Every time I stand up I fall over.

This is potentially a tricky one as it will blend medicine with an overall philosophical interpretation of what is wrong with some aspects of doctoring.

Where to begin?

I’ll start with the straightforward – a lesson in physiology.

I will not go into the details as they are long forgotten in a brain that was at medical school in the 90’s.

The essence, or the principle is –

Blood pressure keeps us alive.

Our beating heart sends blood flowing around our body, supplying oxygen, nutrients and other important things to our organs.

The two most important (if specialists will allow me to employ some anatomical one-upmanship) is that brain and the heart. Without either getting enough blood for more than a few minutes and you are dead. That’s it.

Not enough blood to the brain you end up with a stroke, your heart, a heart-attack.

The heart pumps the blood round the body by means of arteries.

Enough blood and enough pressure and all is well.

If the pressure drops, because you are bleeding profusely, that is a problem and also another blog, we’ll call that one shock.

If the pressure drops the most sensitive organ in the body is the brain.

Drop the pressure for a minute or less and you will feel light-headed, keep it dropped for long enough and you will pass-out, continue that low blood pressure and you will die.

All of this is interesting – what does it have to do with standing up?

Well, think of it this way.

If you have a pressure ‘x’ we measure it oldfashionedly using millimetres of mercury. There are two measures – systolic and diastolic – the big one and the smaller one.

120/70

120 = systolic, when the heart pumps

70 = diastolic, when the heart relaxes and fills with blood

The big number is when your heart is pumping or squeezing blood, that is systolic and the lower number is the time in between when your heart is resting and filling-up with the blood that has just been send round your body, this is the diastolic.

Some people have low or high blood pressures, it tends to be whatever your body gets used to that is important.

In the West, high blood pressure ‘hypertension’ tends to be the problem as this can lead to strokes and all sorts of other problems.

More and more, particularly with older people and increasingly as a result of ‘Long-Covid’ we are seeing that low blood pressure is a phenomenon of concern.

If your blood pressure is OK, there is enough pressure in the system to push the blood from your heart the 50 of so centimetres to your brain (depending on the length of your neck/overall size as well as some other factors).

If the blood pressure is too low, you have the problem I mentioned above.

Now, here is the tricky bit that relates to standing-up.

When you are lying in bed or sitting down, the blood requires less pressure as your brain is not as high-up, when you stand, the pressure needs to increase a little, otherwise you have the light-headedness (gravity also pulls blood down to your legs).

I won’t go into this in more detail as I want to get back to the bit that matters to me.

Suffice it to say, if every time you stand-up you go light-headed or dizzy, it is possible (there are other causes) that you have the condition called postural hypotension (or, ‘orthostatic intolerance’)

I have never been one for intolerance, I therefore prefer the former.

This is an incredibly common phenomenon, linked closely with some conditions such as diabetes and Parkinson’s disease although anyone can get it. It tends to be more common as you age.

It is a major cause of older people falling.

Older people falling is often a bad thing.

Falls in older people can be the difference between life or death, independence or a life in care, further falls and restrictions in mobility. Pain.

For a long time the national guidance has been to check blood pressure with a person lying then standing, especially after a fall and especially for people who are 65 years and older.

You see, this is such a common contributor to falls, if you don’ take this measurement, the diagnosis is often missed.

Recently, I have been delighted as what we refer to as ‘lying and standing blood pressure’ or, for short, L&S BP, has been entering the mainstream.

And here is the thing.

Here is my syndrome.

I haven’t given it an official name, although if you want to call it the ‘Kersh-effect’ I am sure my parents would have been proud.

Here is the example.

An 80 year old man, let’s call him Oliver.

Every time Oliver stands he feels odd, he describes this to his doctor as ‘dizzy’

His doctor tells Oliver he knows exactly what is wrong, ‘You have vertigo Oliver, I’ll send some medicine to the chemist.’

Oliver receives a drug called Betahistine (Serc) a few days later from his chemist (he is too dizzy to walk to the shops, he has to wait for a delivery).

Oliver takes the medicine.

A week later his doctor calls-up. ‘How are you doing Oliver? How is the dizziness?’

‘No better, just as bad.’

‘It will be the dose. Try 16mg three times a day.’

Another week.

‘No better, I feel just as bad, last week I fell twice. Whenever I get up things are awry.’

‘Darn that vertigo,’ Says Dr, ‘Let’s try something stronger.’

Stemetil, otherwise known as Prochlorperazine arrives from the chemist. Oliver is taking Stemetil and Betahistine three times a day

‘Well, how are things?’ Asks the doctor.

Not wishing to appear ungrateful, Oliver replies, ‘Maybe a little better.’

‘Fantastic. I’ll call you in four weeks. Keep taking the medicine, it must be working.’

Four weeks pass.

Oliver falls twice.

Once he is taken to A&E, he has broken his wrist. A Colle’s.

‘Sorry, to hear about your wrist,’ says the doctor, ‘I guess you aren’t much better?’

‘No, just as bad,’ says Oliver.

‘I think we should refer you to a specialist.’

The referral take 10 weeks.

By now Oliver is falling every couple of days. He is finding it more difficult to cope at home. He has noticed his movements slowing and a shake has appeared (we call this drug-induced Parkinsonism, a side-effect of the Stemetil.)

You’ve probably worked it out by now.

I meet Oliver before he has seen the ENT person (who wants to order an MRI in case he has the rare condition called ‘acoustic neuroma’).

I check Oliver’s L&S BP.

Yes. When he stands his blood pressure drops. This had never been checked. It’s the diagnostic heuristic (where a doctor latches-on to a diagnosis and doesn’t let go).

I stop his blood pressure medicines. I stop the Betahistine (that had been causing him indigestion)(I forgot to tell you, the GP had prescribed medicine for this as well), I stop the Stemetil, his shakes settle. He is still dizzy.

I start Midodrine, a blood-pressure raiser.

A week later he is recovered.

This is my syndrome.

Maybe syndrome isn’t the right word. Perhaps condition.

No matter. It is something I find every couple of months. I don’t think readers would believe how common this is.

For want of checking the blood pressure a whole array of mismanagement begins.

And, even if the disorder is suspected, there is a strange phenomenon where my number-one drug – Midodrine, is not used, instead doctors prescribe either support stockings (not sure if anyone has tried to wear these on a warm day) or another drug called Fludrocortisone, which in my experience doesn’t work very well. They may even throw-in a little Stemetil.

(Until a few years ago Midodrine was not licensed in the UK – it was only specialists (like me) who could prescribe; now it is in the formulary and available. I believe it is this hangover that has stopped widespread use) (It was commonly used around the world, just the UK were slow to adopt).

Anyway.

Apologies if this is over-technical.

It is something that has been bugging me for ages.

Now, suffice it to say. If you are a patient, consult your doctor before stopping or changing any medicines. This blog is me thinking out loud – it is not medical advice for you, for this, you need to speak to someone who understands your health, who knows your past and is privy to relevant investigations.

There is nothing to stop you buying a blood pressure machine and checking