Friday, November 9, 2012

Case History : The Good, The Bad and The Ugly..Scene 2

What a day today. I am on call for the hospital covering all cardiological admissions  'after office hours' till 8 am tomorrow., meaning all cardiological emergencies and referrals..... Still very high on adrenaline at 2 am especially after the last ' primary infarct angioplasty case which I had just now, I could not sleep......

Started the day very well at 6am after 'fajar' prayer, did a short surf on the internet just lurking around and reading my mails etc  and etc. Came across a wonderful  already 'dated' utube  'article' from Down Under. Very happy to note that my  fellow endurance competitor Meg Wade, four time Tom Quilty champion, and several consistent top ten's at world level, recovering very well from her near-fatal equestrian  brain-injury sustained  after a fall in mid 2009 in a local 160 km ride in Australia.
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Indeed Meg Wade up to the time of the 'spurious fall', [ that can happen to anyone actually competing at any level in that 'crazy' but self enduring sport ], the top rider in the world, following  and replacing the footstep of the legendary,aging Ms Valary Kanavy of USA, the undisputed endurance queen of the early  and mid 2000's. They share the same common denominators: They 'eat, sleep and breath equine'. Kanavy is born into 'old money' in Vermont, USA with acres and acres of  farmland ideal for endurance. Meg Wade used to fly her own helicopter to keep track of her farmland herds in northern Victoria, Down Under.

We went a long way together even though we do not know each other personally.I first competed with her in the World Equestrian 160 km Championship  in Dubai in 1998, myself riding and ex-race Thoroughbred, Boss, very much a 'rookie' at that time.  Then, at Canberra Open FEI 120 km in 2002,  where she was a very fast 1st and myself just completed at 9th position. Another event locally in Putrajaya over 80 km in 2012, a small event for her presumably. Again in the World Equestrian Games at Jerez, Spain in 2003.  I think she was top ten at that Game. I was around number 40 in a field of two hundred horses, when my mount , Floyd , a leased horse from  France, collapsed at the penultimate round of a total of seven rounds/phases of riding . Exhaustion plus plus, camouflaged by massive herbal antidote given by my French handlers.  I had on board a heart rate monitor on Floyd and he was looking good all the time 'cardiovascular-wise'. I was too polite to tell the FEI people about the 'herbal thing' given to Floyd at every rest stop, and thus was made to be a 'pariah' in the international endurance scene, for prusumably 'pushing the horse to far'. Horse death in the sport, especially at this level of competition, is taboo despite everyone wanting to do their best. A paradox.  I was exonerated a year later by the Secretary General of FEI himself, Mr Michael Stone. The French Equestrian people,  of course went ballastic  and their 'press' had a field day on  me for weeks after the event. Lucky I don't read French! But looking back, it is all worth it. I lost face for a year, at the most two. The lady owner  and her husband lost her horse for her  own 'naivity' and mistaken belief that 'things herbal are OK and cause no harm! . My disclosure at that time would have cost her more 'pain'.  I can handle my 'pain' but was not sure it is fair that she should have a share of it, at that point in time. Time is a great healer anyway.

By morning outpatient clinic I was into the 'thicks of things'. Saw  a young Malay chap, just 34, obese plus plus, who came in with classic 'angina', with a total cholesterol of 9.3 mmol !! Stress test  is positive. He need admission rightaway for a  coronary angiogram, to get a road map of his coronaries, plus minus angioplasty plus minus ad-hoc 'stenting'

At angiogram, was found to have a 'left main stem' lesion. We , plumbers' , whenever, we see a LMS lesion on the screen would say a little prayer of: " My God, let me finish this study without mishap ". If a LMS blocked 100 % acutely, it would mean instant death for any individual. And an occasional LMS do get disrupted occasionally during even an angiogram study. 

This young man, in my book, will be scheduled  for 'bypass surgery' soon. It is not often now that we sent our patients for CABG [ 'bypass surgery'] given that stents and equipments for angioplasty are becoming better and better with time and techniques have improved by leaps and bound, making cardiac surgery in most cases almost unnecessary. Cardiac surgery , from the standpoint of bypass surgery, is fast becoming a 'sunset profession' the world over. Only valves operation remain their last bastion and even that is going the 'endoluminal' way as cardiologists are invading into their turf with new valves. I emphaties with my surgical  colleagues but the problem facing  cardiac surgeons all over the world is monumental and fundamental at the same time: While in cardiac surgery especially, they basically have only their pairs of excellent hands and skills to depend on, we cardiologists have  a myriad of people and new 'tools ' to play with: bioengineers, geneticists, new science, the whole gamut of the fast moving pharmaceutical industries and free enterprise , are all behind us.  It is not a level playing field certainly.

Having said that, LMS is still in 2012 , at least in my book,  a 'surgical animal' in most countries except Japan and Korea. I will refer patients for surgery , even at 34, without having to think long and hard about it. I belong to the 'conservative' very 'British school of thinking'.

My patients oftentimes ask me why we Malaysian cardiologists do not follow the Japanese or the Korean way and do more 'Left Main Stem' cases, apart from the occasional ones during dire emergencies. I  always have to tell them my favorite story:
In Japan, if a patient dies on 'the 'table' after a difficult procedure, The 'professor' can be assured that the next day the late patient's  son of daughter would be queueing  dutifully in the professor's outpatient clinic or office with a bouquet of flower for him and some form of 'profuse' apology to the effect, ' Sir, I am sorry my late dad gave you a lot of trouble etc etc and etc..'.

Elsewhere in the world , including ours, we may be lucky to escape with a very 'hot' lawyers letter fishing for details and what not! Time has change.

At 10.30 pm I get called to see a 43 year old Chinese gentleman with sudden onset central chest pain and profuse sweating plus plus. He was drenched in sweat when I saw him. EKG showing an acute phase of an oncoming 'massive anterior infarct' [ heart attack affecting the front part of the heart due to 100 % blockade  arising from a plaque rupture]. An ST-T EKG changes of 5 mm depression in all anterior leads....very 'angry looking and threatening EKG' indeed!
No time to waste. His lungs were getting 'wet' by the minutes. Every minute and second counts. He was brought straight to the cath lab and our emergency team alerted for a 'salvage, emergency procedure. We must get a 'road-map of his blocked arteries and 'start from there.  Surgery is out of question, there are 'slow animals' as far as we are concerned. At angio,  I nearly 'died'.I found out he had an acute LMS  total occlusion.. My God!!...seconds count now.

I could not cross his acute occlusion with my 'guide wire'.
Pulmonary oedema sets in very fast,  breathing difficulty,then slow heart rythmn [ 'bradycardia' ], followed very fast by no rythmn, then, ventricular fibrillation [ cardiac arrest ].
When things like these happen , they happen very fast. No time to stand and stare.
Patient succumbed on the table at around 1 am, despite more than one hour of resuscitation..

'Innalillah hiwainna ilaihirojiun'
From Him we come to Him we return.


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