diagnostic unit, where I've been the clinical lead for patients who have syncope, which is where people pass out. And the testing modality there is a tilt table test to try and figure out what happens to blood pressure and heart rate when people pass out. 

And the interest with respect to long COVID Is that people with long COVID over the last two and a half years that we've seen, have had an increasing incidence of feeling lightheaded and dizzy. And some of them, in fact, do come very close to losing consciousness. And so we had an initial tranche of patients coming through who were feeling like they were passing out. And so the observation from my Tilt Table testing and reporting now over, I think 60 to 80 patients, I can't remember exactly, is that we were able to put out a very rapid communication on the first of January 2021. So a year and a half ago, and it's been one of the most cited papers, which is entitled The Long COVID autonomic dysfunction in Long COVID - Rational for treatment and management. And the experience of seeing these patients have a very clear diagnosis on the tilt, together with demonstration of their blood pressure and heart rate variations and triggering of symptoms during the tilt has been quite a validating experience for them. So we're here on the long COVID podcast talking about long COVID. There's other stuff that I do but specifically, the focus is on long COVID.

Jackie Baxter  2:57  
Amazing, thank you so much. And you know, you touched on something that I think will be very close to a lot of people with long COVID hearts, which is this idea of validation, because so many people, they come back with all their tests being clear, you know, which is good. But when you know that there is all sorts of things going on that are wrong, having something that shows that there is something wrong is quite validating, I think.

Boon Lim  3:22  
Yeah, and I think my advice there is that you have to forgive people who are in their silos of sub speciality medicine, because one of the things to recognize with long COVID Is that it was a term coined by a patient group. It's not something that doctors came up with. And really there have been very strong patient advocacy groups coming up to say, Hang on, we haven't really got a good understanding of this illness process. And, you know, to challenge the medical community to say, look what's going on. 

Medical communities at large don't, unfortunately, practice in a general view. They are very sub specialists, including me, right? So I'm guilty of it. Because if you ask me how to treat, for example, a heart attack, I've come out of doing balloon inflating at 3am in the morning - procedure called coronary angioplasty, many moons ago because I didn't ever want to wake up at three in the morning to go in as an emergency to help patients with a heart attack. And equally, somebody who blows up balloons, or your coronary doctor may not know very much about how to put a pacemaker in. So we've gone into our sub specialist silos. And within those silos, we are not even being able to keep up with the latest innovations within those silos. So the latest generation pacemaker will have some training that maybe I haven't gone for. So it is no wonder that you see a general cardiologist or cardiologists with a sub specialism who may not know that much about long COVID. 

And so, all the standard testing from this cardiologists, rheumatologist, gastroenterologist neurologists, any ologist may well end up with drawing a blank. And what do they say? They might say, there's nothing wrong with your heart. And that is a very, very jarring experience for somebody who needs to know what's going on. And so when you feel this kind of emotion of doubt, and maybe even self doubt, because the person in front of you who is a very learned individual who's supposed to fix you, says to you, everything is normal, go away. Or he doesn't say that. But that's what you hear. You hear, everything is normal. Therefore, it must be in my mind, or they must have got it wrong. Or, you know, he doesn't understand what I'm saying. It's a very negative set of emotions that comes away from that clinic visit, right? Because you've gone through the time and the waitlist, of having three or four diagnostic tests, which could be an echo, an MRI, halter, an exercise test, cardiopulmonary exercise test, and you've come away having normal testing. And so this is the advice I like to give is to forgive the person in front of you. 

And actually to forgive yourself - this, this kind of idea of forgiveness is a very important concept and to recognize we're all human, especially doctors.

Jackie Baxter  6:28  
Yeah, that's a very good point, actually. Would you be able to give a sort of overview maybe of some of the common heart issues that people are experiencing as a result of COVID and long COVID?

Boon Lim  6:42  
Yeah, so in my experience, the most common heart symptom would be breathlessness, and palpitations. Now, breathlessness is a dual symptom, it's quite interesting because it is a symptom that people mostly associate with the respiratory condition. And therefore, patients are normally shunted via a respiratory clinic. And so most of the long COVID clinics that are run across the nation are led by respiratory consultants. 

Now, in my experience, when we talk about long COVID, as an entity, these are typically symptoms that occur after a relatively minor illness without very much changes in your lung capacity, volume, fibrosis or scar. Because if you have very severe COVID, you require an ITU admission, you have scar in your lungs, and you take time to recover with breathlessness from that issue. This in my book is not a typical long COVID picture. So we have to be very clear what we're talking about with long COVID. 

And I don't know, Jackie, if you feel that a lot of your listeners or people in the long COVID community will identify with that, ie those people who have been in and out of ITU and are still breathless, six weeks down the road. Those patients are typically not, they don't consider themselves as long COVID. Whereas it is the patient who has a relatively minor illness and makes a recovery in a week or two afterwards. And then is floored completely. And the symptoms get worse, and in fact, probably much worse than they felt when they had COVID, which was a relatively minor illness. And that's the kind of group that we're talking to today. Not not really the ITU scarred lung patient, right.

Jackie Baxter  8:33  
Yeah, I mean, I think there are definitely both but I would say from the support groups and things that I've seen the majority of people were not hospitalized.

Boon Lim  8:43  
Yeah. If we bear that in mind, with that caveat, I would say the most common symptom would be breathlessness, followed by palpitations, and then chest pain. And then dizziness and lightheadedness. And these are all the common heart issues that are experienced with people with long COVID.

Jackie Baxter  9:03  
That's very interesting, because I would not have associated breathlessness with being a heart issue. So that's a very interesting point, actually, that it all ties together. 

Boon Lim  9:16  
Yeah, I mean, I hope to expand on this as we go along in the conversation. But I also just want to make clear to your listeners that I'm not suggesting necessarily it's a heart issue, but it's a cardiovascular autonomic issue.

Jackie Baxter  9:29  
Yeah, yeah. It's very interesting our sort of perception of things. And I guess it ties into what you were saying beforehand about everything being very in its own box. And actually the idea that your breathing and your heart, actually, you know, I suppose it's fairly obvious, isn't it? They're very closely linked, when you think about it, but the you know, the sort of current system is that they are very individual areas.

