Just Visiting.........

After a very busy Saturday morning clinic, I went back to the ward to visit a dear friend of mine. A Malay College old boy network, senior to me by a good 10 years, we did Haj together in the mid 80's. He, dying slowly but definitely of cancer, squamous cell carcinoma of the lung, his left lung riddled with tumour masses and inflammatory fluid, his right lung still cancer free from the look of chest X-ray. Myself, a week earlier I thought I was also dying. Funny, how 'little illnesses 'can change one's perspective  to life, and  once healthy, back in the grove, you think the world is yours ! Today, I am still groogy and feeling fuzzy in the head with a tinge of that 'pregnant feeling', but already  on the verge of thinking the world is mine.

Mashaallah, this heedlessness , this'ghaflah' ! Astagfirullah hal azim.

" Doc, Dr Ashoka has not put up any referral yet for you to see Yang Mulia Sutan Kahar Budiman ...", the ward sister muttered politely reminding me I have no business here
" No. I am  an old friend of Yang Mulia. Just visiting....."

Sutan Kahar Budiman [ not his real name of course ] in his days could have done better than Sammy Davies Junior and  Matt Munro put together. A karaoake expert. A livewire at dinner gatherings. When I went into his room he was standing, looking breathless plus plus, plus supported by his children and wife on both side. He was a shadow of his old self, half the size. His hands and feet are cold and he appeared ashened. Fear sketched on his face.

I reorganized his bed, made it more upright and reconfigured it into a trendelenburgh position to prevent body slippage, and with the help of his son, got him back to bed. Standing and getting more anxious would not help his poor oxygenation in the lung.

"My friend , I know this difficult time for you... it is difficult breathing for you but you have to reallywork on your mind to take away your anxiety and ease this real breathing difficulty.  This may work if you try hard enough and sabr. Concentrate on ...ya Salam, ya Salam ya Salam....or ya Latif. Think Astagfurullah, Astagfirullah,... and  do a lot of 'Selawat on the Nabi'.....This will help you immensely." I am being diplomatic for want of something to say. He needed to be ventilated, but for what ?? To prolong his agony and give his family a false sense of something being done!? His time is up......I can see the futility of it all.

I know the score. In a few days time at the most or even tonight, Sutan Budiman may go into coma due to respiratory failure. May need to be  ventilated artificially. But as long as concious level is still intact, it is critical at this time to be in continuous remembrance. It eases the pain and the fear.....

Success is a mind game as the cliche goes. I would venture further from this. From my perspective, Life[ and  for that matter even in death ] is a mind game. If we are in continuous remembrance of Him throughout our lives,  insyaallah, even near death , we could still remember Him. And the difference is tremendous. It could well be 'husnul khatimah' and not  'suul khatimah' !

Remember the 'evil whisperer' at work.

As I sadly walked away from his room towards the cafetaria  for a late late lunch my memory was drawn to another near death incidence, some six years back. Then, I had a small piece of TOL land in Cyberjaya. I gave permission for Wak Karman from Indonesia to stay FOC on the land while he and his wife worked on a nearby farm owned by a Chinese farmer.

He must have been about half my age but hardship made him looked older. Wak Karman , being ambitious , I think, must have borrowed some money from the infamous Acheh triad to organize his own farm on some abandoned land in nearby Putrajaya. The long and short of it was that his business venture did not work. His farm was Ok but he could not sell his produce fast enough. His Chinese towkey friend, who now considered him their rival, just pulled the carpet from under him. Vegetables aplenty but no market. Wak Karman was a dead duck in a week! Figuratively and literally. His Acheh connection did not take too kindly to unfulfilled promise......

One morning the village was rifed with the news that Wak Karman was found paralyzed from neck downward, sustained after a presumed fall from a rambutan tree. The tree was at the most part, only 8 feet tall ! In Serdang Hospital he was diagnosed to have a clearcut, precise  fracture at the C4 C5 vertebrae and the CT showed clean trans-section of the spinal cord. From my perspective a nice place to wack someone really hard from the back with a long wooden thing. It was clearcut homicide, if he dies, and surely he was going to die. His breathing was laboured, his abdomen was distended from retained urine and inability to move his bowel. His young wife knew it and there was already 'desus desas' amongst the small  ' illegal Indon 'community in Kampong Meranti about potential candidates taking over 'the vacuum' with his impending demise.

The 'desus desas' was not on just generalities. There was already 'open 'discussion' on the 'specifics', whether the new suitor should wait for the three month 'eddah' or whether that was not necessary since it was common knowledge in the kampong that the couple was having a hard ' patch ' for over 4 months already and has ' not been together' . Such is justice and the nature of things operating at this level of 'illegal communites' here which not many people knew. They are basic people coming here to earn a morsel here and a morsel there, no time for superficialities and facetiousness of the upperclass!

