Last day as a student-doctor

Alhamdulillah, thumma alhamdulillah.

My last day as a student-doctor. A lot of memories, struggles and challenges faced throughout 6 years of journey. Thank you Allah SWT for  the help, assistance and guidance through teachers, family and friends.

Hoping for a constant and continous guidance to benefit humankind insyaAllah. It's a real privilege to be chosen to shoulder this job, hearing the sufferings and connecting with His blessings.

May Allah makes us all beneficial yesterday,today and tomorrow for the ummah and for human being insyaAllah.

1/11/12
15th Dzulhijjah 1433

How Islam Changed Medicine-Article from BMJ

How Islam changed medicine

Azeem Majeed, professor of primary care (a.majeed@imperial.ac.uk)

Author Affiliations

Department of Primary Care and Social Medicine, Imperial College Faculty of Medicine, London W6 8RP

Arab physicians and scholars laid the basis for medical practice in Europe

Islamic civilisation once extended from India in the east to the Atlantic Ocean in the west. Buildings in Andalusia such as the Alhambra in Granada, the Mezquita in Cordoba, and the Giralda in Seville are reminders of the architectural imprint this civilisation left on western Europe. Less well remembered, however, is the impact of Islamic civilisation on Western science, technology, and medicine between the years 800 and 1450.1 As was argued this month at the Royal Institution, today's Western world might look very different without the legacy of Muslim scholars in Baghdad, Cairo, Cordoba, and elsewhere.2

As Islam spread out of the Arabian Peninsula into Syria, Egypt, and Iran it met long established civilisations and centres of learning. Arab scholars translated philosophical and scientific works from Greek, Syriac (the language of eastern Christian scholars), Pahlavi (the scholarly language of pre-Islamic Iran), and Sanskrit into Arabic. The process of translation reached its peak with the establishment of the “House of Wisdom” (Bait-ul-Hikma) by the Abbasid Caliph Al-Mamun in Baghdad in 830. It made Arabic the most important scientific language of the world for many centuries and preserved knowledge that might otherwise have been lost forever.

As well as assimilating and disseminating the knowledge of other cultures, Arab scholars made numerous important scientific and technological advances in mathematics, astronomy, chemistry, metallurgy, architecture, textiles, and agriculture. Techniques they developed—such as distillation, crystallisation, and the use of alcohol as an antiseptic—are still used.

Arab physicians and scholars also laid the basis for medical practice in Europe. Before the Islamic era, medical care was largely provided by priests in sanatoriums and annexes to temples. The main Arabian hospitals were centres of medical education and introduced many of the concepts and structures that we see in modern hospitals, such as separate wards for men and women, personal and institutional hygiene, medical records, and pharmacies.

Ibn Al-Nafis, a 13th century Arab physician, described the pulmonary circulation more than 300 years before William Harvey.3 Surgeon Abu Al-Qasim Al-Zahrawi wrote the Tasrif which, translated into Latin, became the leading medical text in European universities during the later Middle Ages. Al-Zahrawi was also a noted pathologist, describing hydrocephalus and other congenital diseases as well as developing new surgical technologies such as catgut sutures.4 5 Some describe Al-Razi (Rhazes), born in 865, as the greatest physician of the Islamic world. He wrote Kitab Al-Mansuri (Liber Almartsoris in Latin), a 10 volume treatise on Greek medicine,6 and also published on smallpox and measles: his texts continued to be reprinted well into the 19th century. The medical texts of Ibn Rushd (Averroes) were also widely used in European universities.

