[VIDEO] On Truncated Lives

[VIDEO] Redha...

Redha : Very simple to say, but profound and damn difficult to practice. But Redha is the bedrock of Islamic practice. 

"My friend, redha earlier than later. I must admit I had had a fair mix of the un-redha states in my past life...and I have paid dearly to that ' stupidity ' of mine. "

Passing On : The Queen.......

I was in the Doctors' Common Room just yesterday at Subang Jaya Medical Centre. Queen Elizabeth the 2nd's death was still playing in my mind despite a busy morning clinic. Death somehow always make me ponder. And the Queen is not any ordinary folk. She has been the bedrock of the British monarchy for more than 70 years. Never controversial like some clowns down south here somewhere.

 

Regal, and not overbearing and for 70 years of Britsh history, not Malaysian history. That by any Malaysian standard, is a record. Ours , inslots of every 5 short years, usually fails miserably.

My colleugue and old time medical classmate of mine, senior paediatrics consultant oncologist, thought loudly that Queen E's physicians attending to her at Balmoral Castle must "let her off " easily, gracefully and gently into the next phase of existence. 

 " No lah Lee Lee,....... given the scenario that just 28 hours earlier Queen E was able to see and greet the new incoming PM at Balmoral, I dont think that Queen E, went on that just like that easily.It must be one of two things...Either she had a sudden cardiac event, like a cardiac arrest culminating, in a sudden cardiac standstill or ventricular cardiac arrest or a major cerebral event like a sudden stroke, more likely the former....the "our Queen is now in a state of serious illness" drama on TV, giving a breathing space of say 12 hours is just 'royal wayang kulit' for public  and news consumption......A fine very royal PR job, to keep the populous ready to accept the impending demise of a very much loved monarch!" 

" Or, following the catastrophic event,  she barely lingers on, on full cardiac and ventilatory support....It is pretty unlikely though because if that is the case, she would not be managed in Balmoral. They can but it is hihgly unlikely. She would be very quickly transported to any centre of excellence in Edinburgy or even London.....Definitely very unlikely that she has an unresolving pneumonia..Otherwise she would not be able to attent to the new PM a day earlier." 

 " The decision to keep and manage her in Balmoral Casttle , if she still lingers on rather than transfer her to say a top medical centre or tertiary centre in Edinburgh was a fine line though which speaks volumes of the level of finese and wisdom of the Royal Family of Britain in dealing with this kind of family emergency. 

 "I am very sure if I am the one managing her , as the sudden event took place , she will be rightaway transferred to the Medical Facility within the Castle..It is not unexpected that in the UK , with a 96 year old Head of State around, they dont have ICU facilities within Balmoral ,or Windsor. It is not Britiah to not have these.... " 

"I would have started her on triple or quadruple inotropes [ heart pumping intravenous medications ] intravenously, hoping for her vital signs such blood pressure and respiration to pick up. I am pretty sure at some point when vital signs seemed dire and dicey a decision to intubate her and sustain her temporarily would be on the card. If her son , Prince Charles was around, this would have to be discussed with him. Such procedure in a way would give some time for the other close royals to arrive and percolate fast from any where from England to Balmoral....Given that she had been on intravenous triple ot quadriple inotropes, plus minus artifuicial ventilation, and her vital signs does not pick up measureably, this would give the royals time to gather and ponder over my next action." 

 " Vital signs not coming up, Bp hovering in the low systolic 40's, fundal examination showing feable reaction to light I would then bring on Prince Charles aside and tell him........Your Highness, In my considered opinion, it is futile to go on...I think Madame Queen is not coming back......" With his permission, upon general agreement with all his siblings and close royals, Prince Charles would have agreed to the game plan: slowly slowly start tailing down all the inotropes, and subsequently even off the ventilator , if upon taking off all the inotropes, Queen E was still hanging on. That constitute a gentle, graceful exit for a monarh of 70 years. Death would have followed shortly aftwer that".

If I am a betting man though, I would bet that the Queen had sudden cardiac death, and all the BBC and CCN and al Jazera dramas for a good 12 hours at least were just a good PR exercise, preparing for a Commonwealth of Nations and the world at large to come and accept the inevitable.

Inna Lillah Hiwainna Ilai Hirojion

From HIM we come , to HIM we return

I love King Charles the 3rd very much. I have been following him over much of my adult life over 50 or so years. ..He is just 3 years my senior...I pity him sometime because he bear the brunt of oftentimes, biased and unfriendly press for decades.

