Sunday, September 11, 2011

Case History 2.......

When I was research registrar at St Bartholomew's Hospital, London, some 3 decades ago, come Fridays we registrars on call for the weekend always cannot help feeling 'abandoned' and that familiar deja vu feeling of melancholia invariably seeped in. Why not ! We could feel the rest of the hospital medical staff, juniors and seniors already in 'weekend' mode. By 2 pm, 50 % already disappeared to some pubs [ some lucky blokes with eager-to-please young student nurses in tow ] somewhere near Smithfield Meat Market [ the biggest meat market in Europe during those old empire days ] around the vicinity of Little Britain and EC1A area.

Weekend calls those days were pretty long and 'lonely' affair, at least for me : Friday, Saturday, Sunday and you see your bosses only on Monday morning. Of course they are contactable but the unwritten rule is, if you are 'worth your salt', you don't call them.[ 'God' is there all the time, but you don't call him on Sunday ! ] You are the substantive registrar and 'consultant' and you hold the fort! I find being the boss and 'coolie' at the same time in a substantive Central London teaching hospital, at my level of incompetence at that time, for an extended period of 3 days, very daunting and stressful experience plus plus. Till Monday you are the boss lording over an active cardiac unit with your senior house officer, unless of course someone almost at the same level of the Queen of England get admitted in Bart's. Only then would you have the reason to call 'god'. [British medical consultants those days have a class and style of their own.]

In egalitarian London of the 80's, that would be rare. The Queen's hospital was St Georges anyway, and I think still is at the present time though Prince William was delivered at St Mary's, another hospital of mine before I moved to the more fashionable and more reputable St Barts.

St Bart's, though in the City and surrounded by lawyers offices, barristers and Queen's counsels and brokers, was still working class, a wee bit stiff in the upper lips, but not yet quite enough!

I would come on Friday morning, with some 'gloom' already working up in my head, with a big loaf of bread and a turperware full of my favourite dish,' beef or mutton kuzi' cooked by my dear wife, to cheer me up, nicely stored in the junior staff quarter's refrigerator. The frozen 'kuzi' would be cut a block at a time and defrosted for breakfast , lunch and dinner for the next 3 days. By Monday morning , just mention 'kuzi' and I would want to vomit. They did serve steak and fish and chip at the cafeteria but despite reading HAMKA and all [ HAMKA is quite liberal in these situations ], I find these 'junks' could not get beyond my glottis!

St Bart's is one of the oldest hospital in London , if not the oldest. History has it that in the old days, when the internist physicians could not treat their cases of carbuncles, tumours and growths, they 'refer' these rather troublesome and embarassing cases to the excellent butchers across the street. These 'gentlemen' by virtue of their 'working class standard' usually creeped into the hospital and 'operate' by night. In the grand round the next day, the internist physician would lord over their patient and claim the glory of success. That, I was told by a senior, was the beginning of surgery as a speciality. No wonder the British still calls them 'Mister' and not the usual honorific 'Dr'.

Even now, years as a 'big time' consultant I still take weekend calls as a pain in the neck....2 days [ Saturday and Sunday ]you find yourselves unable to go anywhere or plan anything. I am on for this week.
Just as I was about to go home for lunch this 52 year old gentleman, a Malay chap. supervisor at a factory somewhere in PJ owned by a multinational company [ on a scale of things, MNC and Japanese companies treat even their non executive staff well, not like most Chinaman companies ! GLC quite OK, TNB and Bank Negara are best. Petronas, I dont know why, is slipping quite significantly on their staff care !!!! RM factor ? ].,was admitted with central chest pain and breathlessness of sudden onset. Risk factors :Diabetic and hypertensive over 4 years, with poor control and surveillance and a smoker. Diagnosis : Hyperacute phase of an inferior myocardial

Standard operating procedure : Admit for primary myocardial infarct angioplasty.
Angiogram showed severe triple vessel disease with culprit right coronary artery totally occluded. Passed guidewire across occlusion, aspirate clot plus plus. Lost wire access in the process and unable to rewire across lesion due to probable change in the plaque configuration.

