Dr. Rap

Samuel Kojoglanian, MD, FACC, FSCAI
One of our ICU nurses was experiencing chest pains and a blood test revealed he was having a heart attack. His EKG spoke of trouble so we headed straight to the cardiac catheterization lab.

The first picture showed a 99% blockage in the left artery and a 99% blockage in another major branch.  Wires were placed down the artery and a stent was deployed. Despite a 100% opened artery, my patient’s chest pains intensified. The artery segment downstream from the stent was dissected, and I covered this cut with another stent. My patient’s pain escalated, so I thought it must be the other artery since the mended sites looked excellent.

We began concentrating on the other artery, placing a stent there as well. My patient was distraught that we had to place a stent in another artery. He continued to have pain, despite fixing everything possible. By this time, I would have been finished, but his ongoing pain prompted me to search. I looked back at the first artery and noted another dissection, one upstream from the first stent. It took 20 minutes to manifest itself, as it wasn’t present in the previous pictures. We placed another stent there and the pain resolved.

I think it’s fair to say that we hate pain. We’d like to go as far as we can on life’s freeway without hardship, sickness, conflicts, trials or betrayals. We’d like all our prayers and wishes answered in our time and our ways, and We’d like to exit before we lose our minds or our strength. But have you noticed? Pain has its own agenda.

We don’t have to wave down pain; life hurts, and someway pain finds us. I don’t like it or invite it, but I have to deal with it. In my patient’s case, multiple blockages and ongoing pain helped me detect a critical problem and fix it before it led to my patient’s demise. Blockages, road blocks, suffering and pain can be a catalyst in helping us succeed, excel, and heal. Don’t waste your pain. If we listen to it, we can correct ourselves. If we heed it, we can protect ourselves. And if we learn from it, we can prepare ourselves to help others.

For further information on your cardiovascular health, contact Dr. Kojoglanian, the Mender of Hearts, at (661) 259-1711. 24868 Apple Street #103, Santa Clarita. Web site: drrap.com

“You’ll do fine with the aspirin alone.” But he didn’t. “We will not be prescribing your Plavix.” They should have. My 87 year old WWII Veteran patient has coronary artery disease. I had placed a coronary stent in him that required Plavix (blood thinner) for at least 9-12 months. Unbeknownst to me, his primary MD refused to refill the drug, which is free from the government based hospital. After being forced off the medication for 5 days, he presented to the ER almost dead with a massive heart attack. The cardiac cath showed a clot in the stent because the Plavix was stopped. We fixed the blockage, and my patient has improved.

A new health care plan is proposed in the US and our President states anyone can choose their doctor….“period.” As Bush Senior once said “Read my lips” and then changed his course, I believe our President will likely do the same, stating, “Yes, I did not anticipate things were so bad.” In a news brief, Mr. Obama said if there is a blue pill and a red pill and the blue pill is just as good, why have the red pill? Well, Mr. President, maybe the patient has an adverse reaction to the blue pill, or needs the red pill like my patient. Why don’t you let me even throw in a white pill? I am not for waste, but I warn against haste. Why are we moving so fast? Slow down, and let us see the truth.

When we go to the MD, we don’t want it to be like the DMV. “No Sir, you’ll have to wait 2 more years for your chemo drugs. Mrs., you’re too old for this procedure. Child you haven’t suffered enough…get back in line.” Because the new plan has Medicare cuts, more MDs will drop Medicare patients and then our patients will have plenty of time to chat while they see their compassionate and loving “DMV MD”.  Scare tactics? Yeah right, just ask my patient who didn’t get his Plavix.

I believe we must surgically remove the lawyers who are filing frivolous law suits and punish them. We could then stagnate “defensive medicine” which would decrease unnecessary medical procedures, and therefore decrease medical costs.  We must warn and penalize physicians who deliberately extend hospital days so that they can make more money. Insurance companies should allow a patient to carry over his deductable into the next year so he doesn’t have to start all over. The insurance companies and their exectutives are making plenty of money and need to stop raising premiums.

But whatever we do, keep the goverenment’s hands out of medicine. I believe Mr. Obama’s Health Plan is conceived with lies, pregnant with trouble, and will give birth to disillusionment, despair and defeat. 