Boon Lim  9:55  
Yeah. So this compartment process where we think of the body as organ systems that don't talk to each other is very much a product of the way we've trained in medicine and the volume of stuff, we need to just understand when we go through medical school and more likely sub specialist training. Because there's enough stuff to do within the electrophysiology of the heart in itself that we don't really have time to worry about other aspects of the heart, hypertension, cardiovascular regulation, and let alone lungs or liver or kidney. So I'm a pretty bad kidney doctor, because I've left general medicine long time ago. And equally, I would say that some kidney doctors or orthopedic surgeons, or you know, whatever the speciality might be, might not be so familiar with heart. So we come back to the first point, right, which is, the person in front of you in clinic may not really know that much about long COVID, especially if they're not really experience with the kind of global processes that are occurring in long COVID.

So in my personal experience, I think long COVID has been one of the most important shifts in medicine for people to be, in fact, for doctors to be more aware of their own limitations, and to practice a different style of medicine, one that is centered on kind of heart focus, compassion, empathy, but also taking a more generalist, top down approach view. And if you don't adapt as a, as a medic to understand the processes involved with chronic ill health with a multi faceted, driving processes or driving process, it's very difficult to help your patients because if you're going to say the end of all your sub specialist investigations, everything is normal, you're not really going to help the patient.

Jackie Baxter  11:44  
Yeah, yes, definitely. So you've mentioned autonomic dysfunction. And you know there are several sort of things that are banded around as sort of underlying causes, you know, we talk about inflammation, endothelial damage, autonomic dysfunction is one and I'm sure there are others as well. What are your thoughts on sort of, I guess, underlying cause? And what do we think is causing the damage or the, the altering or whatever it is of the heart?

Boon Lim  12:14  
Yeah, so I think the jury's out on the actual mechanisms at play. But I think it's a nice segue into talking about the autonomic nervous system. And I think in some of your other podcasts, a lot of your other very august speakers have spoken a bit about the autonomic nervous system, and I'll give you my own two cents worth. Now, I will just say that that bit of the brain that controls all the subconscious, or unconscious, bodily functions, and regulation of homeostasis, which means trying to keep a stable state of your blood pressure, heart rate, temperature regulation, breathing rate, peristalsis, capillary dilatation, sweating. These are all processes that are not necessarily something we think about on a day to day basis. And therefore it resides not within conscious brain activity, but subconscious. 

And, you know, I quite like this analogy, I'm going to kind of show you that if I said to you move your finger and bend it back and forth, what you're doing is you're having a conscious thought to say "finger move" in your brain, and that translates to a finger movement. Now, if I said to you, Jackie, push your heart rate up by 20 points, or calm your heart rate down by 20 points. You couldn't, I think most people, could not consciously bring their heart rate down. Some can. But the process by which you bring your heart rate down resides not within conscious thought, but within subconscious. And I will tell you a secret, Jackie, you can do it. So do you want to try with me now let's try an experiment. And I want all your listeners to also try. 

So I appreciate this as a audio form podcast, but I'm going to say to your listeners that I can see you, Jackie, in front of my eyes. Now, I want you to sit back in your chair, like your listeners, close your eyes. Put one hand on your belly button, and one hand on your heart or on your chest, go on. And now take a few deep breaths, as deep as you can, from your belly. So when you're breathing in, you should feel your belly hand move out. And when you're breathing out, imagine your belly button touching your spine as you contract the stomach in and this form of breathing as you continue this way, Jackie, is called diaphragmatic breathing. 

And when we breathe like that, just for two minutes, Jackie, which I hope will continue and all your listeners will try and do now. What will happen, amazingly, if you're breathing slow and all your mental focus, and energy is going into imagining the breath coming in through your nose, through the back of your throat, deep into your lungs, especially the bases of your lungs. And imagining that this diaphragm, which is a inverse U shaped muscle, which is called the muscle of respiration is straightening out as you breathe in to expand those lungs, and push the belly out and contracting and forming a kind of dome shape to expel the air from your lungs as you breathe out. So just focus on the breath in and out.

And there have been beautiful demonstrations, including one that I demonstrate on the website, stopfainting.com under breathe yourself better, that we can definitely modify and modulate our heart rate and our coherence, which means the stability of our autonomic nervous system, to bring it into a sense of balance when we breathe slow, and we breathe through our diaphragm in this way, through our noses. 

So I've spoken for about two minutes, Jackie, and I want you to open your eyes now, release the breath. And just tell me how you feel after that two minute exercise, 

Jackie Baxter  16:22  
Very relaxed. 

Boon Lim  16:23  
Indeed. And most most people feel more relaxed, just with that breathing technique. And they are able to shift their blood pressure down by 10 to 15 points, much more in magnitude than taking a beta blocker or a drug called Ivabridine. And if I said to you the best drug available in your system is within everyone's reach right now with a breath for two minutes. And it's better than any drug there. You'd say Hang on. That's a bit strange. Why is he saying that. But I urge all your listeners to maybe rewind this podcast for just three minutes and just do that breath trick again, this time, take your radial pulse. 

If you don't know how to take your radial pulse, then take two fingers of your right hand, feel it on your left hand thumb side down. So feel your thumb and go down your thumb about an inch below the wrist crease. And you should be able to palpate or feel a bounding worm underneath your thumb, the flesh of your thumb. So come below that below the wrist crease, can you feel yours, Jackie, your pulse?

Jackie Baxter  17:35  
I always struggle to find mine in my wrist.

Boon Lim  17:37  
So you can find it, you can find it in your carotid, in your neck as well, the side of your neck, wherever you find it, I want you all to try and go back. And now with that deep breathing in and out through the nose into your diaphragm, feel your pulse change because you may be able to just control your heart rate if you practice maybe two minutes of breathing every hour. And this is certainly the biggest change in my life, in the last three years has been I do this practice myself every day. And between patients in clinic I'm also doing this pulse check and my my breathing check because I often transition from this breathing pattern of stress where you're chest breathing and breathing through your mouth. Need to recalibrate and learn how to breathe again. And I guess I've done breathing a little bit too long in this podcast, you want to focus on the heart and you've got other great breathwork speakers in your podcast. But I just want to highlight how I, as a cardiologist, fully believe in the power of breath. 