His late Mom was spared of this because she did not have to undergo any apprenticeship at all.!

King Charles the 3rd will be a great king!

He will probably surpass Queen E.

In this current troubled planet, King Charles the 3rd would represent a breath of fresh air.....

Mark my words.

OTHER ARTICLES ON DEATH & DYING :

http://drnikisahak.blogspot.com/2017/10/kassim-ahmad-in-memorium.html

http://drnikisahak.blogspot.com/2017/01/just-visiting-part-2.html

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

http://drnikisahak.blogspot.com/2015/10/truncated-lives.html

http://drnikisahak.blogspot.com/2008/07/not-so-pearls-gem-kaffarah.html

Life Is Tough.......[ but why be sad ]

Life is tough. ..fullstop.

Does not matter whether one has a Daimler in the garage and a trophy wife in bed.

Many of such blokes end up with suicides in the US, Scandinavia, Korea and Japan.

If you are 99.9 percent of what constitute the rest , life is even tougher

If you dont believe me that even those in  the rarefied 0.1 % of the strata find life tough, just look at who wrote a book about it recently, in fact a bestseller... Prince Ghazi, of Jordan.

Or if you have her personal phone number, you can ring Ms Melinda Gates and ask her.

Even Bill Gates probably is finding life, tough currently, disregard the changing SYT's that are sharing his bed at night.....[ a pun no doubt , but what business has one of the richest man in the world to do with lowly characters such  as Jeffrey Epstein etc etc and etc...... ]

On a more serious note, let us listen to what Paul Williams of 'blogging theology' has to say about life:

" Why Is My Life So Tough? ": Exceprt from Prince Ghazi' book...

(from https://bloggingtheology.com/2021/05/10/why-is-my-life-so-tough/)

 

Life Worth Living : Prince Ghazi bin Muhammad..

a wee bit watered down prescription, to appease the secular minds as well, but well, he wrote for everyone, if I can read his mind, and that is very good  of him. 

Very generous heart to share our secrets' with everyone.

That is his global daawah, I presume

In the process , if a few may have their hearts touched, they get the hidayat....they connect it to Islam. 

If they dont, it is OK, this is after all a free world.

    

[     https://youtube.com/watch?v=6tI0lAyW7pI&t=17s       ]

I pick Hamza Yusuf's short discouse , not to provide you guys any simple formullae towards happiness, but just to prepare a platform , a preamble, for you guys to be able to comprehend, the next one by  Khiai Muhammad Bhakiet's discourse, which is several notches up the scale into the realm of aspiring for both ' surga ' in this current realm, and the next..........a very tall order!!!

[    https://youtu.be/3tZRXTOyA_k      ]

"....are fame, wealth, health, all keys to happiness?   "

OK guys from here on, if you are non Muslim, you dont need to carry because you may not comprehend the discourse. It is super heavy stuff.

If you are just Muslim, and not yet Mukmin, you can also stop here. Hamza Yususf's is already good enough for you.

If you both Muslim and Mukmin, put on your seat belt......you can continue but it is going to be tough and rough journey ahead

Jannatul Firdaus in the next realm and 'surga ' in the current is not cheap!

One has to be super tough ' up there '.

It is a tough mental game for the few.

[ ..if I am beginning to sound like that character, Tom, in Mark Twain's 'Adventure of Tom Sawyer & Huckleberry Finn ' to my son Joe, who is familiar with my prodding and suffers well and silently so far, I dont blame him. This is a my way of prodding him along in this tough journey called LIFE.

He also have read ' Tom Sawyer ', out of curiosity.

A compulsory reading for all of us form 1 pupils at Sultan Ismail College, Kota Bharu in the early 60.s

Tom, the main character was tasked by her aunt to whitewash and paint the concrete pagar of their house. A dreary task. He had his friends lining up to join in the 'fun' and each of them paying him in return for the 'pleasure'. In present day scenario, Tom would have landed himself a very successful marketing or advertising career! ]

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

If you want to have the 'no hold barred' formulla to happiness, and want it NOW!!!, the one word answer is RIDHA, in all circumstances. The accent, is on " IN ALL CIRCUMSTANCES......"

In Islamic parlance,  the formullae is very simple, just 3 words in Arabic,  Alhamdullillah fi Kullihal , ie tranlated, " Praise be to Allah, in all circumstances. "

In time of 'expansion',  Al Hamdullillah .

Very easy this one....

