Saturday, November 21, 2009

Letter to a prospective Son in Law....[ On Ranjan Das ]


You asked me why Ranjan Das, that young 42 year old, top and much talkabout Indian MNC CEO, died of a massive heart attack, after a robust workout in the gym. He was a keen marathoner.Everyone on the web has been asking whether this is related to lack of sleep!!??

First an foremost he is Indian. When I was a cardiology research registrar some 25 years back at St Bartholomews Hospital, London, my bosses there were surprised that the median age of our patients from the Indian sub-continent[ immigrants, legal and illegal ] were in their early 40 and late thirties, while the local 'whites' presented in the late 50's.This early experience 'coloured' my practice even now. If an Indian man come to see me in my clinic nowadays complaining of 'atypical' chest pain, I would not send him home , until minimum he had shown he had a normal'stress ECG'. That is standard operating procedure in my sub-concious.As early as in the mid seventies, we MU students were always hammered by Prof TJ Danaraj that "coronary disease is not an elite disease.It is highest in the poor Indian rubber tapper".That may sound racial but it is a fact. That time we have not yet coined the term 'Insulin resistance' and 'metabolic syndrome'.

It is an Indian disease .At least in Malaysia,next come the Malays and only lastly ,Chinese.

To put things in proper perspective, many more seemingly fit people die from a 'coronary' at even younger age. Just 2 weeks ago a young estate agent, aged 32 was admitted to our medical facilty in the wee hours of the morning with a massive heart attack. I pushed him straight from ER to our 'cath lab' and carried out primary infarct angioplasty and coronary stenting.He had complete occlusion of his left main stem artery.How he managed to reach our hospital intact was beyond me.Left main stem occlusion normally does mean instant death, on the spot.He had cardiac arrest while I was talking to him in ER, arrested agian on the table while I was opening his arteries. Arrested several times in the CCU. Difficult case plus plus plus.He anyway died 4 days later despite heroic post procedure measures with aided ventilation and intra-aortic balloon pump counter pulsation [ IABP ]inserted to help his beating heart, due to what 'we' euphemistically called " pump failure". There is no more adequate 'living' heart muscles to adequately pump the blood around the young body.

My youngest 'coronary' patients was however years ago when I was a lecturer in HUKM. He was a 22 year Chinese motor mechanic. Not CEO of course.

I used to jokingly tell all my male coronary patients, to the consternation of their wives ,if they were around, that "Life for man, at least ,really starts at 50.The clock though starts ticking at 40"...The wife stopped getting angry with me after the added proviso....If I go into the actual ramifications and the meaning of this seemingly pseudo-profound statement of mine, I run the actual risk of being called an Ustaz by the end of the consultation....But really life is like that.From my vantage point, I can say that life is actually more fragile than one actually think.

One can have a burst artery in the brain,block a left main in the heart,had a fatal heart rhtym out of the blue, or a beam can fall on one's head from nowhere!....and you just die.Only when this happened to happen to a VIP,only then everyone and sundry start asking ..."Eh how come he could die soo young !?".

But before we go off thinking living is dangerous, let us stop for a moment and take a deep breath and sigh: People just do not die because of too much work or to much lack of sleep,too much study, or too much thinking.....Let us return to our Prophet's sirah..

Our Prophet on most nights woke in the last third of the night and 'berzikir' and 'tahujjud', oftentimes till both feet get oedematous and swollen due to prolonged standing, reading Al-Baqarah, An Nisa, Ali Imran and several other surah at one go, during the rakaat.During the day he went to the market place trying to earn a decent living ,earning a morsel here and a morsel there. He was the kaiser of Arabia but lived like a pauper! He lived up to the ripe old age of 63, fighting against kufr, right up to his death, was judge,permanent imam for Masjid Nabawi and never relegating any prayer to an assistant right up to his last days..... Prime Minister ,Head of State,Field Marshal,father and perfect husband to nine happy and fullfilled women, all in one! The average life expectancy around that time must have been in the late 30's or probably early 40's, due to ravages of infections, lack of sanitation ,poor nutrition, no vaccination, no antibiotics, no hospitals, etc etc and etc.

When our Prophet died he did not have a coronary or a brain stem stroke. From the detailed description of his sirah, the description of the feverish torment that he went through, I think our Prophet had a fatal bout of typhoid fever.

He lived a life of active piety,low caloric intake ,full of thought and dzikir all the time, an excellent example for his people of that era and for generations to come till Doomsday.His worldly needs were simple. He lead the obligatory prayers all the time except on the day when he was dying when Abu Bakar took over. He just celebrated life to the fullest the only way he was taught to do by the One and Only:Only to worship Allah and follow His precepts and be an example par excellence to Man of that generations and all future generations. He was and is the Perfect Man..