And if you asked me about your control of the autonomic nervous system, coming back to the point that you were making, what is the autonomic nervous system? And is there a mechanism that it contributes to your symptoms of long COVID? I would say that the autonomic nervous system in at least 60 or 70% of patients with long COVID plays a major role in development of your symptoms, because this is the system that handles as the master controller for every other homeostatic system in your body. And so some of your listeners might find or might be asking or having symptoms in clinic of a combination of things including inability to sleep, brain fog, shortness of breath, bowel change, temperature dysregulation. In my mind, all of those symptoms can be explained through a kind of single source issue. Rather than saying, you've got a problem with your bowel. You need to have that investigated with a colonoscopy or gastroscopy. Or you have a problem with your heart. You need an MRI echo, ECG or you have a problem with your brain, you need to see a neurologist or you have a problem with temperature you need to see an autonomic temperature specialist. If we focus on the fundamental bit of the body that controls all those things ie the autonomic nervous system, you often then come up with an answer. And this has been something that, as I alluded to earlier, validated in our tilt table test experiences. 

I recognize I've been going on for some time. But But I guess if this is of relevance to most, I'll ask one question on your behalf, which is, how do I know if you're a listener - How do I know that I've got autonomic dysfunction? And is it not myocarditis that I have? Or, you know, have I got something more serious with my brain? And to me, the biggest discerning question you can ask is, are your symptoms much worse when you're standing up. So those patients who stand up, especially first thing in the morning, or after they've been sitting on the sofa, or lying in bed for a long time, particularly, they're dehydrated, those patients who stand up and within 10 seconds, or half a minute of standing, start to feel the resurgence of all their symptoms. And then they lie down again, because that's the most comfortable position to find themselves in, and the symptoms go away. This orthostatic, which is postural change, that exacerbates symptoms, but also takes away symptoms, when you lie down is one of the most, if you like discerning markers of autonomic dysfunction, which is your body's inability to control your homeostatic mechanisms that maintain an upright posture.

Jackie Baxter  21:33  
Yeah, that's interesting, because I mean, I've noticed it, and I'm sure I've seen other people saying similar, that, you know, you wake up in the morning, and you could almost kid yourself that you're okay. And you think, Oh, I'm laying in bed? Is this going to be a good day? And then you get out of bed. And you think, oh, no, no, no. So that's very interesting.

Boon Lim  21:54  
So I would say not everyone has the symptom. And I'm not proposing that I know the answer for every long COVID patient. But if you do have that symptom, as you've described, so top tip for you, like wanting for you personally to take away Jackie is have a ice cold flask from the last night, a thermos of ice cold water, perhaps with an isotonic electrolyte tablet that you don't put in there yet, because otherwise it fizzles all night, or it stays and gets flat, that you've put in that ice cold flask of water. First thing the morning, let it finish with three minutes. So something like Science in Sport noon, or Precision 1500, Anything you can get from a health shop to aid in a marathon run, for example. So this training runs, you put that in that ice cool flask of water and you take 500 mils, you lie in bed for another three to five minutes, let the cold and let the water redistribute and boost your blood volume. Try that Jackie. And when you stand up, you might just notice that you feel a little bit better. And that that initial kick up in the morning to kick to kind of blood volume is a really helpful exercise. So try. That's that's all I can say. Try that. 

Jackie Baxter  23:07  
Yeah, I will do. Thank you. Earlier, you mentioned dehydration potentially being an issue could that you know, obviously overnight you're generally not drinking. Could that be why it often does feel, you know, when you first get up in the morning?

Boon Lim  23:21  
That's That's exactly right. So you know, the time that we are generally as a body, the most dehydrated is first thing in the morning when you wake up - why because at night,  in the eight hours of sleep that you get, it is the probably the only time in a 24 hour period that you're not drinking at all for eight hours. You're also breathing all the time, and therefore the respiration induced fluid loss. For example, if you just breathe in a winter against the cold window, you will notice that you condense a lot of fluid. And so you're losing all that fluid with your breath. You're also under the duvet or the sheets, and you're sweating but evaporating, so you lose blood that way, although you might not wake up drenched in sweat. And the last thing is you're you're producing urine all the time. So most people wake up with a semi full bladder, and they need to go to the toilet. And that is something that you need to try and avoid which is standing up to rush to the toilet first thing. In fact, have your routine first, and then three minutes later get up and go to the toilet. 

And you're absolutely right, because you're so dehydrated, and you're so underfilled by definition, what happens when you stand up is that this process of adrenaline of fight or flight activation occurs and I'll take maybe two minutes to describe this Jackie? Because it is fundamental to understanding why is it you get symptoms. So imagine you're lying flat and your blood is distributed amongst your core organs, so your brain and your heart, but then also in the peripheral circulation which is your lower limbs which are huge reservoirs of blood- your skin, which is the largest organ and the gut, let's say, for example. When you stand up, gravity pulls blood down from your brain and your heart and it empties your blood pool into the lower limbs, right. And so just gravity alone, which seems remarkable. In a long COVID patient who has a degree of dysregulation of the autonomic nervous system, creates this emptiness in your heart and reduction in blood volume coming back to the heart, so you're not bleeding out, you haven't donated blood, you're just empty. And this blood, when your whole system of vessels in the heart are empty, pool selectively into the lower limbs rather markedly. And therefore the heart is empty. 

Now when the heart is empty, there are two carotid receptors which are on either side of your thyroid gland, which is in your neck. And they sense stretch. And when you have a normal, healthy blood pressure, blood volume, these receptors stretch in a very healthy way. But when you're empty, they stretch a lot less don't they, because they're not having that volume come and stretch them out. And this is a panic trigger for your brain. Because this sends a signal directly to the autonomic centers in the brain to say hang on a minute, we're bleeding out, we're very dry, our blood pressure's dropping. And the way you increase blood pressure is actually to spew out an industrial amount of adrenaline to activate the fight or flight response. So that the overall cardiac output, which is how much blood is circulating in every minute to perfuse your brain, your kidney, your heart, is still maintained. And the way we maintain it is we make the heart rate faster. And that's called tachycardia. We make the heartbeat stronger. And that is the strength of contraction, which may give patients a bounding sensation in their chest and may even cause chest pain. And it makes the vessels of the body also vaso constrict, which is squeeze. And when the vessels in the lower limb squeezes, it pushes the blood back up into the heart. And guess what, the neck receptors which were not so stretched just five seconds ago, start to get more stretched. And when they get more stretch, guess what they down regulate the panic signal to the brain, and the adrenaline then just dies down. 

