time is myocardium!

yesterday's call was horrible. it was initially ok, i just chilled out in my room having nasi goreng ayam while watching Tentang Dhia. The MA called me around 7.45pm to review an x-ray. nothing much, just a closed distal end of left radius and ulnar fracture. yeah, no big deal bout that. just pull and cast it.

it started when a malay uncle around 60+ yrs old came for chest pain. he was having the pain since 9am, but only presented at 8pm. sigh. the pain was typical for acute coronary syndrome (ACS). in addition to that, he had vomited around 4x on that day and having epigastric pain. typical for ACS as well. something was hiding actually. overlapping symptoms. yes, the ECG showed LBBB. i took it as a new LBBB. firstly, i don't have a baseline ECG to compare. secondly, the chest pain is typical. thirdly, this is the first episode of him having this kind of pain. in district hospital like KKB, we don't have Troponin T or even CKMB. just the unspecific CK. the most we have is cardiodetect kit, which detect the h-FABP and it's limited. so, the CK value was 2000+, sky high! and to my suprise, his RBS: 20.0 and urine ketone was 3+. remember, no ABG machine here. obviously he was in DKA as well. oh my!!things get complicated when his BP was persistently low. not more than 90/60mmHg, and i had to start him on IV Dobutamine. he gave me a real headache. cardiogenic shock secondary to acute myocardial infarction complicated with DKA. definitely i was unable to give him IV Streptokinase, considering his BP was low and he presented quite late. furthermore, the platelet was only 83 and INR was 1.5. forget about streptokinase. and suddenly my brain was numb. how the hell should i hydrate this DKA fellow??his heart is failing...i can't give so much fluid to him. i really don't know what to do. to hydrate or not to hydrate...(anyway, i had asked for second opinion regarding this). i only gave him crushed aspirin and GTN. he might be having some kind op sepsis on board which trigger the MI and DKA but i couldn't find the source of infection.

1 hour after that, around 9pm a lady came in brought by ambulance from GP. she have no past history of bronchial asthma. she had an acute breathlessness and left sided chest pain since 4pm. at the GP, her BP was 173/114mmHg and there was generalized rhonci. i don't have a slightest idea how the hell the GP treated her as acute exacerbation of bronchial asthma with uncontrolled hypertension. she was nebulized twice and T. Nifedipine 10mg and S/L GTN was given at the clinic. crazy!!i mean, with that high BP and generalized rhonci and crepts, she is having cardiac asthma, damn it! hurriedly, i asked the staff nurse to insert the urine catheter and shoot her with IV Frusemide. ECG was done subsequently- it's ST elevation. she's already in acute heart failure state. i thought my heart stopped beating for few seconds!! 2 myocardial infarctions at a moment.

God, it was a real palpitation. i never experienced this before. i mean, 2 MIs at a time and i was alone. just the MAs and staff nurse helping me. all decisions are all mine! it was really scary, knowing that time is myocardium! it's like i was having chest pain as well and if another MI came, it's gotta be me! i managed to give IV streptokinase to the lady, and thank god, no complications occurred.

obviously both patients needed CCU care. at that time, i knew it was quite difficult to get 2 CCU beds in same hospital. anyway, i just tried my luck. firstly, i called Hospital Serdang, unfortunately their beds are full. not to waste time, i tried HKL. the CCU MO oncall was very-very nice to me. she accepted the second patient, but for the first patient she asked me to give a try to IJN for rescue PCI. but i refused as IJN don't accept direct referral from district hospital. i had an idea maybe physician needs to assess the patient for suitability of rescue PCI. at last, she accepted both patients. alhamdulillah.

last thing i heard was the first patient (uncle) had collapsed in yellow zone at the referral centre. sad. i was sad that he couldn't make it. but i have gave him all out when he came to me. the best that i could do for him. the second patient, i hope she will survived.

do you know the feelings when you treat your patients sincerely, doing the best you can do for them with you limited resources, and in a weak voice they thank you....it's priceless! insyaAllah, you will get the barakah for every cents that you gain. this might be the once in a lifetime experience for me, and i really appreciate it and these 2 patients. i learned a lot from them, and from this experience, it helps me grow. wallahualam.