Sunday, July 29, 2012

Case History : Young Deaths....

Remembered this conversation [ monologue from Ru's viewpoint, probably ] with my somewhat morbidly obese son while vacationing in Redang a year ago...
" Ru, In Maui, Hawaii you dont get to see coconuts like this. All the fruits, young or old, get pruned off early, for fear of litigation, in case it fall on the hotel guests. This Berjaya people are cavalier. You only need one coconut to fall down on one American tourist, then  there will be a multi illion ringgit suit, preferably in America and Berjaya will be out of business elsewhere in the world..... But Ru, Papa is not not worried about Berjaya  going out of business.....TS Vincent Tan is filthy rich, they can afford that sometime as a lesson...this coconut trees reminded papa that even young coconuts  also do fall and they do fall with as much regularity as the old ones !"
Even now, I was sure  Nadzru could not understand his dad's oblique  and dry sense of humour. Eating and lazing about are still his hobbies. His idea of exercise is having a short walk from the car park to the nearest restaurant Syed with some of his equally obese friends !

Too much young deaths this one month. Two to be precise. 
Case 1 :
E Shazwani, 26, [ not her real name of course], came in via ER, with an abruptio placentae [ bleeding from the placentae ] at 37th week pregnancy with a bp of 170 systolic and 120 diastolic...Preexclampsia , as well, by our definition . 
Had  generalised convulsion shortly after in the ward.  That prompted a Code Blue and that  was where I came into the picture.

As cardiologist on called, it is our job to respond to all hospital Code Blue  at whatever time it is.[ hospital euphemism that someone's heart is stopping, someone in a 'great hurry' to carry on to the next phase of 'the journey' ]. 
E S duly intubated and ceasarian section in progress when I reached there. Her gynae was super quick to response.  She need to be, otherwise, both baby and mum would not make it.... maternal  and neonatal mortality is a no no no....It will a negative impact on our index of being a progressive nation state.

Baby and mother sent to  neonatal ICU 2 hour later, mother on huge doses of IV antihypertensives for her very labile BP.  Her initial Bp surge  had pushed her to transient heart failure.She  responded well to treatment and by third ICU day post OP, mother and child were reunited and good enough to be sent to postnatal ward. 
Heart echocarcardiogram and chest xray being normal.

3am , got called by another Code Blue..
' Doc, there is a Code Blue in Postnatal', retorted the operator.
' What the ! I am not on call !!'
" Your patient in postnatal , sir ..'

E Shazwani died in her sleep, her husband sleeping next to her on the couch.
Possible cause of death :
??Primary Ventricular Fibrillation. 
?? Sudden massive brain haemorrhage due to sudden  burst of high bp surge. 
? Pulmonary embolism. Most probably.
But  all highly conjectural as far as I am concerned, since Postmortem request refused.
[ Those  theoretical  'assholes'  warming their bottoms at the District and  State level Maternal Mortality review board are going to have a field day looking through their 'very  very clever retroscopes' ]. 
Why this , why that, why not this why not that ?
Have you considered this, have you considered that ?
Damn it.
Inna lillah hiwainna ilai hirojiun.

Case 2, just yesterday, 9th day of Ramadan :
Muhammad, 32, [ not his real name of course, but my God !, just about my son's age ], Kuwaiti student at that 'universiti under the highway', MSU. Refered from DEMC Hospital. Presenting symptom : chest pain, veryhigh bp,  210/80, tropT positive, ECG changes of acute coronary syndrome. Obese plus plus 

Duly underwent cardiac cathetherization on admission  at 2 am, with  a view towards ad hoc angioplasty and coronary stenting 'on sight' with intravenous anti hypertensives on board.
Some slight aberration in the right coronary artery seen and a  smallish circumflex but why ??
....Looking  down at the  thoraco- abdominal aorta, Lo and behold ! This young man has a bigger plumbing problem plus plus than just  his coronary. He has acute thoracic aorta dissection !!  His main blood vessel, the aorta, that come off the heart  has a major crack in the wall ! It is not bursting yet otherwise he would be dead on arrival. It cracked, tearing the wall into a false lumen within the wall and  the crack progressing upward  towards the root of the heart and downward within the vessel towards the groin arteries. Dire emergency plus plus.. CT abdo and thorax confirmed the 'extent and gravity of the problem. His aortic dissection right from the root of the heart, right down to his scotum, one kidney was already devoid of blood supply and his mesenteric arteries [ blood supply to the gut and colon] are closing. He need cardiovascular surgery now. 

Two to three experience surgeons all working on him at the same time. There is only one place in KL having that number working on one patient :...IJN. 
Major plus plus plus cardiovascular surgery and even then it is 50 : 50.

" Young man, I am going to have to tranfer you to IJN now . I just talk to the boss number one there and he is waiting for you. You need major surgery"...Half reassuring and reminding  myself that he could make it. The CT thorax told me he is already a 'gone case'...beyond help.
" Doc....why am I feeling this short of breath..."
" Muhammad, try not to waste your breath talking  to me or anyone... Just concentrate your mind on this..I want you to just close your eyes and concentrate on ..Laila hail llallah..laila hail llallah...laila hail llallah....".  I knew he would not make it.

Events oftentimes got the better of us whatever we do.
30 minutes later he went into coma and died.
His parents still in the air between Kuwait and KLIA.
I wish I could tell them that their son , did the shahadah..... it make a world of difference if you are an Ahmad or a Mustapha !

It is cases like this that keep me going at 60 plus. being reminded of the 'inevitable' some 30 times in a day, 30 days a month
Inna lillah hiwainna ilai hirojiun.......
We are from Him, to Him we all do return.

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