So in a normal healthy individual who is not dehydrated, it happens very rapidly, this homeostatic control of orthostasis or standing up, occurs within an eight to 10 second period. And even I, when I stand up, will have a heart rate rise by about 10 to 15 points. It's It's true of anyone, but it will start to reduce again, because as my adrenaline kicks in in the normal way, I regulate the blood pressure, do you understand? So what long COVID does or what COVID does is it alters, it knocks the control level of your blood pressure and adrenaline surging, and your venous pooling, such that you need much higher doses of adrenaline to keep it up, to keep your blood pressure and volume up. And because of that, people with long COVID or autonomic dysfunction in long COVID, tend to have this surging adrenaline throughout the day as long as they are bright. So most people choose to lie flat. And you know what that exacerbates the problem, Jackie, because when you're lying in bed all the time, guess what you become deconditioned. Your autonomic nervous system also becomes deconditioned and so you're less and less able to stand up. So it is a vicious cycle of assaults. 

And I think there are a few simple tips and tricks and some of them I guess we won't have time to cover in this podcast in entirety. But on the website, there is a link to a PDF leaflet on Stopfainting.com under the autonomic dysfunction section, that you can just get the tips and tricks for free. One of them I told you is cold water with some salt or electrolyte drinks. The other one is compression stockings. The other one is isometric exercises where you're squeezing your glutes, calves & quads to try and use your internal muscles to squeeze the blood before you get out of bed. So if you like you sit on the side of the bed, Jackie, and do these muscles in your legs. You might want to do some bicep curls as well and get your juices flowing so that the heart is full of blood before you stand up. And that is the way to down regulate the adrenaline.

Jackie Baxter  29:44  
That's really really interesting. I mean, I think everybody with long COVID will probably have heard of the fight and flight response. But that totally explains why it happens. I love understanding why things happen because then I can try and work out what I can do?

Boon Lim  30:01  
I mean, that's, that's absolutely right. And that's the kind of principle of, I guess this podcast, right? That's why this podcast can be so meaningfully helpful for people because as they gain a greater understanding into the mechanisms that explain the symptoms, they don't get that experience, ie, all your tests are normal, I don't know what to do, you know, time will heal you. I mean, that's not very helpful for a patient to hear that. And as I said, at the beginning, forgive whoever it is that told you that, if you're angry, and you might not be angry, you might be very forgiving anyway. But if you are angry at the medical fraternity, you're angry at the government, angry at the COVID policy, let go of all of that. 

And it's a relevant point as well. Because guess what, Jackie, one of the other influences of your amplification of the autonomic nervous system is what - is a feeling. And if you have that very unsettled feeling, if you have great expectations, and you're in a high flying job, and you've always been an A star performer, and you just want to get back tomorrow, just give me that damn drug that gets me back tomorrow. Guess what that's going to do to your autonomic nervous system, it dials it up to full, right. So when you stand up, and the adrenaline is being released by your carotid baroreflex being activated, because your heart is now empty, that thought, feeling or that state of being, that unsettled feeling that you have, and that high, high expectations. And the whole kind of backdrop of, you know, this, I would say chronic stress, because of illness mainly, but all the other stuff that's going on in your life, financial, social, relationships, career, all that stuff will amplify the adrenaline and actually will amplify it in a chronic sense. So whenever you're upright, that all just keeps going on in the background. And so you go into a vicious spiral. 

And you know, oftentimes when I see patients, they're now kind of nine months into long COVID. And if they were just two weeks into long COVID, and I said to them, do the compression, the fluid, the salt, the isotonic drinks, and understand what it is that's going on in long COVID, the recovery is a lot quicker. But when you're nine months down the road, my experience is that you need to work on a second aspect, which is a bit more difficult to talk about Jackie, I mean, I'm more comfortable talking about it now. But it's sometimes makes me a bad cop. Because no one ever wants to hear that there is an amplifying stress component that makes the symptoms worse, what it's not in my mind, I'm not stressed, give me a drug, fix me, right? There must be something you can do. It's not always like that when you're living with such a chronic process. And what I'm saying is you do all the things that you can do from a physical point of view. But then you have to modify your feelings and your thoughts. And actually understanding and educating yourself on the multifaceted inputs into your autonomic brain, or the lizard brain or the stress brain or the fight or flight brain is going to be an important component. And that's why I love all your previous podcasts on people who have focused on breath work, on meditation, on mindfulness, because these are some of the components that help heal and down regulate the adrenaline in the autonomic nervous system.

Jackie Baxter  33:43  
Yeah, I mean, we all know from personal experience, unfortunately, that, you know, stress can hugely exacerbate symptoms. I mean, I've noticed, you know, I've had an argument with my partner, and then I've not been able to sleep for a week, or you know, something happens, whatever it is, you know, and it brings your symptoms up. And that kind of explains a bit about that as well, doesn't it? So then if we do the opposite, if we try and remove the stress and do the things that de-stress our bodies, then it should help?

Boon Lim  34:15  
Well, I mean, I you know, since you given a personal anecdote, I will say to you, about two months ago, just shy of two months ago I caught COVID and I am not the kind of person who ever thought I would catch COVID I'm genuinely a positive individual who breathes well. But I caught COVID because I was going on holiday and I needed to clear so many things in the week before and I normally handled stress quite well but I couldn't handle the lack of sleep in the kind of email backlog and everything that needed to be cleared before I went on a Easter break. And I was down and I was rundown. And you know, and all the listeners will know that you just need couple or three nights of bad sleep, whatever, four hours or interrupted sleep, plus long days at work, and a constant kind of barrage of emails and stuff to do on your To Do lists. And that really gives you an unsettled feeling so that when you finish one task, you open your task list and there are 15 more, and they keep coming. And you think, oh my God, I'll never get away on time without finishing everything I need to finish. That kind of chronic stress over one week gave me pretty bad COVID. So I needed an admission to hospital myself. 

And in the convalescent phase, I needed to take three days off where I was by myself in a kind of b&b in France, while my family were elsewhere. And my god, the experience there at the time. Interestingly, it was one of the most calm experience that I've had full of gratitude that I, at the time, I didn't feel it so much, which is I'm thankful I had COVID. But right now, two months down the line, I can reflect backwards, and I can change that historical perspective that I had. At the time, obviously, I was unwell. And I felt oh my god, woe is me, Will I make it? But two months down the road, I'm actually changing my narrative. And I want to just share this because it's a personal experience, that I now do not let my history define who I am today, and what I feel and fear about the illness. I actually feel good today. And my recent imaging of lungs have shown that I've completely recovered, and I feel good. But I use this good feeling now to look back at the historical trauma that I've had. And I've taken different spin on it. And I've said this has taught me that I need to slow down. This has taught me to breathe more and handle stress better. And this has taught me that I shouldn't take two week long holidays. I mean, but but I need to, I need to slow down. 