Do you see Americans go to Canada for health care? This new plan will cut down on paper and costs? I’ve seen your papers at the DMV, and I’ll pass.  As for me, it ain’t just red or blue. It’s red, white and blue baby! Welcome to America ya’ll!!

Samuel A. Kojoglanian, MD, FACC, FSCAI

For further information on your cardiovascular health, contact Dr. Kojoglanian, the Mender of Hearts, at (661) 259-1711. 24868 Apple Street #103, Santa Clarita. Web site: drrap.com

Samuel Kojoglanian, MD, FACC, FSCAI
 

A middle aged man who takes care of horses was in his barn on a hot Southern California August day. While working, he reached back for an 8 ounce water bottle, and chugged it down. Feeling the heat beat on him like a cruel hammer, he was forced to sit down. He felt ill, had blurry vision, was unable to move his legs and passed out at high noon.

Minutes later, his wife found him flat on his face and began to panic. She fumbled with the phone and called 911. Our patient was rushed to the emergency room where a head CT scan showed no bleeding. Because of neurological changes, he was diagnosed with a possible stroke. No heart attack was detected and his heart appeared strong.

By late afternoon, my patient appeared alert. “What were you doing in the barn?” I asked. “Working.” “Did you have any chest pains or pressure?” “No.” “Do you recall what happened to you?” “No, I don’t Doc.” “Did you eat anything funny?” “No.” “Did you drink anything funny?” “No, just a bottle of water.”

His wife’s eyes grew big. She gasped as she placed her hand over her mouth. “You drank from that bottle?” “Yes, it’s my water bottle,” he said. “No, no, I placed Dipyrone in that bottle…I didn’t think you’d drink it!” Dipyrone is used for calming horses, usually injected into muscle. It is clear like water, a central nervous system depressant, and not used for human consumption. After startling his family and medical personnel, our patient was discharged home 24 hours later with full resolve. There was no malice or foul play in this loving family, but our patient surly tasted the ill effects. 

As consumers we are constantly drinking from the bottle, whether marked or not. If the bottle is full of tobacco, don’t be surprised with the stroke or cancer. Bottles full of cholesterol usually lead to heart attacks. The bottle jammed with anger will usually lead to depression.  Bottles filled with grace, mercy and love will pour out endless joy wherever they go. Before you take the next sip, make sure you know what’s brewing in your bottle.

My patient was prodded by his wife to visit me. “I don’t need to be here Doctor K. I feel good. I’m what you call shatter proof!” He was in his young 60’s, had borderline high blood pressure, and still worked six out of seven days.  I had never seen a shatter proof patient before so I recommended he undergo a stress test.

During the test, he became quite winded and images showed part of his heart muscles weakening. After going over the results, we scheduled our patient for an angiogram, where one takes pictures of the coronary arteries. A critical blockage was found in his left heart artery and angioplasty (opening up an artery with balloons and stents) was successful.

Several weeks later, while our patient was climbing a ladder, he felt a snap in this thigh. He was diagnosed with a torn muscle, which required hospitalization and surgical repair. During one of the nights, he yelled and screamed that the ceiling was on fire and the spiders were eating his flesh. His son came to the bedside to help his dad. And when the morphine was discontinued, the fires subsided, and the spiders disappeared.

One month after the thigh accident, my patient noted partial blindness of his left eye upon awakening, but didn’t seek medical attention for 48 hours. Two months later his vision has not returned, though he is recovering very nicely and is pleasant as ever.

I marvel at how much our human bodies can take. I marvel at the odds we face on a day to day basis. Did you know that one American will die of cardiovascular disease every 37 seconds; that every 40 seconds, one will have a stroke; that in 2009, an estimated 800,000 American will have a heart attack?

I guess after living life 101, I’ve come to the conclusion that none of us are shatter proof. All of us need some kind of assistance. That no one can arrive alone. That by God’s grace, loving family, and kind friends, we will face times of pain and stand the test. And in the shattered moments, the fire will ultimately subside, and the spiders will leave the building.

