The Passing Of Bulldog Drummond.......

Last night I was at a  wedding reception and my handphone was on a  ' meeting ' mode.
I did not notice the sms from my dear wife that..... " Pak Mae from Setia Kasih 9, just passed away in IJN ", until this morning. He died around 6 hours after an emergency admission to IJN  [ National Heart Institute ] of a massive myocardial infacrtion [ ' heart attack ].  A known diabetic for over 30 years, 5 years now on  subcutaneous  insulin injection, twice a day. 14 years post bypass surgery.


Abdul Rahman  bin Yaacub, from Chetok, Pasir Mas, Kelantan, 68, the local kampong boy, made good via education. A government retiree, His last post was deputy KSU in the Ministry of Home Affairs, having served under luminaries such as King Ghaz and Hussien Onn during their heydays of catching big time opposition politicians and writing and sprucing  up 'research paper' on them prior to his political bosses consideration,  for ISA consideration ...tough job for the senior 'neutral' civil servants at that level.

We, the Wan Abdullah clans, from the Rao family, remember Abdul Rahman  Yaacub differently. He is my third cousin. In the 60's , he and his two other elder brothers[ and their wives ]grew up in our meagre household at Jalan Teliput, Kota Bharu, the ' Damansara Height ' of KB in the 60's.
[ Two of the only three  general practitioners in Kelantan in  the late 50's, Dr Ezanee Merican and Dr Aziz, build their houses along  the prestigious Jalan Teliput. The Old British Advisor's residence'is'  a few houses away from our wooden pondok, now refurbished as an official residence for the present sultan. Dr Aru stayed in ? Jalan Kebun Sultan. Dr Aziz, to recall correctly had two houses in Jalan Teliput, a bigger one for his 1st wife an 'orang luar' , meaning non-Kelantanese , and  down the road, near ours for his 2nd, a local lady.  All the three of them, Dr Aru, Dr Aziz and Dr Ezaneee are 'orang luar'  and wealthy plus plus plus.  Just three Gp's for the whole of Kelantan! ]. 

My late father was just a chief clerk but the 60's in Kelantan at that time was a great time of sharing. We relatives ,all share in poverty and in 'relative' wealth . My late father [ who died at  the ripe old age of 41 ! ] drove a Ford Prefect in the late 50's.  By the early 60's he graduated to an Opel with a special number, T7000. No mean feat. That made him an elite!

Abdul Rahman's  school friends called him by the Kelantanese eponym,' Budok Derg'omae ', .but my elder brother, who is the same age as him and went to Sultan Ismail College with him, was more imaginative and diplomatic. He fondly called him 'Bulldog Drummond' after a fictional British pilot/hero/spy in the 1st World War. And that  endearing 'private' name stick amongst us, the senior Wan Abdullah brothers. Mr Bond, James Bond double '0' seven was not yet created, otherwise we would have named him as such. Such was our fondness.

'Bulldog Drummond' must have lead a very clean and pious life throughout, in my estimation, for Allah was with him at the time of his demise. I gather that he must have been in severe pulmonary oedema [' wet lung' ], for otherwise in a facilityb such as IJN, the obvious choice would have been to proceed to primary infarct angioplast there and then but  I gather from his son's description of  the terminal events, he was in bad heart failure which negate the 1st approach  in some instances.  

He was intubated and given artificial ventilation  shortly after to help in his breathing. He was still conscious and able to say .." Allah, Allah, Allah...". In his dying throes he asked his sons for a piece of paper. On it he  weakly scribbled,
"..read Yasin for me please.."

I told his sons at their home in Setia Kasih just now,
" Your dad died in good circumstances. Don't be sad.  I want to teach you one ilm which I              got direct from one of the Imam in Masjidil Haram some 30 years ago. Read this very short doa,..'  Rabbir Firli Waliwa Lidayya wal Mukmini wal Mukminat '..In your sujud, in your rukuk and in your remembrance of him. Insyaallah, he will be in good Hand "                      

Innalillah hiwainna ilai hiro jiun [ from Him we come, to Him we return ]
Bismillah Himajreha Wamursaha Inna Rabbi laGhaffur rurRahim
[ In the name of Allah, He is our anchor and journeying. He is al Ghaffur and al Rahim ]


nik howk

Post Script :
Just now at 230 am, I was wokened up to see a 42 year old young Malay gentleman at our ER who came with central chest discomfort and feeling short of breath. He has been having the sypmtom since after his dinner at 8 pm, but waited and his sypmtom was getting worse.