And so coming back from this experience, I put more priority and focus on my health and my routinesof breathwork and mindfulness. And I've, I've actually shared that since with colleagues and patients as I round. So it's actually changed the way I practice myself, but changed my practice of medicine for the people around me. And it's been very uplifting. So yeah, what am I trying to say? I'm trying to say that, as you get struck by an illness, you can potentially also elevate yourself and one might say like, regroup, recreate or reinvent yourself or have a have a look and think about what it is you're doing in life and to modify it to dial down the initial triggers for for COVID. 

Because part of the the experience that that I have with seeing patients with COVID, but also, you know, coming to a point about myocarditis is that myocarditis in my experience before COVID, before COVID hit, I used to see patients come in with myocarditis whenever I was on the wards, maybe two patients a week, when I was handling a ward of say 30 patients with daily ward rounds. This patient almost invariably, in my experience had a preceding viral illness, and rundown. And this is the key thing no one asks about the rundown aspect of patients who develop the myocarditis. But they were either changing jobs, in a very stressful time, not sleeping, whatever social situation with neighbors or kids waking them up. And relationship issues, these were stressors that cause I guess increase the susceptibility of the initial viral illness, but also increase the susceptibility of the immune response to the viral illness that attack the heart ie inflammation of the heart ie myocarditis. 

And, you know that that feeds into the question, which is what can I do to prevent myself getting myocarditis or, or COVID for the better?And I would say this daily practices that are centered around relaxation and changing and shifting your autonomic state from a more fright or flighty mode to more relaxing vagal mode would be the key thing that I would suggest. And part of that comes with the understanding that you don't need to push so hard in life to achieve everything out there that you feel you need to achieve yesterday.

Jackie Baxter  39:26  
Yes, and, you know, and that, again, it's not exclusively, but there's an awful lot of people who are very driven or who are, you know, very into exercise or, you know, that sort of type of person that do seem to have ended up with long COVID. Again, and it's not exclusive I'm sure, but it is interesting, isn't it?

Boon Lim  39:47  
Yeah. And, you know, this is also my my experience. Again, this is quite anecdotal. But that ability to heal after a COVID experience requires a degree of convalescence and awareness that COVID potentially is a serious illness. So unlike other illnesses, you don't just get back up and go. Right? It's, it's something that tells you, you need to be kind to yourself for a while longer, maybe two or three weeks, don't get up and try and get your personal bests in two weeks time. And often the - not often, but you know, there have been startlingly clear long COVID cases where the patient to the day can remember the triggering event for long COVID. 

So they, as we talked earlier on have had a mild COVID illness, they shook it off within five days, not even a cough, not even a fever, but just a sniffly kind of sensation, or just off the normal best, they feel better and better. And then 10 days after they recovered, they go for a really long run, or they do a really long night or they travel. And then suddenly, the next morning, they're floored. And they don't understand why after seemingly recovering from COVID, with a relatively minor illness. They're suddenly very unwell. Very interesting. And I don't fully understand that myself, but I'm just sharing kind of an anecdotal experience of some patients who I'm sure who are listening who will say, Oh, that's me. I did this particular activity after I thought I was getting better. And now I'm so much worse. Three months, six months down the line.

Jackie Baxter  41:28  
Yes, yeah, that feeling of hitting a wall was how I described it. We've talked quite a lot about autonomic dysfunction and everything. And I'm sure we will talk more, because like you say, it's very apparent to so many people. But, I mean, could there sometimes be more than one mechanism at play? And how would you narrow that down? What's caused by autonomic dysfunction? And what could be something else? And and how would you know when to be concerned about that something else? I mean, that's something I've noticed, you know, I get horrible heart pains or I get, you know, whatever symptom it is popping up, and, you know, is this something I need to worry about? And that was what I think was for a lot of people so terrifying. You know, is this going to kill me? Or do I just need to calm down?

Boon Lim  42:12  
I mean, that's a great question. And I don't think I can give you a kind of reassuring enough answer. But the points that I would consider in addressing this question, or if if I were a patient, I would say, educate yourself. Number one. So listen to this podcast again, and understand what I said earlier on, about ortho stasis or standing up. And the key feature here, which defines in my books, and this is from experience of tilting many, many patients, if your symptoms get worse, when you stand up, including chest pain, and when you lie down and elevate your feet and you drink water, the chest pain goes away. And it remains away until you stand up again. In my mind, that is very, very unlikely to be a myocarditis or pericarditis, right. Because if you truly had inflammation of the heart, it would be agnostic to your posture. Correct. So the autonomic perturbations that occur with a postural change is, in my opinion, the most discerning part, or the most discerning history that you can take. And so ask yourself that question, do my symptoms generally get worse when I stand up and generally get better when I lie down including palpitations, shortness of breath and chest pain? 

And just just to say, and to kind of expand on the shortness of breath issue that you mentioned earlier that you were quite surprised to learn that it was to do with the heart? Well, it's not entirely to do with the heart. It's to do with the autonomic nervous system. When you activate fight or flight, and you imagine that you are kind of a gazelle grazing in the savanna and a line is swishing his tail in the long grass. You activate fright or flight, suddenly, you stop eating or chewing or munching, right? You shut down gut peristalsis because there's no way you're going to divert the energy into digestion. You want to activate maximum oxygen and maximum readiness to flee or to fight. And what do you do? You breathe quickly? What do you do - you get your heart beating a bit faster. What do you do? You divert blood into the muscles, you expand your pupils, capillary dilatation so you can have increased visual acuity. You become hyper reactive. So your ears are a practice up so you're very aware of sounds. You're very aware of temperature changes, you're very aware of light changes and smells, and this hyperreactivity is also one thing that patients describe to me, they can't stand sitting in a busy restaurant or pub on a Friday night because the clinking of glasses and the kind of conversations around them are so jarring to the system, gives them a headache. You can't tolerate bright lights, you want to be in a dark room, because you are driving that autonomic nervous system. As if the lion is circling in a long grass, you will almost be better if the lion jumped out and chased you and you ran. And then you you got safe, or you got eaten or killed, but you got safe. And therefore you could dial down again and start to graze and eat your grass again, because you know, you've escaped the lion. In this case, with autonomic dysfunction, you are always in that state. And so you dial it up more and more. 