When the emergency call came in, it was after midnight. A 47 year old gentleman had presented to the ER with chest pains which had began 12 hours before.

He had visited a Korean restaurant and eaten to his heart’s content. Soon after, felt chest discomfort under his sternum. Thinking it was indigestion, he pulled up into a McDonald’s and ordered an apple pie with a large cold coke. Drowning his pain, he felt a little better, so he returned back to work.

Not feeling well, he slipped into a store to buy Mylanta, which gave mild relief. Went home, watched TV and then decided he was out of shape so he visited the gym. Played hard core basketball but noted he simply couldn’t keep up as usual.

Arriving back home, he took a hot shower, and placed Icy-Hot on his shoulders to alleviate “my basketball injury.”  Not feeling a “100%”, he made a banana-strawberry milk shake and chugged it down. He then decided that this may be his heart and came into the ER.

He had a full blown heart attack with a 100% blockage of his right coronary artery. We went in and fixed it. His heart muscle had lacked oxygen for 12 hours and a certain segment was not moving well. In fact, it is not moving at all. His heart function has dropped more than 50%. We talked about the Korean food, the slew of things that got in the way, and the all mighty Icy-Hot therapy. He knew he had made a mistake and understood what we now faced. He delayed his presentation because he wanted to “make sure it was the heart.”

A delay in cardiology can be very costly. It can make a difference between life and death. It can change one’s prognosis. It can dictate one’s quality of life. A delay in life can also be unfavorable. Sometimes we are so driven to perfection that we miss the opportunities that stare at us.

Caution is wise. Passivity is costly. Conscientiousness is golden. But denial can be unforgivably detrimental.  Before all the T’s are crossed, ensure your status, ask for advice, not only get your heart checked, but check out your heart.

Ever been to Disneyland, the happiest place on earth? A young mother in her 30’s took her daughter to celebrate her birthday. After seeing Mickey and friends, they settled down to celebrate. The tables where they sat were not bolted to the ground. That particular day the wind blew hard. So hard that one of the tables was hurled and became airborne. The edge of the table hit the young mother’s temple, and she fell to the ground.  

Rescue teams surrounded her.  She was horrified, and when she came to, she was lifted up. A report was filed and all went home. Back to work, back to being a mom, and back to countless tasks. But that would not be the end of the matter.

Two weeks later, while laying in bed, this young mother had an awful seizure, shaking uncontrollably. Fear, uncertainty, and confusion gripped the whole family as she was taken to the emergency room. The seizures stopped, but fear still lurked its ugly head into the hearts of the family. What if it happens again? Because of the uncertainties, her driving license was suspended.

Do you start Phenobarbital? Will it be Keppra? I don’t know. I don’t work on the brain. I work on the heart, and this news was heartbreaking.

I guess I am ever reminded of our fleeting days that somehow turn into years. I guess I have seen the strong become weak. The young become old. The rich become poor. I guess I’ve seen that even in the happiest place on earth, there can be unhappy things that occur. This does not taint me or harden my heart. It does not scare me to retreat into an isolated shell. It does not prevent me from taking risks.

It just reminds me. We are here for a little while, and the days under God’s sun are few. It just reminds us to consider what counts. To give with all of our heart and strength when we’ve got what we’ve got. To cherish people, not things. Protect each other, not assets. To celebrate the day, not waiting for that one priceless moment, but savoring this moment, that is in itself, priceless.

For further information on your cardiovascular health, contact Dr. Kojoglanian, the Mender of Hearts, at (661) 259-1711. 24868 Apple Street #103, Santa Clarita. Web site: drrap.com

“What did you find Dr. K? Am I going to be OK?” My patient must have asked because usually I’m not that silent. I stared hard at the monitors as the catheter engaged his left coronary artery. Seven years had passed since I performed his last angiogram. At that time, he had terrible chest pains, and a complete work up elsewhere showed he was “normal”. I then saw him, and emergently did any angiogram where we opened up a 99% blockage. He was overjoyed that he had cheated death and was alive. 

My patient was lost to follow up for the next seven years because he “felt fine.” Now he was waking up in the middle of the nights gasping for air. He tried to find his medications, but couldn’t since he had run out years ago. I then saw him for the first time in seven years in the hospital.