In time of dire constriction, still able to say, Al Hamdullillah , or at worse, Al Hamdullillah..Inna lillah Hiwinna Ilai Hiro Jion .

This require a life long of data collection of ilm , ilm and ilm.

A life of Sabr, Ta'at, Shukr and Riddha

A maqam not easy to comprehend , let alone to aspire, especially if our mainly secular minds " banyak sangat songeng " and have too many , ifs , buts , whys and hows ". The problem inherrent with our secular upbringing and millieu.

Listen to Khiai Muhammad Bhakiet, and don't ask me...., if you cannot comprehend him, it is because you have not been able to leave your  " ifs, buts, whys and hows..."

[     https://youtu.be/tbA-kVESfQM    ]

But comprehension  is one thing, achieving it is another....

A lifetime of practice.......

36 year old man with an occluded Left Anterior Descending Artery........

36 year old planter with a big GLC.
Hypertensive for 5 years, on irregular treatment and clinic follow up.
Borderline cholesterol.
No family history of ischaemic heart disease.

Presented to me at the outpatient centre, SJMC, with a history of recent onset central chest discomfort related to mild exertion  and occasionally , even at rest, with radiation of discomfort in between the scapulae bones in the upper back, and " classical " radiation to neck and jaws".

 

"Dokto, saya rasa "senok di dada" dan "bebal"  saja di tulae gerehae saya ". He is Kelantanese..,"bebal", means dull ache.." Gerehae means jaws!!.." senok" or "sekok" to me is angina , unless proven otherwise.

The Kelantanese vocab is one of the richest in the world, their wording very precise!!

To old "kakis" like me, " senok" or "sekok" , with pt pointing their closed palm centering around the chest is sine qua non to ANGINA, unless proven otherwise!!

This chap does not need an ECG or Stress test.....He is having ANGINA, fullstop......It is academic.

His Resting ECG, done earlier by his GP is normal anyway.

I now seldom do resting ECG in such a classical case of chest discomfort presenting at my outpatient...go straight for the jugular...i do Stress ECG...if stress ecg at rest show abnormalities, we stop there..if normal, I process with the exercise.

Stress ECG very abnormal with ST-T depression on mild work load , and this ECG changes took long to recover in the recovery phase.

No play, play with calcium score or ct angio.
This young man needed an urgent coronary angiogram YESTERDAY!!!, and his blocked arteries opened!!.......YESTERDAY!!

He needs coronary angiogram to show me the exact " road map " for me to be able to triage him into one of possible 4 classes :

1. Normal coros, which is pretty unlikely in him but still possible......in which case, he has no coronary problem but the chest pain being "non cardiac" in nature, and he has a False Positive Stress ECG..

Very very unlikely, the way he present and the degree of positivity of his stress test, but nonetheless still possible.

2. Has coronary lesion/plaque or multiple plaques, but non-critical...also unlikely, the way he presents.
In this situation, if that is what the angio shows, he would need long term low dose aspirin and optimization of medical therapy and regular follow Stress ECG and high dose statin 

3. Plaques, single or multiple and critical.
If amenable to angioplasty and stenting, it would be done either ad hoc, or staged, depending on complexities and number of lesions..

If complex and nature of lesions borderline, in between BYpass CABG surgery and endoluminal techniques seemed to be of equal standing, I would stop the procedure right there, and discuss the angio the next day for pt to deliberate and discuss.......or even get a 2nd opinion, if he wish.

4. Multiple lesions and diffusely diseased, involving both the medium size middle portion as well as the small tributaries and branches....in which case, both CABG and endoluminal technique are not optimum modalities of treatment strategy.
He is only for " optimization of medical therapy ".
A euphemism actually. 

Not a nice scenario to be in , at any age.

We see this often in pt with long standing diabetics

I personally would not wish to be in this group.

The 'coros' that follow that same evening........

A coronary angiogram view of the left coronary artery. Here the Left Anterior Descending Artery is missing. It is 99 % totally occluded and one can only see a small blot in the centre of the cine picture, just a 'ghost' view of rthe remnant of the LAD, supposed to be biggest artery supplying the front portion of the most important 'piston' in the heart, the left ventricle.

With a wee bit of 'persuasion' and difficulty, i successfully passed a 14th thousand of an inch diameter guide wire,

sonne blue wire, passed across the occlusion...when this is done, 80 % of the " battle" is won...

since opening the occluded artery and subsequent placement of stent is contingent on having a metallic wire passed the site of occlusion...it act as a " railway line for balloon and stent delivery in the artery.