Ibn Sina (Avicenna) was known in the West as “the prince of physicians.” His synthesis of Islamic medicine, al-Qanun fi'l tibb (The Canon of Medicine), was the final authority on medical matters in Europe for several centuries. Although Ibn Sina made advances in pharmacology and in clinical practice, his greatest contribution was probably in the philosophy of medicine. He created a system of medicine that today we would call holistic and in which physical and psychological factors, drugs, and diet were combined in treating patients.7

Eventually, the Islamic civilisation constructed by the Arabs went into decline. In the east, new powers rose: first the Mongols, who in 1258 devastated Baghdad, the greatest Arab city of its day, and later the Ottoman Turks, who brought large parts of the Arab world into their new empire from the 14th century onwards. Weakened by internal strife and civil conflict, most of the Islamic cities of Spain had been conquered by Christian armies by the 14th century. The last Islamic state in Spain, Granada, surrendered to the Spanish in 1492 and its ruler, Boabdil, was exiled to North Africa.8

The flow of technology and ideas from the Islamic world to the West slowed and, in the past 600 years, has reversed. Academics and politicians still debate the reasons for and consequences of this decline in Islamic science and technology. The legacy of Islamic civilisation, though, remains with us in making possible Europe's own scientific and cultural renaissance.9

Footnotes

• Competing interests None declared.
• BMJ 2005; 331 doi: 10.1136/bmj.331.7531.1486 (Published 22 December 2005)
• Cite this as: BMJ 2005;331:1486

References

1. ↵ . Islam and the West: speech at Oxford Centre for Islamic Studies, 1993. http://www.princeofwales.gov.uk/speeches/religion_27101993.html (acccessed 3 Dec 2005).
2. ↵ . Science and learning in Islam—a shared legacy. Royal Institution of Great Britian, London, 1 December 2005.
3. ↵ . The discovery of the pulmonary circulation revisited. http://www.kfshrc.edu.sa/annals/152/mh9422ar.html (acccessed 3 Dec 2005).
4. ↵ . The scientific history of hydrocephalus and its treatment Neurosurg Rev 1999; 22: 6793.
   Medline
5. ↵ . Thousand years of missing history. Manchester: Foundation for Science, Technology and Civilisation, 2004.
6. ↵ . Oriental medicine: an illustrated guide to the Asian arts of healing. London: Serindia, 2003.
7. ↵ . Doctors and ethics: the historical setting of professional ethics. Rodopi: Amsterdam, 1993.
8. ↵ . Moorish Spain. London: Phoenix, 2001.
9. ↵ . The case for Islamo-Christian civilization. Irvington, NY: Columbia University Press, 2004.

Pearls of ICU – At the verge of life and death

Pearls of ICU – At the verge of life and death

In the name of Allah, Most Gracious Most Merciful

      It has been a spectacular, interesting and rich four weeks of ICU rotation so far. Each case has been an eye opener, more and more so when time is spent next to patients and their family after heavily informative ward round. Very interesting, in normal medical or surgical wards, we do encounter cases that touch our hearts, but patients are normally stable and do not need intensive care and monitoring. In ICU, the environment is really different. As trainee intern, you are surprisingly valued by all, from consultants to highly trained nurses. Intensive care also means intensive learning, close monitoring of system physiology and understanding how they interact with each other. It is also an understanding of pathophysiology and how drugs intervene in the physiological process to keep patients basic homeostasis at satisfactory level. Having what defines human being at the back of the mind, the focus will initially be about sustaining life before starting to link life to complicated human demands. It is also unique from medical perspective since it ties three big fields of medicine nicely, namely medicine, surgery and anaesthesia.

      What is the core to medicine? Some may argue it is medical sciences. Some may say it is doctors. Others may say patients. We have seen in the history of medical practice, medicine shifts from paternalistic model of doctors telling patients what to do to a more patient-centred medical model now. Tell us what you think is wrong with your body and we can share the idea and goals of how to get you better. I came across a medical article discussing about this issue and apparently, medicine revolves around suffering so to speak. It is quite an interesting perspective and I suppose it holds some truth in it especially when doing ICU currently. Suffering teaches us a lot. Learning from suffering and from seeing others suffer give us a push on how we can better the situation next time. No wonder people involve in research, to find answers to questions that may shine lights to others in their lives. Hence, at the very least, learning and researching to ease the sufferings would be the energy that drives the expansion of medical dimensions including sciences, ethics, cultures, principles and values as human being. 