ECG and troponin T [ blood test ] were both normal, but our casualty MO was not happy by the way he look, thus he called me. I have nothing substantive to go by either but my gut feeling was that he look like an ' acute coronary event'. he was beginning to cough and the chest Xray was showing a 'wee bit ' of congestion in the upper region. In my mind if we were to wait another hour or so for the ECG or the blood test to be 'more positive', we may lose the window of oppoertunity to save a lot of 'cardiac muscle' from cardiac muscle death and with 'wet lung that usually follows in a massive heart attack,, I will have a 'wayang kulit' in no time. The window period for muscle salvage is critical, and it is short.

He was wheeled to the theartre and lo and behold, the coronary angiogram showed total occlusion in the left anterior descending artery, just 0.5 centimetre away from the Left Main  [ the 'widow-maker's junction ]. The occlusion was duly crossed with a guide wire and ballooned and stented.
Insyaallah he will be out of the hospital by Monday or Tuesday.

Oftentimes, when the presenting ECG and the initial blood test are  normal, we 'plumbers' have to rely on our gut feeling and clinical acumen. Time is of the essence.
We 'plumbers' often live dangerously. 
[  http://www.youtube.com/watch?v=3Z2DaU0GBAE&feature=related ]









Other articles on ' Death & Dying '  in the blog :

http://drnikisahak.blogspot.com/2008/05/not-so-pearls-gem-nik-isahak.html

http://drnikisahak.blogspot.com/2008/11/death-eternal-life-after-death.html

http://drnikisahak.blogspot.com/2011/02/unto-him-is-journeying.html

http://drnikisahak.blogspot.com/2009/01/pearls-gem-redza.html

http://drnikisahak.blogspot.com/2012/07/case-history-young-deaths.html

.....monologue on egypt

Doc Azman,

You are a graduate of the Egyptian education system

I know you go to their medical school in Cairo in the 70's  and not to the famous brother university, the al Azhar but by your silence on this Egyptian debacle, I hold you fait accompli in this mass slaughter of Muslims by  socalled 'Muslims'.

I would love to call these 'socalled muslims'  and  the 'people  sewaktu dengan mereka' as hypocrites but I am not a scholar, I do not have the prequalicationa as such, so I will stick to that term instead.

I know you are at all not  related to the butcher from Assisi but your resounding silence is deafening!

 Why????

As way back as early July, the reknowned jurist, Shaykh Yusuf Qardhawi has already given his advice and fatwa on the possible ouster of Morsi

[   http://english.alarabiya.net/en/News/middle-east/2013/07/06/Leading-Sunni-cleric-says-in-fatwa-Egyptians-should-back-Mursi.html ]

WE, the Muslim ummah , have always looked up to his fatwa on whatever subject  before, but why now the sudden global  inertia and selective myopia.

Had guys like you and thousands others from the al Azhari alumni joined in the bandwagon making ' 'animal noise' against it, this subsequent bloodbath could have been avoided. Where is the OIC [ oh i see ] ?

Your 'cik gu' in al azhar, the sheikhul al azhar, was so quiet like a poodle, no fatwa, no advisory, nothing..........

until the infamous photo shoot with the general and the 'imam' of the coptic church. He certainly know which side to butter the bread ! So sad for an ulama of his calibre and office. It is a shame really.

[ when  does a 10 % become more important than a 90 %....my god ! what kind of equation is this! ]

After the bloodbath , he conveniently disappeared from the radar screen!

Frankly, the office of shaikhul al Azhar has lost its meaning , we should not bother about them anymore, as  a source of rujukan

Our collective silence is a crime in islam, my friend.

nik howk

http://drnikisahak.blogspot.com/2013/07/egypt-oh-egypt.html

ps: now i can conprehend why nabi used to say, at the bottomomost of the heap  in' an nar' are scholars and scholars ! scholars who are just there for the 'cari makan'




..................................


28th August



http://www.aljazeera.com/news/middleeast/2013/08/20138285655559615.html

a patient of mine who has an office in cairo told me today he is harbouring one of his egyptian consultant in kuala lumpur.

otherwise this chap would be hunted and killed by the egyption secret police. such is the ferocity of the egyptian security apparatus on their search and 'kill' operation.. true to expectation, the secret police went to his house in a cairo suburb, and confronted his wife and family.

