One day, a middle-aged man presented himself to our clinic at the Sheri Kashmir Institute of Medical Sciences Srinagar (SKIMS) hospital where I was pursuing my post-graduation in Internal medicine years back. “Doc,” he said, no sooner do I feel a headache, than I become pretty sure that my blood pressure must have hiked up. I immediately take the medicine to bring it back to normal. I have been doing exactly this for many years now”, he went on. On taking it, I noticed that his blood pressure was very high. I then examined the back of his eyes with the help of a funduscope1 and saw that the thin blood vessels were tearing as a result of the damage caused by prolonged high blood pressure. It was obvious to me that his high blood pressure was causing similar damage to other blood vessels in his body, a fact of which he seemed to be completely ignorant. “Uncle, I said, “it seems that you are not taking your medicines regularly. Taking medicines once in a blue moon, the way you have been doing, will inevitably cause damage to all organs in your body” I explained to him further. “In addition, not only the table salt needs to be restricted but in consultation with our dietician, please understand the hidden sources of salt in your diet, and restrict those too” I said. He watched me carefully, while intermittently nodding his head as well to show he understood me. I went on. “In addition, to try and lose some of your excess weight I suggest you to go for a brisk walk at least five times a week in case your busy schedule doesn’t permit you to do so I advise getting a treadmill and using it.” Having listened to these words, he left the clinic. My next clinical encounter with him was in a few months’ time. The blood tests at that time showed some kidney impairment. “Uncle, the tests on your kidney function show that we need to be careful about further damage to the kidneys. Kindly don’t underestimate your high blood pressure. It is a silent killer,” I carefully explained to him. It seemed that the cruel arms of hypertension had damaged his vessels everywhere and consequently damaged the organs in his body. His wife was with him and told me “He never takes his daily dose of medicine, Doc!”, while glaring at him.
When I saw him again in the clinic several months later, I felt very sad. He had lost his healthy facial sheen, and an ultrasound of his kidneys showed that both had shrunk, due to his persistent and uncontrolled high blood pressure. “Doc!” he complained, “I am tired all the time, and it is now starting to affect my business,” he went on. “I’ve never felt so weak in my life before,” as he turned his head and glanced down. Blood tests had revealed that his hemoglobin levels were low, and on further evaluation there was no obvious source of blood loss, the low hemoglobin level was clearly a symptom of the progressive kidney disease. He was started on injection Erythropoietin the blood-producing hormone, which his diseased kidneys were refusing to produce. Unfortunately, the patient had no insurance cover and was forced to purchase lot of medicines from the open market, thus adding to his increasingly precarious financial situation.
One day, in the dead of night, he was brought to emergency room in a drowsy state. His anxious wife explained that despite a high intake of fluids, he was unable to urinate properly. Once we examined him, we found that he was suffering from fluid retention and consequently his kidneys were unable to flush off his blood and needed an artificial support dialysis2. “Dialysis!” said his wife, striving to understand what the implication of this was. “Doc, does it mean that his kidneys have failed?” “Unfortunately, you are right. He has kidney failure,” I explained to her. “Oh no, Doc! Is it a single kidney or both of them? his son whispered from the corner of his bed.
“Unfortunately it is both,” I replied in a sad voice. We immediately connected him to a hemodialysis machine and the dialysis was started. Hours later, he was feeling much better and started talking again, and after few days he was discharged.
On his next follow up visit to our clinic he remarked to me “Doc! my son is now looking after the business as I don’t sleep properly, and my capacity to work is severely impaired as I get tired so easily I never wanted him to interrupt his studies, please believe me,” and with this he burst into tears. His renal disease was killing him inch by inch, and one day our head of dept. talked to him and his family. He explained that if the patient could have a kidney transplant, his fatigue and his quality of life would be improved, but that it was a very expensive procedure. “Doc! we will sell everything we have to help him come out of this misery. Please save this ring, which is very dear to me. I value it very highly and have had it for 30 years, in fact since the day we became engaged. But Doc, it may not fetch enough money …” his tearful wife said. While speaking her voice broke, and she wept bitterly. “Take my kidney sir! I am ready,” she said. “All his life has been spent in building us a good home and in the education of our children, Doc. He is my darling and I cannot imagine life without him”. It was decided that his wife would donate kidney to try and save her husband. The patient’s face flushed with happiness, and a new ray of hope emerged in his family. He was registered for the operation, and the preliminary work up for his kidney transplant was started in the couple. Kidney transplant seemed to end the misery and rejuvenate their yesteryears. They happily sold their house and started collecting money and getting ready for the transplant. With the family full of the hope for the
good outcome of the renal transplant, he was brought to our Emergency room one day with severe chest pain. He closed his fist and rubbed his closed fist over the breast bone, saying, “Doc, I am having terrible chest pain here”. The blood tests and ECG showed that he was having a heart attack. “Auntie, we need to send him for cardiac catheterization as he has unfortunately developed a heart attack,” we gently told her.
