Case History

I am 'insomnic' tonight. How to sleep!? Just back from my 'energy sapping.' Ramadan umrah' and now on call. From 12 midnight till now 230 Am, I have had 3 nonsense calls from the hospital. Dr Syed at ER is not giving me any reprieve. He is currently at it with a vengeance !

Something crossed my mind, CASE HISTORIES.

A year ago,
AHW, 22 year old young Malay man. Could have called him 'boy'.[ My 2nd son is younger and much much heavier thanks to his mum who think she has to remain champion cook in Subang Jaya ]. Trainee bank officer, just slightly overweight for his height of 170 cm, ie 78 kg. Central chest pain and heart burn whole day . Seen and scoped by gastroenterological specialist colleague, no obvious redness or ulcer in stomach. About to be discharged with some antacid and proton pump inhibitor, Controlloc. His GP father, who was my student during his med-school student days, obviously not quite happy, requested me to see as a second opinion prior to discharge.....

Coronary angiogram later that same evening showed a myocardial infarct, fortunately involving a non major artery, that was why the presentation was non classical !
Culprit : smoking and trainee bank executive ,with stress plus plus and uncertainties. Young trainees nowadays made to work for several years on probation on pittance [ someone has to look at the banking industry, especially the goings on in Ex Bank Bumiputra's CIMB,...with bumiputra Nazir and Charoen at the top, the rest at the bottom and middle, I dunno ! I am being very cheeky here. ]...??. Cholesterol neither too high nor normal, nothing spectacular.

Just now at 7 pm : Seen at ER, KRS...
27 year old Malay gentleman, ex body builder. 2 years on cyclical oral anabolics with two weekly intramuscular injection of stanazolol [ 'Doc, 100 %of body builders on anabolics '!, he said as a matter of fact ...]. A maddening 30-egg, 2 whole chicken daily suprahigh protein diet. Came to ER with heart burn and chest pain that radiated to neck. Resting ECG looked suspicious but not aggressively abnormal. KRS is 85 kg with a body like Arnold Apakahnamadiadah Susahsangatnakeja. Even I could send him home on anti gastric medication had not the TropT blood test showing some positivity [ We heart doctors and ER doctors sometime live on our wits and could get to be in our under-wears if we get sued often enough. Patients do not come with the diagnosis emblazoned on their foreheads !. Oftentimes just a sixth sense that something is amiss, do help us... most time if we are unsure, admit for observation when things begin to unfold to give a fuller picture ! ].

Told mum upfront,the current observable cold statistics : procedure mortality risk 2 % with primary infarct PTCA/stentin. Conventional chemical thrombolysis treatment, if just involve proximal anterior descending artery, chances of opening blockade, 70 %, mortality risk 30 %. If Left Main Stem involved or near Left Main Stem, whatever we do conservatively, mortality risk 90 %. Our hands more or less are tied towards PTCA/stenting whatever the risk. Time of intervention is of the essence. Must conclude I have never met a most decisive mum this side of the Southern Hemisphere.
She did not bet an eyelid.Made our side of the 'business' easy.

" Please proceed Doc, He is only 27. He is getting married to his fiance next week "

Pushed straight to the cath lab from ER for primary infarct angioplasty and stenting[ Angioplasty, 30 years old technique now, or PTCA as anacronym, is European, Swiss in origin by Andreas Grunzieg 1980's; stenting, an extension of PTCA, is an American innovation] :
a 90 % blockade at the ostium of Left anterior descending artery [ Federal Highway numero uno ], barely 0.5 mm away from 'The Widow Maker's Junction' [ Left Main Stem artery...my God ! ]. Immediately crossed lesion gingerly [ Malaysian, with a wee bit of prayer, just the ubiquitous and truncated, 'bismillah' without the Hirrahmanirrahim ]with BMW 0.014inch guidewire [ German or British ], clot aspirated with an Export Catheter [ American ], advanced in a 'monorailed' fashion[ a technique initially popularised by the Japanese and the French ] advance via guidewire guidance. Thereafter, culprit lesion dilated with Terumo/Ryujin balloon [ Japanese] at 10 atmospheres. Removed terumo/Rugin ballon and advance a 3.5 millimetre diameter,15 mm length, Xience Stent [ American ], over the BMW Guidewire, and duly implanted at site of narrowing deployed at pressures of 19 and 21 atmospheres respectively. Another tense moment and another series of 'Bismillah'. A burst artery at this juncture could spell doom. 'Bloody' Stent moved a wee bit forward on implantation as very close proximity to 'Widow Maker's junction make very precise positioning crucial but the 'damn heart' of course cannot stop moving and shoving. BP/Pulse hemodynamics stable, patient concious, cooperating and importantly well sedated and quiet, not in distress. A series of 'Alhamdullillah' here is in order.