An appropriate balloon is then slided over the wire and expanded up to appropriate atmospheric pressure to open up the occlusion...when this step is deemed adequate, the balloon is taken out, and the artery is then ready for stent placement.

This is the final cine after stent deployment at high pressures between 16 to 20 atm pressure...the occluded Left Anterior Descending Artery is a really big dominant artery in this young man!!!

The whole procedure took about an hour an a quarter.

I was quite"lucky" with him actually, since the wiring into the occluded artery just took me less than 5 minutes.

It could well be much much longer.

I remember chatting away with pt about his recent trip to a Musang King durian plantation and the nice time he had there!....Oftentimes a necessary diversion, to keep what actually is a quite considerable tense an hour or two for pts like him, lying flat on the radiological table, fully draped and strerilised from the neck down to his feet, with myself and my scrub nurse, working thru a small needle size hole via his femoral artery......" playing video game of sort", with help of

an overhead radiological image intensifier

As you can see, these procedures are all done under only light sedation, to keep risk lower , as doing under GA would entails another additional risk, apart from an additional unwarranted cost.

My game plan most time is to ask my pt to concentrate on his favourite zikr while we work, if he or she is Muslim, but this time the young man was a 'bundle of nerves', so the 'Musang King' or "nasi Beriani" diversion was a necessary adjunct.

Pt was discharged well the next day on low dose aspirin and plavix and a statin to bring down his ldl cholesterol to below 1.4 mmol.

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

PS :

I am reminded of a car mechanic and a top American cardiologist in Idaho

The mechanic, after repairing the cardiologist sleek looking Mustang, handed him a rather hefty, atypical bill, definitely double the usual  Idaho 'going rate'.

" Why sooo much? ", quipped the cardio

" Doc, my bill is just peanuts compared to yours! "

" Well young man......your bill will not be peanuts, if you can repair my burst gaskets while the engine is still on! ", replied the cardiologist.

Lailatul Qadr 2021.....Upping The Ante

 Ru & Joe,

You two asked me last night after Teraweek what is papa's modus operandi for this year's LailatulQadr.

Papa's answer is very simple....Papa just up the ante further compared to last year and make it more simple and succinct.

After 'presiding over' the family teraweeh, papa try to sleep at 9. Not sooo easy as the mind is like an overactive 9 year old!

My overgrown prostate wakes papa up usually every 3 hours , so by 12 midnight papa am already up and about.

"Subhanallah wa bihamdihih subhanallah hil Azim , astagfirullah wa atu bu ilaik " for half an hour to one hour depending on the mood.

"La ila haillallah ", for half an hour

"La ila haillallah hu wah dahu la syari kalah ..lahul mulk ku walahul hamd du.........wahuwa ala kullishai in qadir ", another half hour.

Then recitation of the Quran.

You guys know papa still ''merangkak like a new found mualaf baca quran'', so papa follow Shaykh Abdul Basit on the hand phone while having the hard copy in front, for 1 hour or so.

By then it is usually nearing to 4 am.

Time for Tahajud prayer, papa do 4 cycles of 2 rakaat each , in between , 200 selawat to the nabi.

By 5, papa could hear 'Bibik Noor' opening her kitchen office to make nasi goreng.

Papa 'wash' the night with my usual prayer of expiation, the solatul tasbeeh, 2 rakaat each , 2 cycle.

If you guys get to papa's age, and try doing this on a daily basis or even weekly,   you both will pleasantly discover it is the 'sweetest' of Allah's gift to mankind, in the form of 'solat'.Of course Jo's tok guru like Dr Rozaimi and Maulanaapakahnamadiadah may not agree with papa.

But of course, when we have time papa will discuss with you guys about some ulama who chose to be "perpertual school prefects, and some moves on to join the lovers".Papa , am atracted to the Lovers.

While you guys sleepily trickle down for sahur at 530 am , papa try to complete solawat to the nabi another 200, to numerically complete a 1000 selawat 'cash' before subuh.

1000 is nothing magical about it. It is just a number, no sanad of course!!....a starter for the day for papa.

Before going to the hospital at 830, papa try to get a wink or two but 80 % of the time, the brain cannot rest.

The antidote is to listen to Khiai Muhammad Bhakiet's discourses or TJ Winter's etc etc,on the utube.

This give papa the necessary 'ammunition' to 'kacau' some of paps's friends on my broadcast groupings.

The rest of the day is just bonus for papa.