“Doc! I have always regarded him as a brave person. He has never had any heart problem in all the time that we have been married,” she said. “His vessels had become hard and the blood supply to all his organs has been affected. With kidney disease as well, the damage has quickly got worse,” we explained. The patient underwent coronary angiography which opened the vessels of the heart. In this manner, his chest pain was relieved and he was discharged home again a few days later. During his stay in hospital, his blood sugars were found to be elevated on repeated occasions, and as he was a prospective renal transplant patient, he was started on Insulin. With addition of three more drugs, the family’s monthly drug bill inflated further.
Keeping in view this episode of the heart attack, the renal transplant was postponed. He was put on blood thinners to prevent further blood clotting in the vessels of the heart. Over the period of time I knew the family, I observed that the financial strain was draining them, and that the son, being inexperienced, was unable to handle the business as effectively as he should. He would always accompany his father for dialysis, which was done thrice week. One day my patient was brought in with a history of black stools, suggesting blood loss from the gut. An endoscopic examination was done, and we observed that he was bleeding from his stomach. We quickly realized that this was probably due to blood thinners he was taking, which had been prescribed with the intention of preventing the clogging of the vessels in his heart. These medications had eroded his stomach, and caused the passage of altered blood with the stools (melena). The situation was akin to that of being between the devil and the deep blue sea.
He was given a blood transfusion and other necessary treatment. The carry bag of the family’s medicines was progressively increasing, and so were their hospital visits. The family had become familiar to everyone in the hospital as they were visiting every week for dialysis as well as for appointments in other two departments. Our patient’s chubby face was becoming gaunt and pale and his wrinkles were getting prominent. One fine day several months later he was brought in in a deep coma. His son and his wife were carrying him on a trolley. He was in a deep unarousable sleep. “Doc!” exclaimed his wife in despair, “he is now taking his medicine regularly, so why he is getting complication after complication?” I had no answer to her question. I sidetracked and started calling the radiology dept. for a quick appointment for a CT scan of his head. The scan revealed a massive hemorrhage which was not amenable to any surgical intervention, and which was causing the coma. He was started on conservative treatment and the poor prognosis was explained to the family. “Doc, please explain to us whether we could have helped him before the rupture of his brain vessels leading to his deep coma,” his son very innocently inquired. The uncontrolled hypertension had mercilessly damaged his blood vessels everywhere in the body. The nasty game had started way back, I explained to his anxious son. “But Doc, he was taking his medication regularly and we were taking every precaution to keep him going” said his son. I kept my hand on his shoulders, and I gently remarked “My dear, it was all too late.” The blood leak due to the damaged vessels in the brain was in the vital centers of his brain. He was breathing but not responding to any painful stimulus, verbal commands etc
Even though every effort was made to resuscitate him, one day as the morning was growing, the angel of death kissed him and his soul flew back to God. He could never have his kidney transplant, and the dream of the family was devastated. They carried his body back to their tenanted accommodation. Dear reader this gentle man left on his heavenly abode and left some messages. Never underestimate hypertension.
Headache due to hypertension occurs only when it is very high, otherwise it is a silent killer and doesn’t cause symptoms before organ damage It badly devastates blood vessels all over the body. It can affect the heart, the kidneys, the brain and other organs, so it is very important to know the cause of the hypertension and to manage it properly. After diagnosis is made it is very important to regularly take medication, control weight and salt restriction. It also requires proper follow up of complications, and regular treatment. The index case I have described in this story had features of metabolic syndrome.
Metabolic syndrome is defined as the co-occurrence of metabolic risk factors for both type 2 diabetes and cardiovascular disease (CVD). According to the National cholesterol control program and Adult treatment panel III, any three of the following can be called metabolic syndrome; central abdominal obesity, hyperglycemia, dyslipidemia, and hypertension (Blood pressure more than 130/85mm of mercury). It is an important risk factor for the subsequent development of type 2 diabetes and/or cardiovascular disease. Thus, the key clinical implication of a diagnosis of metabolic syndrome is the identification of a patient who needs aggressive lifestyle modification focused on weight reduction and increased physical activity. Reduction of risk factors for heart disease includes treatment of hypertension, cessation of smoking, glycemic control in patients with diabetes, and lowering of serum cholesterol according to recommended guidelines. “Sorrow prepares you for joy. It violently sweeps everything out
of your house, so that new joy can find space to enter. It shakes the yellow leaves from the bough of your heart, so that fresh, green leaves can grow in their place. It pulls up the rotten roots, so that new roots hidden beneath have room to grow. Whatever sorrow shakes from your heart, far better things will take their place.”
– Moulana Rumi
Excerpt from the Book Bumby Roads authored by Dr. Ibrahim Masoodi who graduated from Govt.Medical college Srinagar, Kashmir and completed his DM in Gastroenterology from PGI Chandigarh India . Apart from his work as a physician Dr Ibrahim has keen interest in literature. He can be mailed at [email protected]