Doctor's heart dropped to the floor and his BP transiently skyrocketed to the roof following a sudden purge of internal adrenaline......followed by a small cursory four letter 'curse' and another "bismillah". Have to implant another stent, slightly shorter proximally, juxtaposing and kissing the 1st stent, as the 1st one did not cover the culprit lesion wholly due to the slight shift due to heart's continuous movement. Done."Alhamdullillah". Everything in place and OK and patient seem quiet and happy and hemodynamics stable. End of procedure.

Called anxious mum and family in and discussed the cine loop on video. Patient on the table ready for transfer to CCU. Mother and son had a small chat and both seemed relieved. Fantastic feeling.

Patient alive and well at CCU in half an hour asking when he could start his body building programme again ???? My God these young people nowadays, they are in a hurry !

Reminded me of my distant cousin, aggressive businessman, whom I managed some 20 years back, Mr FY, must be around 45 then, who had had a massive infart and left with a left ventricle hardly pumping [ LV ejection fraction of 15 % ], who asked on his 3rd hospital day:
" Doc Nik Howk, when can I start my badminton again ".
He died in his house a month later of cardiac arrest. Tired heart.

Now Dr Syed of ER is calling me again, this time no false alarm : He is admitting a 26 year old Malay gentleman, with a heart as big as a football , bp 170/90, in pulmonary oedema [ euphemism for heart failure or 'water in the lungs' ]. This gentleman has IDIOPATHIC DILATED CARDIOMYOPATHY and on follow up with my junior colleugue Dr Nizar, but absconded on his medications for a week. Nizar still 'skiing' his hard earned 'ringgits' with family somewhere in Europe. Nice and lovely to be still young and hopeful !. And Hari Raya and Ramadan can sometimes make us do stupid things [ our patients , I mean...like missing on the meds ]!

Idiopathic dilated cardiomyopathy, reminded me of my St Mary's Hospital,Praed Street Jewish mentor some 30 years back, the late Dr Peter Kidner, cardiologist par excellence :' We doctors are IDIOts because we do not know the actual cause of this problem, and our patients generally PAtheTHIC, because our line of management could only at best be conjectural and 'cookery'... ' ]

From my vantage position,I must accept now that, at best, LIFE IS PRETTY FRAGILE !....and very unpredictable too.
Always tell my friends and patients that, for some special men, CEO's and those 'gladiatorial', type A sorts especially, to the chagrin of their missus if they are around during the discussion, that LIFE REALLY STARTS AT FIFTY FOR MEN. But the damn clock starts ticking well before their proverbial forty.

Go figure out how you want to live your life with these two incongruous variables.
If I ponder and discuss over it too long you would not call me a 'Doc' anymore. An 'Ustaz' prefix would seem appropriate.

I must be going now............that young man with water in his lungs is waiting in the cardiac ward. Our CCU is 'chockerblock full' to the brim !

That young body builder, I was told by the CCU nurse in charge, is still dreaming good dreams in cloud nine. He is going to be married in a week's time. Insyaalah he should be fully recovered by then.

Mashaallah, this is my life.......
It is cases like these that keep me coming back and glued to my job.
A vocation that continually remind me on a daily basis the 'fragility and transient nature of this life'.

Hublum minallah....Love of Allah.
Hublum minan Nas.....this is is the difficult part for most of us mere mortals.
We easily get clouded by greed, nepotism, crass materialism, ignorance and intellectual impotence.

Rivalry in worldly increase distracteth you Until ye come to the graves. Nay, but ye will come to know! Nay, but ye will come to know! Nay, would that ye knew (now) with a sure knowledge!
For ye will behold hell-fire.
Aye, ye will behold it with sure vision.
Then, on that day, ye will be asked concerning pleasure.

al takathur, 102 : 1-8




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