And the breathing pattern disorder that happens or dysfunctional breathing, it becomes very apparent people take shallow breaths through their mouth, and they breathe through their chest. So chest breathing, shallow breaths. The other thing is a breath hold, which is very common. And you can even see in yourself or in people that you meet people who hold their breath, and then they take a big sigh. So the sighers, the breath holders, the shallow breathers the chest breathers. These are the people who have a slightly elevated autonomic nervous system fight or flight response that should be modulated. And coming back to the breath, I will say that of all the systems under control of the autonomic nervous system, the breath is one special bit of the lungs, which are under dual control, Jackie, and if you understand what that means, if you're not conscious about breath, you can have a stress breath or an adrenaline breath, shallow breath. 

But when you become conscious, and you take control, like we did earlier on in the two minute exercise, and you breathe in and out slowly, consciously, through your nose with your diaphragm. And ideally, with a kind of deep, anchoring positive feeling or emotion like gratitude or compassion or forgiveness, you are gaining control of your autonomic nervous system. So not only are you changing your heart rate and down regulating the fight or flight through breath, you are changing your mental state. Actually, you're down regulating that emotional state when you do breathing because you're expressing vagus, or the parasympathetic nervous system. So in my mind is still one of the most powerful things to be an adjunctive therapy alongside the physical therapies that we talked about the fluid, the salt, the water, and you know, it's an important thing not to be underestimated. It's not just in the domain of Yogi's and yoga teachers and whatever, healers, no, I think it's a fundamental bit of how we need to improve ourselves. And I for one, practice breath work every day, in every moment that I can be conscious about my breath, I try. And I fail. Because you know, when I'm in the thrall of a busy day, I know I'm breath holding, I know I'm not diaphragm breathing. And I know I'm sighing so we all could do better with our breath.

Jackie Baxter  48:20  
Yes, I love that idea of we can all improve ourselves. I mean, I've spent a lot of time working on my breathing since since I realized it was a problem. And it has made a huge difference to me. But I think to start with, I thought, Oh, I work on it for a bit and then it's fixed. And it's not like that at all, because I still have bad breathing days now. And I still have a lot of things that I could do better. So it's like you say, it's always going to be work in progress, isn't it?

Boon Lim  48:48  
Absolutely. And long may it be a work in progress, because we should all be keen to always experiment and make ourselves better. And you know, if you achieve the end point, what's the point? So you know, the journey is very important here and life's a constant journey of improvement. For everyone, everyone, especially me, right? 

Jackie Baxter  49:07  
Yeah, totally. We talked a lot about breathing and a few other things. Is there anything else that people can do to influence your autonomic nervous system and to help it to sort of tip back?

Boon Lim  49:20  
Yeah, so specifically with the ortho stasis or orthostatic intolerance, what I would consider a bottom up approach. So the things you can do would be to keep super well hydrated with a kind of front loaded routine. Because if I said to you drink two and a half to three liters of water a day, but you drank it all after 5pm, It's pointless and you'll pee all night. So what you need to be doing is actually front loading, that idea that you have a thermos of cold - and why cold, Jackie? Cold because cold is a great vasoconstrictor, Yes? When you put your hand in a bucket of ice or snow, your hand turns white from red or pink. Guess what that means? That means there's no blood in your skin. The skin is the largest organ. So that blood is being shunted and pushed back to your core circulation, your heart and your brain. So when you keep your body cool, and you keep your internal body cool, ie. your gut. 

Your gut, by the way, has a lot of circulation in it. And when you have a large, stodgy meal like say, a pasta bolognese, what happens is that you vasodilate in your gut. And so some of your listeners will be finding this, if they have COVID and long COVID. They have a large meal, they feel sleepy, they get palpitations, they get chest pain. I don't know whether you feel like that as well, Jackie? 

Jackie Baxter  50:41  
Yeah, I've definitely noticed that. 

Boon Lim  50:43  
Yeah, so the kind of simple key tips are, you know, exactly, to understand what I've said, and understand more about the dynamic of shifting blood volumes, and know that if you unfold your gut villi and microvilli, the capillary bed would fill the size of a tennis court. And that's how much blood  may not have not that much. But the network can fill the size of a tennis court, not all of that blood vessels, but you can shunt a lot of blood away from your core circulation into your gut when you eat in this way. So lighter meals, not so carbohydrate laden, would be a way to help to mitigate that kind of risk of too much pooling. And certainly not eating with alcohol in a warm environment. Because that triple whammy in a kind of champagne reception in a marquee on a summer's day is a disaster. Because you're drinking, you're having stodgy kind of bites and you're standing, those three things will make you feel quite unwell, will make anyone feel quite unwell. Right. 

So the understanding of your patterns of eating and what you eat, and how you might need to be a grazer. So smaller, more frequent meals, perhaps that might be a helpful tip, have front loaded fluid, that means I advise my patients to have probably two liters by lunchtime, and the third liter by 5pm. I know it seems a lot. But if you focus on this front loaded fluid with salt intake, and with salt, just have a slight caution here, check your blood pressure. So buy an upper arm cuff blood pressure, it's 30 quid, get an Omron, let's say or one of the reputable brands Omon is a pretty good brand M2, I think it's 35 pounds online. So get an upper blood pressure cuff and ensure that your blood pressure is not higher than let's say 135 over 85. If it's closer to the 100 or 110 over 60 to 80 Mark, then you're in the low normal range, the normal being 120 over 80. Right, the higher range being 135 over 85. And anything below 100 over 70 is considered low. 

So if you're low or low normal, and you feel the symptoms whenever you stand up, then feel free to go crazy with salt - succumb to your salt craving, which means whenever you feel like salt, take it, and I would favor a complex salt like a sea salt or a ground Himalayan pink. And you just grind it in your breakfast, your lunch, your dinner. And having more salt actually will expand your plasma volume and improve increase your blood pressure. So salt and fluid are key. 

And then compression stockings could be very helpful - when I say compression is not below knee, it will be something that comes to your waist and you only wear it in the daytime, not at night. And when you wear compression in the daytime, you are actually having external force compressing the lower limb vessels which are the biggest reservoirs of blood and you're fighting gravity to certain extent. Do internal compression too - So learn to squeeze your butt, learn to squeeze your calves and your quads. And the way you squeeze your calves is to just lift your toes - try it now - towards the ceiling. And when you do that you feel the back of your calves, it gets hard. So do that kind of motion. And if you want, cross your legs and start to fidget, like move one leg on top of the other in a fidgeting way whilst moving your your toes to the ceiling. And here you're activating a second pump to keep the blood from pooling. 