     “Ask me any question you feel like asking, but please don't ask the question why this happens to your family”, said one of the ICU consultants in a family meeting. Truly it is probably one of the biggest challenges by doctors and medical professionals dealing with hugely emotional situations and predicaments faced by the family. It is easy enough to explain how secondary brain injury can be reduced and controlled. It is probably easy enough to inform what can be done to treat what is possible but to face patients or family members with possible answers of why this has to happen to them will be something that no man will have an answer. The answer will very much depend on reconciliation between our own heart and our own faith. While people will suffer due to physical debility, and all following consequences that shall affect activities of daily life and quality of life, the main suffering shall come from failure to reconcile oneself with one's perception about why this has to happen to he/she.

I wish to share and reflect over a few of the cases that I involved directly as a clinical student.

A case of traumatic brain injury and multiple injuries

      Miss A is a 28 years old lady who involved in a severe motor vehicle accident when her car was hit by a carrier van drove at a speed of 100 km/hour. She was the right back passenger wrapped by the car steel as the crash happened. She sustained serious multiple injuries including fronto-temporal hematoma, bilateral pneumothoraces, L forearm fracture, unstable pelvic fractures, bilateral comminuted subtrochanteric femoral fracture, left tibio-femoral butterfly fracture, right distal phalangeal fracture also with R 4^th toe laceration.

     Her GCS has been very poor on presentation with pupil size 2 mm L and R with sluggish pupillary response to light, E1 V-intubated M1. She was sedated with propofol and fentanyl infusion, intubated and attached to mechanical ventilation. Blood transfusion commenced as well as crystalloid transfusion to keep the SBP>90 and MABP between 50-70. ICP and CPP monitoring were in place and ICP target outline by neurosurgical team to be < 20 mm Hg. Hb target set at 110. Over 24-48 hours, she has been left deeply sedated to ease metabolic demands as well as pain and patient response which can shoot up the ICP. It was initially a difficult ICU management trying to juggle between replenishing fluid secondary to blood loss from pelvic and other bony fractures and maintaining reasonable but not high MABP to limit ICP level.

    Days afterwards when she was weaned off sedative agents, she didn't show much response to pain stimuli or commands. It went to an extent where we thought could this be a locked-in syndrome which would then mean a big disaster for this patient and her family. MRI could not be done due to ex-fix of pelvis and nobody would want to be absolute that those metal/steel/carbon would run alright through MRI machine. A few complications developed throughout ICU stay but she was managed well. From neurosurgical perspective, the chance for this lady was quite bleak. Given her young age, there is a possibility of recovery but to what extent shall be a continuous mystery. Severe traumatic brain injury as reported by journals give 25% a statistical figure of patients who are able to live independently again. That would mean one in four, but who knows the fate for this lady. Nobody can tell given hugely heterogenous outcome from severe traumatic brain injury. This patient remained in vegetative state up till now, able to breath but mechanically supported, heart is till beating but loss interaction with the world and surroundings. This relates again to the quest for the meaning of consciousness and being alive.

    This patient, looking from the bedside seemingly loss her autonomy, and things which normally define human being. She is alive but bodily dead or perhaps very minimal response. I still remember one day when her sister came and visit, looking her from the side, trying to console the heart, to ease the beloved sister on ICU bed, rubbing mostuiriser, grooming her to give this sense of human being, tears collected in this sibling's eye. Father was on the way since this family was not from NZ. No medical insurance, no travel insurance, this will be a second huge burden that awaits the family.

    SubhanAllah, life is so fragile, what initially planned as part of working holiday plan turned out to be permanent severe disability which shall be endured for the rest of the life for the patient and the family. 28, what a young age. This also poses a big ethical question from Islamic perspective as well as from general ethical perspective. Should we wean the support very early on, but we don't know what shall be the possible future, should we support and be aggressive like what was done? Again, it is going to be a constant battle in medical world in trying to tie between medical care, resuscitation and what it shall mean for patients and family as well as what shall be the best decision.