I try to do some zikr with some of Allah's sublime and magnificent names in the morning in between patients. ''Ya latif'' , is one of papa's very favourite..It is a very 'cooling' zikr.

It is a wonderful simple life, so far, and papa look forward to another  great Ramadan, insyaallah in 2022.

Insyaallah!!

Papa

Interventional Cardiology 101.......Coronaries of Diabetics

 

https://youtu.be/FkT5-ZTEVoc

Normal Left Coronary Artery. 

The central big long vessel, the Left Anterior Descending artery [ LAD ] supply the main "piston" of the heart, the ''main driver or pump" of blood moving out of the heart chambers to all part of body, via the major blood vessel , the Aorta.

The LAD supplies mainly the  anterior segment of the left ventricle. The Left Circumflex branch supply the back portion of the left ventricle. This cine shows normal circulation of both arteries with rich healthy branches.

You imagine your heart as big as your fist, these arteries sit on your heart, astride on the heart, like a 'mat rempik' on his 'motor bike'.

The LAD and the L Circumflex  branch join together to form the Left Main , which got itself inserted to the root of the big vessel the Aorta, receiving highly oxygenated blood just gushing out from the pumping left ventricle. This flow into the LAD and LCirx , which then move on on into the small arterioles and vessel which ramifies into the ventricular muscle wall, to supply oxygen and energy , ATP's, required by the hard working , non stopping muscle fibres of the heart.

When your heart stop pumping , you also STOP!!!

https://youtu.be/rlnfnX91jBQ

Compare that left coronary system with this one angio I did on an obese diabetic pt of mine, who just celebrated his 40th birthday, married, with 4 young children in toe. ..in his Left Anterior Descending artery itself I can see 4 significant lesions to be ballooned and stented. 

The Left Circumflex branch has one narrowing  which need ballooning plus DEB ballooning [ drug eluting balloon ] or small stenting. The view in the extreme left appears crowded because there is late appearance of distal circulation of the right system. It should not be there. The fact it can be seen from this left shots means the Right Coronary Artery is totally occluded....

This young man has severe triple vessel disease, at an early age.

He has had maturity onset diabetes since age 30.

Currently he is in deep 'shit'...he needs revascularization...1st choice would be bypass surgery. Given his relative young age, I have great  reservation about sending a young man for bypass, but it still remain 1st choice from the viewpoint of extent and severity of the blockages in the both the left and the right coronaries.

To me the left side is easily dowable even though I may end up implanting 3 stent there, but his right total occulsion as seen from the left coronary shots poses special difficulty for us 'plumbers'.

1stly, we may not be able to the cross the occlusion with our guidewire, a necessary pre requirement before we can balloon or stent the lesion. The guidewire acts as a 'railway  sleeper and line for the balloon and stent deployment.

Nonteheless, if this young man refuse surgery , I will do him in 2 stages.

1stly the left system. If I am happy, with the result, I may not even attempt to open the right, since it is already well covered by the retrograde flow from the left.

Of course some 'purists' amongst the plumbers would insist on doing the right, whatever the cost, even though there is a high risk of wire perforation of the artery, since the occluded portion in the right appears too long for comfort.

To me the right coronary is already a 'lost cause'.

The young man has had a 'silent' heart attack in the past on the right side...something common in a diabetic...damage to that side has been done...and now he has some blood supply to the right side from the diseased left. If I correct the left, the right side will get better supply., full stop!

Bypass surgery in this young man , though the 1st option, is not even ideal. The LAD would need sequential graft with a LIMA graft, since there are multiple blockages in the LAD.

Like everything, even bypass surgery has  a 'shelf life'.

By 10 to 12 years, some graft may reblock.

Stents and ballooning also have its  problems....restenosis...though it is easily repeatable.

We are looking at shelf life and shelf life.....whatever we do!

This is not an ideal world...the world of a diabetic with coronary problem.

I approach coronaries like playing 'gin rummy'.

To me, CABG is the all important 'JOKER'.

If I can delay using my 'JOKER', I will delay playing it, and by time 1st with balloons and stents.

'Gedebuk gedebak gedebuk gedebak' young diabetic with coronaries problem give special headache to both us 'plumbers as well as to surgeons!

Diabetes with obesity are causing major problem in the young people this millennium further compounded by a relative lifestyle of physical inactivity.

There will be an epidemic of diabetes amongst the younger generation now since the IT, the handphones, and the video games have produce a whole generation of obese, 'couch potatoes' amongst our children.