No improvement to wire access even after a bolus shot of RHEOPRO [ 5 ml of this precious fluid cost more than gold ! ]. Last ditch effort since a life at stake, add 5000 units of METALYSE [ more expensive than rheopro ]given intracoronary, wire still not crossable. Patient's haemodynamics stable ! Mashaallah ! Alhamdullillah !
10 minutes post intracoronary infusion, another cine taken. RCA still totally occluded. Call it a day since patient still stable and procedure already 1.5 hours.
Patient had VT/VF [ cardiac arrest on the table ] prior to transfer to CCU. Duly defibrillated successfully. Alhamdullillah ! That is a good sign of delayed recanalazation by chemical fibrinolyis [ rheopro and metalyse ]. Totally dead muscles usually are quiet. Semi dead muscle due to microcappilary re-canalization ' fibrillate' and thus has reperfusion arrthmias such as VT/VF needing even defibrillation [ electric shock]. My Cath lab staff went blue. 'Dont worry,Good sign. You guys will see him Monday, God willing !', I told them .

Today, Sunday, patient in CCU stable and well.
For check angiogram tomorrow expecting to see some reopening of the occluded RCA. Check Angiogram this time to prepare patient for possible bypass surgery in 2 months time. If RCA reopens somewhat he goes for CABG. If not, we will have to optimise his medical therapy. We seldom refer patients for CABG these days unless they need at least 3 vessels to be bypassed.


Just now 5 pm get called by Dr Shu, neurologist on-call to see a young Indian girl, 32 years old, with Idiopathic Thrombocytopenic Purpura [ ITP , ie severe dysfuction and reduction of platelet due to unknown cause ], moribund, in coma and fully ventilated in ICU. Her BP is on the bfloor at 50 / ??, had a run of VT. She had earlier being on state of the art therapy under hematological consultant who successfully upped her platelet to al most normal count. Today brought in with severe headache and shortly after admission had massive intracerebral bleed needing to be ventilated in ICU and in deep coma .Urgent referral plus plus.

Over phone order:
IV bolus xylocard 100 mg given STAT.
IV infusion of dopamine and noradrenaline, BP normalised in 10 minutes to 120/ 70.
Earlier MRI brain showed huge, 6 cm diameter intracerebral bleed in the motor cortex and building bigger with time. Wth stable hemodynamics now we needed to bring in the primadonna, the surgeon. Neurosurgeon on call still busy operating . Got to call 2nd neurosurgeon.

2nd neurosurgeon in KGNS improving his golf shots.
He has to come in and decompress the brain right away, otherwise this nice looking young girl will not survive the night..........and given the bleeding tendency, she may not even survive the op. Hobson's choice but what choice do you have when faced with a young 31 year old dying due to a 'burst and leaking' pipe in the brain and a bleeding disorder problem ?

Reminded me of this poem we standard six school children of the past memorized by heart. Was it by Anonymous or was it by William Henry Davies, I have forgotten ? I think it must be Davies :

What is this life if, full of care,
We have no time to stand and stare.
No time to stand beneath the boughs
And stare as long as sheep or cows.
No time to see, when woods we pass,
Where squirrels hide their nuts in grass.
No time to see, in broad daylight,
Streams full of stars, like skies at night.
No time to turn at Beauty's glance,
And watch her feet, how they can dance.
No time to wait till her mouth can
Enrich that smile her eyes began.
A poor life this if, full of care,
We have no time to stand and stare.

post script : Monday morning, 7 am,

The young girl had emergency burrhole and decompression surgery done late last night.
This may not even be helpful for her as her bp plummeted down this early Monday morning to unrecordable despite being on full dose triple inotropes. I do not see any prospect of survival. Primary physician, the hematological consultant discuss and explain in lenght grave prognosis to close family.
....again an example of the transience and fragility of life.

The 52 year old diabetic factory supervisor survived the weekend very well. Check angiogram done at 2 pm today showed 'recanulated' right coronary artery. I resisted a natural urge to just dilate , balloon and stent this lesion in view of the fact that his left system is adequately diseased as well though not totally occluded.
He is for CABG [ bypass surgery ] 4 to 6 weeks time.

And that young body builder [ case history 1 ] got married this weekend.

وَقَالَ ٱرۡڪَبُواْ فِيہَا بِسۡمِ ٱللَّهِ مَجۡر۪ٮٰهَا وَمُرۡسَٮٰهَآ‌ۚ إِنَّ رَبِّى لَغَفُورٌ۬ رَّحِيمٌ۬ (٤١)
Bismillah himajreha wa mursaha inna Rabbi la Ghafur ru Rahim.
{Hud , 11 : 41 }
[ In the name of Allah be its course and its mooring. Lo! my Lord is Forgiving,
Merciful.]..Prophet Nuh alaihisalam on the eve of 'The Big Flood'.

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