Needless to say, his stress level from the 'kuffars' of Mekkah, the 'Munafikuns' of Medina,and the Jews surrounding Medina must be tremendous, but those lonely night virgils, those 'zikir' and those 'tahajjuds' must have been an effective de-stressors for him. But of course as a leader par excellence he did not need to worry about to which crony he should siphon the massive 'wang ehsan Petronas',which 'durian contractors and pickers' he should select to look after this and that dusuns' all over the place[ the super big dusuns are called 'GLC's ], no Scorpene, MISC nor Altantunya. Neither did he has to worry which public 'accountants to promote' to look after the national treasury. Preferably those with exceptional 'creative accounting' talent, who has the magic to turn a couple of billion RM loss this year to a couple of billion profit the next!....and which 'young' punk to look after national investments, and which 'holes' in PKFTZ to close and which 'holes' to just leave open. No false KPI's either to consider.

Of durian pickers and dusuns, there are small pickers and small dusuns, medium and large sized dusuns with many pickers and durian contractors. Some are just for tax diversions,some for national and 'by-erection' purposes, some for show and some just for the Puan Sris and Datin Sris. Complex and complicated,our Malaysian political, cultural and economic millieu nowadays, certainly not available during Prophet's time, thank God!.... Without all these worries to 'kacau into' the prophetic duties and responsibilities, certainly probably did help in not increasing the stress load...Life since then has become more complex and muddled.

What a digression this 'Ustaz'. A bad habit. Back to Ranjan Das,that, young upstart from India: Why did he die so young? If it is not due to sleep deprivation ,than what is it?

We know that a person at his age can have plaques in the heart's arteries ,coronary arteries, which are really slight indentations on the arterial surface, may be mild , due to chplesterol and lipid accumulation under the surface.During period of stress, these 'weak points along the surface of the artery can at times, rupture and result in a small'bleb' impeding the natural flow of blood in the heart circulation. From there cause escalation of the coagulative process in the artery at the site of rupture causing a blood clot to develop and cause disruption of blood flow.Dont ask me why it can happen: this is G.O.K., an act of God." Lo! and thou wilt die.And lo! they wilt die."[ Az Zumar, 39:30 ]."And Lo! Unto our Lord we are returning." [ Al Zuhruf, 43:14 ]

A total disruption and blockade result in a heart attack.Dependent on where this blockade is ie whether it block a major vessel or a minor one or a branch,you either live thru the attack or you die.Statistically out of a hundred heart attack,30 die before reaching the hospitals. out of 70 who reach the hospital, 5 dont make it.

Stress, stress ,stress stress and stress can induce plaque rupture. The good news is middle of the night tahajjud, zikir, contemplation,leading a 'clean life' and definitely also this lack of interest in "other people's 'money and worldly possesions" can lead to less stress.

I keep reminding my patients, "The clock start ticking when you reach 40.Life really starts after 50". But obviously our national leaders do not think so. That is why you can see these days so many young punks who are still wet in between the ears, running our 'dusuns',super-big, big and small, and what have you.Knowledge is cheap.Experience burns your age. Wisdom, that is elusive.

Perhaps my next blog should be: " Of durian pickers and durian contractors"... Some other time.

Have a nice weekend in Bintulu! Dont ask about how they are going to spend your 'dusun' income.[" Yours are not to ask why,yours are just to do and die": The Charge of the Light Brigade, Lord Tennyson"] You young man, just do your work in the 'dusun' diligently and carefully.No 'outage' or whatever....that is 25% of our GNP daily.Even when you have the opportunity to get up the ladder in future and hand-picked to be a small'dusun durian contractor' don't ever get into the temptation of keeping some of those 'durians' and bring home the leftovers.Let your "boss" or his Datin Sri decide what they want to do with all the durians. That is their own funeral.They are answerable to their Gods, you,yours. Better still be more creative. Get out of this 'dusun' thing, and do something on your own.

Not good for your long term 'health', even being a good 'dusun contractor', I mean. You just ask your 'big boss', Hassan, in 6 months time, I am sure he will attest to that.

Take care!

Dr Nik Howk

"And We created not the heavens and the earth, and all that is between them, in play.
We created them not save with truth; but most of them know not."
[ Ad Dukhan, 44:38-39 ]


RahmatHarounHashim said...

Dear Dr Nik,

Hi, how're you?
Allow me to comment on Rajan Das, CEO,a keen marathon runner and had masive infarction during work-out.
Last time, I had asked you about contineous exercise versus interval excercise. Those marathon runners and aerobic addicts seem to die of vascular pathology especially ACA (Acte Coronary Attack). Sometimes, even during the tournement itself.
I now, advocate interval exercise to my patients. For every 2-minunte strenous exercise, follewed by one minute rest. The idea is to mimic heart attack or vascular event.
How far the concept is true, I won't know. But that's what some American Cardilogist are advocating. I tend to agree with them. No session should exceed 20 minutes. How nice!
BTW, have you got your Tauliah from JAIS? Better get one. Dr ASri with PhD pun tak diberi tauliah automatik?

