Case History : The Good, The Bad, The Ugly.....

What a week !

First I have Ananda Arumugam [ not his real name  ]walking into my clinic after an absence of 6 years. A post infarct patient who lost his job because his boss thought he could no 'longer deliver'. Now a 'boss' himself with twenty or so people depending on him.

Then there is CML, a young Chinese engineer,  just turned 32 year old and just married,  with advance lung cancer complicated by disemminated neoplasm to his pleural cavity [ sac  covering the lung ] resulting in fluid accumulation and partial collapse of both lungs; acute  blockade of his pulmonary circulation [ pulmonary embolism ] due to increased clotting activity [ increased thrombogenicity ]arising from the cancer situation; and if this is already not enough, a very tense and 'compressed heart' due to malignant fluid accumulation in between the heart and it's sac. We termed this 'pericardial effusion leading' to a 'tamponade.
This young man has advance cancer [ stage 4, ie disseminated ] and in real deep 'shit'.

I had to do an emergency evacuation of the malignant accumulated fluid by doing a pericardiocentisis [ pericardial tap] ...[ http://www.nejm.org/doi/full/10.1056/NEJMvcm0907841 ]
That was just the beginning of things to come. He needed top notch specialist oncological treatment with the latest chemotherapy regime available. Two days after the pericardial tap, he went into respiratory failure due to the  dual additive effect of pulmonary embolism and his  lung's encroachment by disseminated  cancer. Needed to be actively ventilated to tide over the acute situation while the chemotherapy take its slow effect.
Prognosis ? G. O. K
Statistically speaking,probably two years at best, in the best of centres[ http://drnikisahak.blogspot.com/2012/08/on-death-and-dying-expiry-date.html ]. Not great ! But this is the reality of life when you happened to be in a 'deep shit' like this.

Madam GkL, 61  year old Chinese lady arrived at our ER in 'extemis'. She was pulseless and not breathing. The ER Medical Officer noted 'ventricular fibrillaiton' on the EKG meaning she has a 'cardiac arrest'. [ http://www.youtube.com/watch?v=nxpYuVr53zQ&feature=related ] The ER  in my hospital is one of the best place to have a cardiac arrest in the whole of KL and PJ! The staff  there are all superb at bringing back people 'who are actually ready to go to the other side' and pull back to 'this side of the realm'. After half an hour of active resuscitation and ventilation, GKL' heart comes back to sinus rthym. She was by now on artificail ventilation and my anaesthetist colleague was in charge of the 'breathing'.

"Sir, you wife has massive acute myocardial infarction and I am bringing her straight to the cath lab now to do an angiogram to look at the blockages and open them up with  balloons and then tacked them up with metal  wire-mesh  which would act as scarfolding, called 'stents'. We have no choice and time is of the essense...it is early days now for us to tell the effect of the cardiac arrest on the brain...that we have to assess later.............". One hour later in the wee hours of the morning she came out of the cardiovascular cath  lab with all her blockages opened  and three 'stents' implanted. That took care of the heart. [ http://www.youtube.com/watch?v=CGwiJjiASEY&feature=related ]..The effect of 'hypoxia' [ lack of blood flow, or no flow due to cardiac arrest ] on the brain need to be assessed the next day. Need to give her sometime

On the 3rd hospital day, she is still fully ventilated, brain function assessed by EEG showed minimal activities. Outlook is grim: a long term vegetative state as a possibility was on the card, 99.9 % probability. She has global 'hypoxic encephalopathy', the period of no 'oxygen and no blood flow to the brain' while arriving to hospital was too long. [ http://en.wikipedia.org/wiki/Cerebral_hypoxia ]

I had a long discussion with her husband. He does not foresee a' vegetative' situation as something that his wife would have liked.

" Doc, you are Muslim and I am also People of the Book. Both of us believe in Him in our very own ways. What do you think I should do?............."

" We have done our utmost best, me as a doctor and you as her husband.....As a Muslim I entirely agree with your plan to bring her home and let God decide...but Sir, things will happen very quickly the moment we wound down her treatment and especially the active ventilation. At the moment she has no ability to breath by herself, the 'signals from the brain are not there' , so to speak..whatever we decide, let your Canada -based son and daughter  arrive at KLIA first tonight and see their mother still alive, after that I will unwind everything....I am not playing God of course..it is just the small things that He allow us to play around with....you know what I mean..it would be kinder for your children, in the long run...and I would do that, if you  and your children could come to an agreement all round....".

That is the Good, The Bad and The Ugly  handed to me on my plate this week.

At this juncture in my private and professional life, I wish I could  be involved more in all  my patients' spiritual life due to this feeling of 'mahabbah' for my fellow humans  but societal, medico-ethical considerations and political correctness, does not allow that 'boundary' to be traversed. A pity.....

Innalillah hiwainna ilai hirojiun....From Him we come, to Him we return.

Case History : Young Man With An Attitude...

Ananda s/o Arumugam [ not his real name , of course ] was only 32 when he had his 'heart attack' some six years back. I could still remember the medical officer on duty at ER calling me at 3 AM  at home saying that he had a young Indian chap who was wokened up  an hour earlier with gripping  chest pain radiating to his jaw and back in between his shoulders associated with dripping cold sweat. 
I told the ER doctor to summon our emergency cath lab team for a 'primary infarct angioplasty and stenting' rightaway. Time is MUSCLE LOSS in this situation. 

 http://drnikisahak.blogspot.com/2012/05/procedures-in-medicine-coronary.html ,    
 http://www.youtube.com/watch?v=TS0Je1m9Q8A&feature=related
   
One hour later , with two, cobalt-chromium, drug eluting stents in his initially occluded Left Anterior Descending artery [ I always fondly called this, the' Federal Highway'] and  one long  38 mm stent in his Right Coronary artery, Ananda was breathing better in CCU. He had a full blown massive anterior infarct just one half hour in the making and TIME IS OF THE ESSENSE. His saving grace was that he arrived early, otherwise , there would have been more  'unsalvageable ' muscle loss leading to impaired LV function, weeks,months and years 'down the lane '. Discharged well on the 4th hospital day and given one full month MC since he needed a lot of rest for recuperation : he was a 'two-tonne'  small time lorry driver to a small ' Chinaman ' outfit. Despite this he had the right attitude. He took the right health insurance cover despite his meagre income.

On the first outpatient follow up Ananda dropped me a bombshell: Ah Kow, his boss, has asked him to stop work, on day one when he reported back for duty, since he thought Ananda would be a liability in the long run. With cash running low, three hungry young mouths and a wife to feed, and no decent job on sight in the near future Ananda requested me to refer him to Serdang Hospital for further outpatient follow up. I consented.

" Ananda, don't despair. Go back and do a lot of thinking . This is an opportunity for young man like you to 'fly'.... God is merciful and compassionate. He will look after people like you, insyaallah !....etc etc and etc "

Today, 6 years later, Ananda suddenly showed up at my busy outpatient clinic for a check up on a niggling 'chest pain '. I was happy to see him again, looking well and prosperous........
Stress test OK, Hbaic not bad meaning his diabetic control is almost optimal, Echo showed normal LV function.....Great news.
" Ananda, you are fine..your ECG does not not indicate any evidence of 'heart scarring'  at all and your echo showed excellent  heart muscle contraction. It is as if you never had that heart attack six years back. Disregard this pain, it is just muscular ", I retorted , reassuring him. " What have you been doing this six years since your dismissal?"

" Doc, I took your advise...now I have 20 people working for me collecting plastic and bottles..I have three lorries and I pay 30k a month to my people in salaries ".

It is 'basic' people like Ananda that keep me going and plodding on...he made my day today.