. how long assisi and his gangsters are going to persue this path we do not know. this is pure madness.

the fatwa has been out. assisi  and the current egyptian government is illegal morally and from the syariah perspective...this is qardhawi's not from al  a zhar.

sheikul al azhar is quiet as a poodle. we should all stop looking to al azhar as an institution famous for its juristic direction.

al azhar as an institution of fatwa has all but lost their moral and religious high ground. their reputation in tatters.

even shaykh qardawi is not safe from this group of gangsters!!

this is the position of islam today.

the real muslims become terrorists and the munafikuns rule the day......this is dunia akhirzaman.

nik howk

ps : ...and doc azman, mbbs cairo u , why are you sooo quiet? you can say your piece you know...

A Young Man Who Came In Smelling Like A Fish.....

Uraemia, [ end stage kidney failure,classic type ] presenting in the clinic smelling ' like a fish' usually now belong to the realm of old classic medical text book of medicine.  One such case walk into my Saturday morning clinic yesterday.
Mr AbdulRazak Aipojo, [ not his real name of course ],a 28 year Nigerian student attach to Taylor's came to see me with a complaint of easy fatiguability and frequent vomitting of two weeks duration. He has a sallow, pale complexion and smelt like a fish . Blood pressure was 220 / 130 !! [ normal for guys his age around 120 / 80 ].

' Young man, you need to be admitted..You BP is sky high and if we delay treatment, you will have a burst artery in the brain or you will have breathing difficulty plus plus..."

Always very difficult to persuade a young man of just 28 who thinks he has another 40, 50 years of life ahead of him. Adipojo is a candidate for sudden death which can come from a sudden cardiac arrest arising from a grossly disturbed electrolyte/ metabolic disturbance following impaired kidney function, a sudden stroke, or acute heart failure due to high bp and fluid accumulation in the lung.

His renal function test [ kidney function ] showed a serum creatinine of 2300 micromol/litre [ normal less than 115 ], an elevated blood urea of 55 [ normal up to 5 only ], and a potasium level of 6.1 [ normal up to 5 only, this elevated potasium level is the one that predisposes to cardiac arrest ]

Uraemia is not my speciality. On admission, he was handed over to a nephrological colleague, who will institute urgent haemodialysis on a daily basis at first for a week or so. His bp need my urgent attention, of course.

This young man need to be on  long term kidney dialysis programme.

Life will never be the same for him, having to be hooked to a dialysis machine, 4 to 5 hours, 3 days a week 

End stage renal disease, oftentimes are quiet , insiduous disease than can surprise seemingly healthy looking people. Commonest cause is autoimmune inflammation of the kidney itself [ parenchymal kidney disease: glomerulonephritis, second commonest, due to choric untreated hypertension ]. In this young man, I think he had insiduous glomerulonehritis. The gross raised bp in him , in my opinion , is a sign of of his inherrent kidney dysfunction, rather than the primary cause. 

At the end of the 

'executive summary', old hands like me, in this 'business of  looking after the sick and infirmed, will write : Adipojo has rather a short fuse!

William Shakespeare, four centiruies ago, opined about this tragicomedy called LIFE, "

the world is a stage, we, men and women are merely players. We have our entrance and exit...... ", or something to that effect.

This is rather sad, at 28 !

From my vantage point, that is the nature life, thrown to us, from the 'Great Beyond The Beyond the Blue Yonder'.

Which somehow reminded me of death all the time
And I am not complaining. I consider this  frequent  reminder of the 'fragility of life', a priveledge.

Inna lillah hiwainna ilaihirojiun








articles in a previous blog :

http://drnikisahak.blogspot.com/2012/08/on-death-and-dying-expiry-date.html

http://drnikisahak.blogspot.com/2011/02/unto-him-is-journeying.html

ABSORB, The New Bioresorbable Drug-Eluting Vascular Scaffold

Just came back from the hospital just now  after reviewing Encik K [ not Datuk Siti Norhaliza's Datuk K of course ]. Encik K , 58, recently retired Oil and Gas man from Petronas and Shell, currently doing some 'oil trading'  on his own told me his lifestyle is " nothing stressful doc" .

His crime? Sub-optimally controlled diabetese over 6 years and smoker, 20 sticks a day, 30 pack-years and carrying excess baggage of 30 kilogram. He weighs 100 kg , but only 170 cm in height. On top of these, he has hypertension over 10 years. All, 'push' factors for early coronary tree aging.