Now one of his main arteries was 100% blocked and his heart muscle strength was reduced by 50%.  The muscle that the blocked artery supplied wasn’t moving. I contemplated on restoring the flow in this artery, but what good would that be if the muscle it supplied were dead. That’s like irrigating Hiroshima after it was bombed…the irrigation could not revive the dead land. I ordered a study to find out if the area was alive, and just as suspected, it was dead and scared over.

As I told my patient our findings, he raised his left hand, covered his eyes, and hid his tears from me. I felt so broken for him and his family as he was so young. As I explained to his wife and parents in the waiting room, they broke down and said, “Where do we go from here?” We stood there, not saying a word for a few seconds, interlocking hands in a huddle.

“He’s been lost for seven years, and he found himself back home. The important thing is that he’s alive…he’s with us and we still have hope.  We’ll mend him one day at a time.”

“How will you do it?” His wife asked.

“We’ll forgive the past and work with what we’ve got.  We’ll tune up his heart, hit him hard with medications, tell him the truth, and top it all off with compassion and love.”

It was 11PM on a Monday. I had finished a long day at the office and had already seen three new patients in the hospital. One more consult remained, and then I’d be home bound. My last patient has atrial fibrillation (an irregularly irregular heart rhythm).

He said he knew all about me, trusted me, and requested to see me. His wife hadn’t left his room all day in fear of missing me. As we spoke, his wife said they had tried to see me for months. Because I take PPO’s only and not HMO’s, her insurance wouldn’t allow them to see me. I had not looked at the insurance papers before I stepped into the hospital room, and until that very moment, I didn’t know that he was an HMO patient.  It was now 11:30PM and I was physically beat. My pen stopped in mid sentence. Part of me wanted to say, “I’m sorry, I can’t see you for insurance purposes.” Part of me wanted to get up, appologize and head for home. Part of me screamed with exhaustion and offered me the perfect excuse to walk away.

Then I saw the child-like faith in the eyes of my patient. I saw the unspoken plea. I saw two people who had waited all day long to seek my opinion. We talked and laughed. I ordered his medications, knowing an HMO doctor would replace me within hours.

It was now midnight. I told my patient that it was an honor to serve him. I placed my hand on his shoulder and said, “God bless you and keep you strong! I won’t be able to see you tomorrow, I’m sorry, but I’ll make sure you’re treated right.” My patient began to sob like a child. He shook his head and said, “No, please don’t leave me Dr. K. You listened to me. Please doctor, don’t leave me.”

I knew that others would resume his care. I also knew despite the mistake of me being called, there was no mistake at all. And I knew despite the “no pay visit”, I was rewarded with someone’s true gratitude. As the midnight met the morning, I was paid with my patient’s tears.

Heading home, I no longer felt tired. I felt satisfied and thankful, and was gently reminded once again: I don’t serve money. I serve people.

Mending hearts one at a time by God’s grace, Dr. Rap.

“I didn’t hear the click, doctor. I didn’t hear it for two weeks,” my patient proudly confided in me. “Two weeks? Why didn’t you call me? Why didn’t you tell me?” I asked. “Oh, I just thought the click would come back; no problem right, doctor? I’ll be ok, right Dr. K?”

Seven year ago my patient had a major heart attack and was diagnosed with severe coronary artery disease (blockage of heart arteries). He also had aortic regurgitation (leaky heart valve). He underwent a bypass and valve replacement. The valve was mechanical (metal), and our patient required blood thinners indefinitely to prevent clots from forming on the valve.

My patient grew weary of taking the blood thinner and thought that skipping a couple of doses wouldn’t hurt him. Mechanical valves have an unmistakable click. They actually sound like the seconds hand on a watch. I had told my patient that “If you hear the click, be happy because your valve is working. If you don’t, call 911 or get straight to the hospital.”

When my patient stopped the medication, clots formed on the valve, and the click was silenced. His valve began to malfunction. He arrived to the hospital two weeks later and underwent a new valve replacement. Three weeks after surgery, he has multi-organ failure. He needs a ventilator for his lungs; medications to strenghten his heart; a pacemaker to help his heart beat; dialysis for his failed kidneys; antibiotics for infections and transfusions for bleeding.