Wak Karman was brought home to his kampong Meranti house to die and his friends expected him to die 'fast'. Many working days already 'wasted' with them milling around his house. Yasin were read, and prayers and prayers had been organized, and he was still there in bed, unmoving but muttering loudly,

" Apa ini Tuhan, apa ini Yasin !...Mana ada Tuhan !!?? "
And now a different kind  and round of prayers needed to be organized again. This must be the local 'jembalang' that has gone into him.  Wak Karman was on the whole not religious, as most of them are anyway, but this cannot be him, they surmised rather collectively.Several kiyai came. And they failed. His friends were getting anxious and exasperated. The Indons illegals are a superstitious lot, I must say, but they are a close community, helping each other in time of needs.

One night , I took time off from my call and decided to just pay him a visit.
His small hut was full of friends, some milling outside, some reading the yasin and most staring into space in despondence. The was an air of total despair that I could sense in that small, house, dimly lit by a 'pelita' powered by old used cooking  palm oil.

" Wak ! I want you to repeat after me, 'la ila haillallah muhammadarasullah' "
"La ila haillallah Muhammadarasullallah! ", he shouted
Then we read the al ikhlas together.
After that, without my guide, he did the Azan!
Mashaallah !
Everything suddenly became so much brighter.....

I walked out into the night and according to my younger brother, who stayed back for the night virgil, the 'illegals' unanimously voted and conferred me an automatic 'honourary kiyaiship'. I did not have to pay any entrance or membership fee !

The next evening Wak Karman died.
During his burial, the local police decided to pay a visit at the local cemetery, and all his friends  fled, including all the grave diggers, only leaving  the poor  imam to read the 'talkin'.
May Wak Karman's soul be amongst the blessed........


Ya mukalibal qulub, thabit qalbi ala kaa di nik
Ya mukalibal qulub, thabit qalbi ala kaa taatik
[ oh the One who changes hearts, firm my heart on your religion
  oh the One who changes hearts, firm my heart in Your obedience ]




Nik Howk




Similar Articles in the blog:

1. Cancer
http://drnikisahak.blogspot.com/2009/01/pearld-gem-cancer.html

2. Unto Him is the journeying
http://drnikisahak.blogspot.com/2011/02/unto-him-is-journeying.html

3. Book : Purification of the Heart
http://drnikisahak.blogspot.com/2012/03/books-purification-of-heart.html

[   http://www.youtube.com/watch?v=rNfQxnRoPHo  ]

Case History : Dilated Cardiomyopathy

http://www.youtube.com/watch?v=RYe-l-mP89k


In my clinical practice I do 'collect' one to two cases of congestive dilated cardiomyopathy  a month, not that rare, but my statistic is skewed because as a cardiologist, this kind of problem do land up on my 'table' .

Notable amongst them is a Malay male,  lorry driver, 45 year old who saw me some 13 years ago with a big ,globular heart on chest x-ray, coming to my outpatient clinic with complaint of shortness of breath on mild exertion. Echocardiogram examination revealed reduced heart pumping action [ contraction, LVEF ] of about 25 %  [ normal LVEF  is between 55 to 80 % ]. He is now 55, has three daughters who are now doctors, one of them in a specialist training program at the UITM hospital in Selayang. Every time I see him in my clinic, I tell him that he is the 'most successful lorry driver in the whole wide world !' His LVEF has climbed up to a decent 48%. Eddy Warman, that is his real name. With success, one do not need to use a pseudonym.
" Would you like me to refer you to Sungai Buluh ,Eddy, because there is nothing spectacular with your medications. All simple and all freely available for free in the government hospital ?"
"...Biarlah doktor. Disini ada barakah. Saya boleh bayar.. "
This 'biarlah doktor' has been going on for 13 years.
It is simple people like Eddy that keep me going all these years.


Which reminded me of a  patient I saw yesterday. And this is a digression from the subject. Not my patient actually. He came in for an 'executive profile' full examination and a stress test by me was one of the 'profile'. I was busy upstairs with my regular patients. I was late for 20 minutes.
" Doc, You guys treat us like animals!!....blah blah blah blah blah blah ", he stood on the threadmill  with arms akimbo, ready to fight. I read him well.
" I am very sorry Mr Ding, this is  totally unavoidable" , I am sorry.. ". 
We do  meet such characters in our daily practice once in a few years.
After nearly 33 years of practice, I thought of giving such young punk just a tight slap on the face , but he was lucky , I have a bad cold and was in no mood for confrontation.
They are usually lawyers. The lawyer-doctor alchemy is a bad alchemy I must say.
Lawyers somehow feel life is always confrontational.