What is interesting in Encik K is that he is my first patient walking around from today with SDMC's first bioresorbable 'plastic-polymer' scaffold.

K presented to me last week just on a routine check up insisted by his wife. HBaic  blood result of 7.8 % told me that for the last 4 months or so his diabetic control was 'moderately sub-optimal'. A routine threadmill stress ECG nearly gave me a 'heart attack' !  He had a long spell of dysarrythmia, we called 'ventricular tachycardia', a precursor to a cardiac arrest, just shortly at the beginning of Bruce Stage 2 exercise protocol. I stopped his exercise test immediately and advice him to have a fairly  immediate coronary angiogram study to get a definitive road-map of his coronaries.

Today, just now at 5 pm, coronary angiogram showed critical 95 % stenosis [ 'narrowing' ] at the proximal Left Anterior Descending Artery near the Left Main Stem [ 'widow maker's junction', we cardiologists lovingly called it ].

After discussion with him [ on the table ], and his anxious wife, waiting outside the theatre, I opted to use the new resorbable 'plastic' stent instead of the now  aging ' 10 year-old  drug-eluting'metallic cage stents' [ stainless steel, cobalt chromium, or platinum coated ].

Vessel preparation and predilatation  and stent implantation technique are almost similar to the traditional metallic cage stenting. Cost-wise though,the new bioresorbalbe 'scaffold'  presently come with a hefty  40 %  increase in price com pared to the present work horse, the metalllic drug eluting stents, but 'insyaallah', with new players coming in, the cost will find its own level, hopefully much lower in future. Currently only Abbot Vascular Laborataries of America are the sole manufacturer of this  stent. It would not be long before others  join in the bandwagon. Siemen from Germany is already waiting in the wing to join the competition


From the cardiological perspective, this 'bioresorbable vascular scaffold' offers us more complete potential for 'restructuring and reconstruction' of diseased arterial tree.  The realities of Ischaemic heart disease it is both a  chronic and unrelenting disease. With the negative effect of affluence, sedentary lifestyle,  obesity, hypertension, and early diabetes,  we cardiologists are increasingly faced with  a new subset of younger and younger patients needing arterial construction. 

From my vantage point as a cardiologist, managing people with coronary artery disease is both an art and science of postponing the inevitable. It is my job to keep my patients from the inevitable ie that is surgery.  The downside to this  philosophy is that when it is time for 'my average patient' to have to undergone the 'final pathway', it is not uncommon now to see a patient in their  late  50's or 60's having  had 5 to 8 stents implanted, over the progress of time, all over the place in the coronary arterial tree. They present to our poor  cardiovascular surgical colleagues, a daunting task since their arterial tree are full of metallic cages.

It is hoped that with the bioresorbable stents increasing usage [ drug-eluting metallic stents still have a big role to play ], our surgeon can still do CABG on these individuals after postponing decades of  disease progression. But cardiac surgery at present is a 'sunset' profession as the cardiological tools and weapons attain more sophistication with the years. This is inevitable as coronary stenting is a multi billion dollars industry backed by engineering, bioengineering , genetics and allied sciences  all galvanized together by multinational devices companies of America and Europe.

At the end of the day,  we, the cardiologists have the best of  both  'soft as well as the hard' sciences', backing us, and a bludgeoning  devices companies competing to outdo each other to produce better and better 'devices'. For the poor cardiothoracic surgeons, they only have their 'bare hands'. 

This constitute 'unfair competition'. But what is unfair to the cardiothoracic surgeons can only be good  to all patients globally. Across the board in the field of medicine, the whole world is moving towards minimally invasive endoluminal techniques and away from having your chests, pelvis , brain or abdomen ripped open. If need be, it would have to be our last choice.


Nik Howk
1.30 am, Tuesday, Ramadan
Subang Jaya

ABSORB :
http://www.youtube.com/watch?v=ccLwmZ6Gwdc



1st Absorb Procedure in Dubai
http://www.youtube.com/watch?v=u91MOZSzhYs



They Are Getting Younger and Younger...
http://drnikisahak.blogspot.com/2013/07/they-are-getting-younger-and-younger.html



It Is Diabetes, Diabetes and Diabetes.........
http://www.youtube.com/watch?v=C30C5dthslc
[ editor's comment : if you are muslim, when he talk on deep breathing etc and etc, think about zikr..
this is a panacea of most ills ]