When he does wake up, he stares into the distance. He does not respond to verbal nor tactile stimuli. Our patient is probably not going to make it. He will probably never go outdoors, and when he does, it will tragically be to his own funeral.

Like my patient, we all have responsibilities: some are simple, and some are a matter of life and death. It is in our possession to make these decisons. Whether it is taking medications, placing the third chocolate chip cookie back down, stopping smoking, or watching our words, it is in our control.

We can blame Mom or Dad. We can blame our circumstances. We can blame the doctor. We can blame time or the lack of time. But we all have choices to make and responsibilities to tackle. I urge all of us to choose wisely, walk humbly, and listen to the “‘click” of our hearts closely. 

“I can’t feel my leg, my leg is cold, please help.” That was my patient’s plea on Christmas day 2008. Hiking with her husband, she suddenly fell. Her husband thought it was a joke and encouraged her to get up. She couldn’t. Fear struck and 911 was called. She was rushed to the emergency room (ER), where doctors noted her left side wasn’t moving. After she was diagnosed with an acute stroke, a slew of tests were ordered. A CT of her chest showed that there may be a mass in the heart. An echocardiogram (ultrasound of the heart) followed…and shocked the crew in the ER.

In one of her heart chambers (left atrium), there was a myxoma, a “benign” tumor, flopping back and forth between one chamber and the other. It appeared that tiny tumor fragments had broken off and followed the course of the aorta (largest artery in the body) and delivered a blow to the brain (causing a stroke), her right coronary artery (causing a heart attack), and her legs (causing a major obstruction, like an ugly traffic jam on the crazy 405 freeway).

Blood thinners were started to prevent further events. There was some glimpse of hope, on that sacred Christmas day, when she began to move her left arm and leg. We rejoiced by her bedside and clapped in happiness. But that was just the calm before the ragging and merciless storm. This episode was so overwhelming for her boday that the heart simply deteriorated within hours, causing heart failure while fluid filled her lungs. A tube was placed down her throat to her breath because she could not breath on her own. A drug called Lasix was given to get rid of the excess fluid stuck in her lungs. Another echocardiogram was repeated which should how her heart had given up the ghost and was no longer strong. The faces of the family became grim. The daughter asked me, “Doctor, when should we really start to worry.” Wow, what do you say? “We are not sure how your mother is going to make it through this, but we are here as a team to do everything under the sun to help her and save her by God’s grace,” I replied.

The left leg with the clot became gangrenous as did part of her right foot. The small tumor pieces had been jarred in the arteries, stopping all blood flow to these limbs, causing her muscles to die. I watched her foot over the 24 hours. It transformed, looking like a dry twig on a bend tree that the winds had conspired against. 

Within a few days, her weary heart started to regain its strength, but the legs became worse. Our patient underwent an amputation of the left leg below the knee and partial amputation of her right foot. The left side still remained lifeless. Soon an open heart surgery followed, removing the tumor. This was to prevent further pieces to break off and harm our patient any further.

She is now doing better. At times confused. At times agitated. Multiple strokes can changes one’s life. Multiples events can break the body. Multiple hits can jab at the mortal heart.

Heartbreaking? No doubt.

Unexpected? No one saw it coming.

How long do we have? No one knows.

Count your blessings? Oh, my every day, every moment. 

I bet our patient would have a request for us all. I bet she would plead with us, “if you have not talked to loved ones, and are so angry with them, find it in your heart to forgive, please, pick up the phone now and tell them you love them.” I just know she would cry out, “If you’re so busy at your work, take a day off, please, and spend it with your family.” I can just hear her heart beat, “If you wanted to use that beautiful china, but were waiting for that one special occasion, take the china out and use it now!”

Should we then live recklessly? No. Simple caution, mixed with laughter and a heart devoted to serve will raise us out of mediocrity and place us in the realm of joy! What do you think? What’s in the chambers of your heart?

Written with a thankful heart, Dr. Rap