So most people who are with long COVID are starting to get back into work will be in this environment where we're sitting, watching each other on the screen on a zoom call, working from home. And a very helpful tip is to have a stool underneath your desk so that you're constantly shifting your leg positions and you're moving your legs so you're having active leg movements rather than sitting there with a man spread where blood is just pulling down as the day goes by, as the hour goes by and making you feel more and more dizzy. So you understand this kind of active process that you can do by just making subtle changes in your posture sitting up right now and again. And of course every hour doing a one to two minute breath stress reset test that we can do. So that is good. And I write about this breath stress reset in my book as a as a top tip as well. So that's very helpful. 

And then keeping cool. Understanding that when you keep cool, you are going to feel better. And the top tip here is if you struggle with a warm shower or a warm bath that you enjoy, most people still enjoy warm showers and warm baths. I will say do a Wim Hof, which means, you know Wim, you've heard about him, that means give yourself a ice cold finish. Maybe not ice cold, that's too jarring. Maybe a lukewarm or a cool finish. And that cool finish vasoconstricts, wakes you up a little bit. And when you're toweling down after the shower or the bath, you tend not to feel so dizzy with the palpitations afterwards, because that's often a tricky scenario for patients who get out of a warm bath. And then the symptoms hit really hard. So get out of the bath and shower down with cold water. It's a bit difficult and painful, but do it and your autonomic nervous system will respond in that positive way to allow you to then come out of the shower a bit more safely.

Jackie Baxter  56:11  
Is that why wild swimming helps as well? I mean, I've been doing a lot of that recently.

Boon Lim  56:15  
Exactly. So swimming is one of the best ways to improve your effort tolerance when you're suffering with long COVID. Because A, you're not fighting gravity, you're horizontal by and large. B, if you do wild swimming, you might enjoy the coal and the freshness, rather than a really warm, humid swimming pool and C, you might even wear compression. So if you wear a wetsuit, it's compression. And D, when you're underwater, it gives you free compression. Because the water itself exerts a squeezing motion on your on your skin and on your organs. That's why you always feel like peeing a lot after you've been in a pool for a short time. And that compression generates blood flow, enhanced blood flow and blood pressure in your core organs, which includes your kidneys. That's why you pee a lot more. Yes, makes sense. Right? 

Jackie Baxter  57:04  
Yeah. 

Boon Lim  57:05  
And so make sure you're hydrated. So by the edge of the pool, make sure you have cold water. Ideally cold. If you're swimming in an indoor pool, make sure you drink lots. And when you get out of the pool, that's the risky time as you come out from that compressive nice situation. That's when you might feel the changing autonomic state. So just be mindful, drink cold water by the pool, get out and try and have a cool shower. If you can control the temperature, in some you can't, in which case you just dry yourself down sit on the edge of the pool for a while before you get out and start to do compression in the legs that you can do while sitting on the edge of the pool. Right, you can start to squeeze those lower limbs. 

And then something complex to talk about Jackie, which will be a bit difficult to explain. But I'll try. When you lay down in bed at night try and elevate the head of the bed by about 10 to 15 degrees. And in short form over a period of weeks or months that might expand your plasma volume. Because what happens when you lie flat is quite interesting when you lie flat. You're redistributing the blood from your lower limbs when you're upright back into the heart and the core circulation. And remember that analogy that I said when you're in the pool with a wetsuit, you need to pee a lot. Guess what, when you're lying flat, and your blood pressure is a bit higher, and your blood volume in the core organs, ie your heart, your brain and your kidneys are higher. Guess what? You produce more urine, right. And so when you're lying flat, you tend to make more urine than when you're upright. 

And if you kind of elevate your bed head slightly by putting bricks under your bed, if it's possible, or sleeping on a wedge or have a bit more pillows, what you're doing is you're not allowing that blood pressure to go too high at night, you keeping yourself from producing and wasting too much urine. And when the blood pressure is low, something interesting happens in your adrenal glands. They've produced more endogenous mineralocorticoid. Now what the heck does that mean? That means they produce a hormone that aims to reabsorb salt. So over a chronic period, it's your natural fludrocortisone - fludrocortisone is a drug that we commonly prescribe for patients with low blood pressures. And you're producing more of that. So in the daytime, you you find yourself tolerating being upright more and more as your plasma volume expands. So that's an interesting idea. Most people find it a bit of a pain, especially if you're sleeping with a partner. But if you can do it, it can be very helpful as well. Because in long COVID, as I said, every little counts.

Jackie Baxter  59:48  
Yeah, definitely. That's really interesting, isn't it? So we've talked quite a lot about autonomic dysfunction. And what a lot of people are learning about, I suppose as a result of long COVID, is this condition of PoTS and what's the link between PoTS and autonomic dysfunction?

Boon Lim  1:00:09  
So PoTS is a term which means postural, which means changing posture, Orthostatic which means the same thing, changing posture. Tachycardia, which means high heart rate, Syndrome. And it is a form of autonomic dysfunction. And I'm just about to submit an article where we've looked more extensively at the number of patients coming for a tilt table test with long COVID. And not everyone has PoTS, maybe 25% of patients would fulfil the criteria for PoTS and another 25% fulfill the criteria for subthreshold PoTS. Some have vasovagal syncope, but nearly all of the patients will come with long COVID have got this phenomenally oscillatory pattern in the blood pressure and heart rate that signifies an adrenaline surge or autonomic activation or autonomic dysfunction. 

If you hit an extreme heart rate rise, ie more than 30 beats per minute, which sustains in the absence of a blood pressure fall, then you have a diagnosis of PoTS. It's a very technical diagnosis. And you might need to just listen to that one more time because I've said a lot in a short time. But the long and short of it is that, don't worry about what it's called. Whether you call it PoTS, subthreshold thoughts, autonomic dysfunction, adrenaline activation, fight or flight response, the treatment principles are going to be very similar. They're going to be all the things that we just talked about physically, all the things that we covered earlier on. Mentally, feeling, thoughts, the breath. 