Pearls & Gem said...

Interval training?
I even have problem getting my patients to exercise.For marathon runners, yes certainly ,more to increase endurance and exercise capacity.Those who want to be amongst the front runners, definitely they need to incorporate interval training and fartlek ie speed play, as their routine.Even then they should not over do this because in interval training you are driving yourself to almost maximal heart capacity, that is when you have musculoskeletal injuries.Not to mention cardiovascular ,rthym problem if you happen to have a latent undiagnosed ischaemic heart problem.I would certainly not advise the average Joe to do interval, the real interval I mean. What you are alluding to is fartlek,speed play, which is less intense and submaximal effort ffor a brief spell

In the average Ali, Ah Chong and Muniandy,just exercise 1/2 hour , minimum 3 times a week is already great. Forget about the Scientufic American finding.That is for the ambitious athletes in competition.

As for the Dr Asri/ Jakim affair there is more than meets the eye.Asri,being a young upstart , is certainly not 100% innocent. he ia playing to the gallery, not caring about real ilmu anymore,collecting all the kuching kurap along the way[SIS, Liberal Islam or whatever as long as there are a crowd behind him], on the other side of the divide we have Othman El Muhammady,who is telling us and cajoling us in fact for weeks on end in the print media, almost,nearly almost that Wahabi is out of Islam.Common, we are all not stupid...

Talkin,tahlil,tawassul... these are all 'ranting' issues. When are these ulama' collectively going to have more grey mater and address the bigger issues of ilmu,scientific progress,real Islamic banking and finance[ the current CIMB one is 99 % halal,1 % alcohol,if that is OK with you!]etc and etc that are confouding the ummah for generations!

Kita ni dah lah lemah, nak berpecah pecah pula on so many fault lines. Cukup saja lah dunia islam ini di bahagi bahagikan kepada Syiah dan Sunni, jangan pula kita nak berpecah kepada Sunnah wal Jaamah vs Wahabi dan etc etc etc.

When are these blokes going to have brains and wisdom?

Oops Doc Rahmat , I tak ada lesen...But I dont give syarahan in masjid or even in private... just blogging only. Jakim belum canggih enough to think about having to apply for a blogging license....yet.

Pearls & Gem said...

"And they say: There is naught but our life of the world; we die and we live, and naught destroyeth us save time; when they have no knowledge whatsoever of (all) that; they do but guess."
[ Al Jathiya, 45:23 ]

Kia said...
This comment has been removed by a blog administrator.
Pearls & Gem said...

Sorry Kia,you are trying to sell your 'product' here on my blog. I have no tolerance for that here.

pammi said...


In today’s modern world, changing lifestyles are leading to increase in the number of diseases related to the heart. With that, many techniques of surgery for the heart have come up. Of all the available options for surgery, Angioplasty has proved to be one of the safest ways.

Angioplasty was first used in the late 70’s. It involves the widening of an obstructed blood artery, which has happened because of atherosclerosis, by mechanical means. A balloon catheter, which is an empty one and is collapsed, is taken and it is passed through the location where the surgery is to be done. Then the catheter is inflated by pressure which is around 200 times compared to that of the blood pressure.

The inflated balloon has sufficient pressure in it to crush most of the fatty deposits on the sides of the artery walls. Thus, the artery opens up properly and the flow becomes proper and the obstruction is now minimal. After this is done, the catheter is collapsed and made empty and is finally withdrawn.

Angioplasty is of several types based on the location of the arteries which have been blocked. Some of these are Renal, Cerebral, Coronary, etc.

Once Angioplasty is done, the patient is kept under observation for a day or two. The blood pressure is monitored continuously along with the heart beat rate. Proper medications are given if necessary.

Since the time from which it has been put to use, Angioplasty has helped lot of patients and has saved their life. The best outcome of it is the prevention of heart attacks and bypass surgeries.

Pearls and Gem said...


If you go to my site at:
[ procedures in medicine ]

one can visualise how it is elegantly done. The technique was 1st perceived by a Swiss radiologist Andreas Gruntzig in 1978.

I would not go so far as saying that angioplasty and stenting would reduce the incidence of mortality with respect to coronary artery disease. It has certainly made it's treatment simpler and more elegant.

Reduction of mortality, incidence etc etc still remain in the domain of primary prevention which is consisted of healthy living, keeping to ideal body weight, no smoking, reasonable diet throughout life and a holistic way of living one's life balancing stress, exercise and leisure.

Secondary prevention[ ie in people who are already diagnosed to have CAD ] consist of optimisation of diabetic control,BP control, weight control, bringing fats and lipids down to 'the floor' is paramount and I am very agressive with respect to lipids and blood sugar etc and etc.

That in a gist is the total over view picture as to how I look at it.