Three ladies with congestive cardiomyopathy on my follow-up over the last 5 years did extremely well. One is an insurance banker, in her mid 40's, who came shortly after losing her baby at delivery and presented with heart failure [ peripartum congestive cardiomyopathy; cardiomyopathy realted with pregnancy ]. To make matters worst and cloud the issue further, she had dengue fever near delivery with platelet level around 12 thousand !

LVEF 12 % ! I had to ask a nurse to follow her whenever she went to the  loo. At 12 %, you can get cardiac arrest anytime or a bad fall in the toilet. Two months down the lane, she was fully active in her job and follow up echo six month later, was normal. Al hamdullillah!

The other two ladies in their 40's had 'tachycardia -induced' [ untreated fast heart beat ] dilated cardiomyopathy. The diagnosis was not apparent initially but much  later in their clinic follow up they came back with fast rythm [ supraventricular tachycardia ]which clinched the diagnosis. I referred both of them to my junior colleauge who did a 'radiofrequency ablation' of accessory pathways in their hearts. In layman's term these two ladies have an extra 'electrical circuits' in their hearts 'electrical cable system' that get  'switched on' for long period of time.
They are doing very well now and their LVEF are low normal.

...and there are young deaths as well. Mr Rodrigo, presented at age 41, a long haul tour bus driver plying Penang KL route, with a heart as big as a football, LVEF 18 %. Lasted for a long 5 years. Miraculously driving until his sudden premature demise at home from a cardiac arrest two months ago. In the UK I would be duty bound to have his license taken off by informing DLVC but in the UK they have good social security as safety net. I knew what was coming, thus advised him early on to co-opt his son to start taking over the business from him.

What is the role of heart transplantation in dilated cardiomyopathy, one may ask? It has a definite role and IJN is the place for it but one or two heart a year with a few hundred or thousands on the waiting list does not make a programme....Cadavaric heart donor is still a rarity in Malaysia.
So in my group of patients I prepare them  and their families early for possible premature demise, and do not put false hope in the horizon.

My 'champion' of course is  Mr LK Lee,a 40 year old dog-trainer, a bachelor, who spent 8 years of his life training dogs for the Saudi Police. I saw him 10 years back, walking into my outpatient clinic with bloated abdomen plus plus and bloated arms and bloated legs due to fluid retention. The bloated legs were so bad , that I could see fluid oozing out from its pores! His LVEF was in single digit and his heart was bloated and hardly pumping as seen on the echocardiogram.

Just last week I saw him on his three monthly follow up visit, looking very good.
"Lee, I did not tell you this but when I saw you 10 years back, I mentally gave you only a  month at the most to live.....", myself ,trying hard to bring the question of mortality on the table...
"Doc, this Tuhan-Allah has been kind to me . I am still able to train some dogs for a living, otherwise how I can pay your bill? "...[ Lee is still 'in this world' and not ready just yet, I thought to myself ]
" My God..Lee, you make me feel guilty. Your drugs cost peanuts compared to those guys who  had stents and angioplasty.."....
For Lee, 10 years is a long long time. Perhaps it is time I address his other 'heart' but political correctness and medical decorum does not allow me that leeway. And he is obviously not ready yet.

This is the 'stuff' that keeps me awake at night pondering, whether I have done enough.
Political correctness versus 'marhabah' for a fellow man.
It is not easy. You feel you have the alchemy and the secret to happiness in this life and the hereafter but you are not willing to share the secret  with the rest.
It is a responsibility we Muslims have to answer.






Nik Howk


ps : 
26/ 12/2013 [ one day post christmass ]

 just saw lee this morning at clinic
" kai fahal Lee? " [ how are you?]
" insyaallah doctor, alhamdullillah "
still the cheerful lee that i come to know 10 years back when he was just 47
he is 57 now, still training his german shepherds for some friends
" bila mahu masuk islam Lee,arab sudah pandai", i said half jokingly, half serious
"..belum ready, doc.."
i have a feeling of 'marhabah' for Lee after all these years
he is my favourite patient and why not: a 'left ventricular ejection fraction of only 8 %
and still around after 10 long years....a world record of sort!!!!







Other articles in the blog :

http://drnikisahak.blogspot.com/2013/01/case-history-takotsubo-cardiomyopathy.html

http://drnikisahak.blogspot.com/2011/12/case-history-most-successful-lorry.html

Purification of the Heart : " Matharat al Qulub'
http://www.youtube.com/watch?v=_ges5k0LTjI