And if needed, we augment your blood pressure if it's consistently low, and you can't get any more help and you're doing everything that we talked about, we sometimes give a drug called midodrine, which is a vasoconstrictor. And that can be very helpful to boost the blood pressure and get you out of this kind of low zone or this, you know this low point that you can't seem to get out of. And when you have more energy or more, you feeling more positive on the midodrine, you can then do all the other things and be more upright during the day. And that kind of sets in a virtuous cycle or circle of improvement. 

Sometimes we give fludrocortisone, which is a mineralocorticoid that allows your kidneys to reabsorb more salt, so it doesn't waste so much salt and so you expand the plasma volume or the blood volume. And that can also be helpful, although there is a slight downside because it is a weak steroid. And I wouldn't want any of my patients to be on fludrocortisone for a very long time, ie more than a year. And then for the specific symptoms of palpitations, we might give a drug to minimize the symptoms of palpitations and that could be something like propranolol or beta blocker, not suitable for everyone and I think not suitable for somebody with a low blood pressure. Or Ivabridine, which is a drug that acts on the sinus node, your natural pacemaker to reduce the rate of contractions. So that gives you a sense of feeling a lot settled from the palpitations in those patients whose dominant symptoms are palpitations. So there you go. In a nutshell, you've you've taken kind of the whole kind of conservative strategies, you've taken the kind of holistic strategies with breath and feeling. And also the drug strategies, which you know, we or I employ for long COVID in autonomic dysfunction.

Jackie Baxter  1:03:42  
That's amazing. And are you seeing improvements in the patients that are going through these treatments?

Boon Lim  1:03:48  
Definitely. And, you know, I want to give everyone hope that the treatments that are given all the - so the first treatment is, I guess, validation and setting your mind in the correct place that you don't have to go look elsewhere. You know, you know what you have to do. And that is a very powerful treatment. And I will say treatment, not diagnosis. Having validation is a treatment, because it somehow shifts something in your brain that really starts the healing process. And I think that's why some of the other less conventional treatment modalities such as Suzy's fantastic program, which is the 360 mind body soul rest recovery program, but you know, with ENO breathe with the English National Opera as well, that sense of community togetherness, the sense of understanding each other is also part of treatment right? So, that aspect is very difficult to quantify and actually very difficult for a medic to fully grasp or comprehend because how can it be that You know, this kind of stuff that occurs outside of medicine can be helpful? 

And yet it is - the ENO Breathe had just published an article in a reputable journal about the benefits of joining this program. That they saw a kind of group of patients who are getting better, Suzy Bolt has gone phenomenal anecdotes of patients who have got a lot better, and some of the patients that come back to my clinic having been on her program. So there are benefits, which come in multiple ways. And I think it's also incorrect to think that, you know, Dr. Boon Lim's autonomic dysfunction program is the only way you can heal, there are many, many ways to heal. And you know, coming back to the first point we made, even before we started this podcast, the mechanisms of long COVID are multiple. 

And you can understand why, because the inputs into the autonomic nervous system, which - it's a master controller is a master controller, even for immune regulation, right? It's the master controller for inflammation. And if you consider that there are so many inputs into that, then obviously, the treatment, there isn't a one size fit all - you need to, you know, go with what flows with you. And some patients have had remarkable treatments without any of the drugs or any of the practices, but just joining a community and feeling grounded and feeling supported. But I would say that is one aspect of this communities that they are generally led by a leader or a person who's so passionate about healing that they have themselves taken a approach of education and understanding themselves about the principles of treatment. And although we don't call it autonomic dysfunction treatment, the principles are very similar.

Jackie Baxter  1:06:49  
That's really interesting. You know, you've talked through a lot of strategies today. And all of these are things that people can do themselves. But, you know, for people that you know, you spoke about a few different drugs that people might need, just then. And certainly what I've heard a lot of people talking about, struggling to be believed by doctors and specialists, because a lot of GPs, either don't understand or don't acknowledge the existence of PoTS, or autonomic dysfunction. And is there like, is there a network of specialists or somewhere that people can go to get that little bit of extra help if they needed it?

Boon Lim  1:07:29  
Yeah, so certainly in the UK, there is a phenomenal resource, and a website, which are run by some people who are really lovely human beings. And they run PoTSuk.org . And they have recently revamped their website in the last six months, and it looks brilliant. So it's a resource that tells you about PoTS. And it's a resource that tells you about the specialists within various pockets within the UK, who you might be able to get your GP to refer to who may have an interest in PoTS. So that that's the kind of go to place. But you know, coming back to your point, I want every listener to apply that forgiveness - is that the first point that we had right at the beginning of this talk, because of all the emotions we experience, it is even more powerful than gratitude and compassion. I think forgiveness is, I would say the most important emotion that one can feel for a break through. 

You know, it's true of all of us, all of us will have things generally to not forgive in ourselves. And forgiving yourself is one of the most important things, I mean, truly forgiving, truly forgiving, to kind of move away and step away from that constant stress into the autonomic nervous system. So forgive your doctors who might have dismissed you, because it's not done from a position of, you know, any harm in intentions. It's a position of maybe insecurity and ignorance, right? And, you know, the day to day life just needs to crack on, they only have 10 minutes or 15 minutes in your clinic. And I'm guilty of this too. But we're all human. You're human. So are we. And we also make mistakes. And we also need to learn from our patients.

Jackie Baxter  1:09:26  
Yeah, that's a really good point. Yes. Yeah, we are all human.

Boon Lim  1:09:30  
This is one one other thing. My top tip here is really bring the locus of control of your health and well being into yourself, into your heart. And let's not think any more that this magical Wonderful Wizard of Oz will heal you. When you finally get to that ivory tower at Imperial College to see Dr. Boon Lim. Let's say if that's the path you want to take. You're not going to have a magical healing at the snap of fingers. The healing will be from yourself, and why don't you look at yourself in the mirror now? And if you want to heal, snap your fingers and make it happen from within. And if you bring that locus of control to within your self and your heart and know that life will get better and express gratitude for that, I think, I think that would be a great start to your healing process.

Jackie Baxter  1:10:23  
Amazing. Thank you so much for joining me today. It's been a whirlwind tour, I think. But there's been so much stuff in there that's been fascinating, but also really, really useful. So thank you so much for giving up your valuable time to speak with me.

Boon Lim  1:10:39  
Thank you. You're very welcome. All the best to you and your listeners. Jackie, what a pleasure. Thank you.

Jackie Baxter  1:10:44  
Thank you.

Transcribed by https://otter.ai