    This is one of many cases encountered in ICU, insyaAllah, hoping to write more when time permits. But for now, it leaves a big thing to ponder about the reality of life and death, to assume resuscitation or to leave the present to take its course. As a muslim, it reminds a lot about ahsanu a'mala, people with the best deeds. The creation of death and life is to see who among humankind are best in deeds. May Allah gives us strength to learn this sign and to constantly better ourselves, inculcating humanity in the heart, responding to His call and serving people in difficulties. Oh My God, Grant us guidance, piety and richness in our heart, as well as the love towards the poor.( du'a of prophet Muhammad saw after the event and encounter with Abdullah Umi Makhtum).

Abu Asr

7/2/2012

Sanity, a gift that reminds, part 1

Sanity, a gift that reminds

In the name of Allah, Most Gracious Most Merciful

Alhamdulillah, I praise Allah for all His blessings upon us that many times we forget and many times we appear, seemingly but not really remember. The essence of gratitude is so deep and so does the essence of realising all these bountiful blessings which requires deep thoughts, meditation and sincere heart. That is perhaps the very meaning of solah, to thank and to invoke, to submit and to remember, to love and to learn to love, to discipline and to focus.

Sanity, a word which describes safe and sound mind. A word that describes normality of mind. A word that differs societal perception and tiering human social and psychological levels. The opposite, insanity is also a word which counters sanity, describing a loss in a great bless that also defines human being and human innate ability. Depending on how we perceive perception, sanity gives us at least two important perceptual definitions, being sane in our thought process and being sane in our thought contents. In our walks of life, we often encounter people that say “You are just insane” or” This is insane.” The context when it refers to thought content often refers to ideas that make out of sense when perceived by others in their comfort of normality. What is sane according to one can be perceived as insane by others. What is sane in others may sound insane by us. Now, there is a spectrum to normality in contents above which things really make no sense. In saying that, there is one important issue needing realisation here, ignorance is a jail of mind and being ignorant jumps one to perceive others as being “insane” so easily. An example of which can be taken when the last Prime Minister of Malaysia, Tun Mahathir introduced the idea of producing local cars in 1980s. To some, it was insane because the idea went out of calculated possibility by some given limited knowledge and creativity. The second issue which limits sanity is absence in component of trust, faith,confidence and socio-cultural influence. People can easily perceive something insane when the content clashes with pre-conceived beliefs, ideas and mental knowledge structure. To an atheist, an existence of a Creator of this universe is just insane given physically imperceivable Power that can be captured by mental and special sense organ faculties.

Sanity can also be defined in the light of thought process. Have we ever come across people who talk next to the road, seemingly so serious and so real, but it just does not make sense. We thought we don't understand, but in reality it can't be understood. The thought process is so bizarre that it went out of spectrum of linearity into circumstantial and tangential thought processes. We know the basic logic as introduced by Socrates, if A=B, and B=C, therefore A=C. Although this is basic and does not hold true in every situation, this flow of logic is absent in people with disrupted thought process. Understanding these two perspectives, we came with an idea that aberrant thought process or content or both throw people into a group we call “crazy” be it literal or with connotation, be it content or process.

Alhamdulillah, life is a lesson and everything that happens is a Sign from Allah Almighty for us to think and ponder over. Hence why the prophet Muhammad saw cried when Surah Ali-Imran, verse 191 was revealed – Verily, in the Creation of heaven and earth, and in the alteration of days and nights, there are Signs for people who would like to contemplate. Contemplation to read His signs in order to believe and to have faith in Him. To contemplate to understand that He SWT is very close and guiding closely with His signs. In the book, In the Footsteps of the Prophet Muhammad saw, Prof Ramadan outlined this very nicely how Khadijah was a remarkable sign of God Almighty's help and support to Muhammad saw, and how Hajar and Ismail were signs of His help and consolation for Ibrahim as. ( Refer Chapt 4). I was blessed with the opportunity to meet one patient who gradually lose normality of his thought content. Here is his story.

He is a gentleman who at his teenage age, developed this bizarre thought that the world is rubbish. He claimed people don't understand him and gradually developed this thought that people are talking and planning something against him. He looked at a drawing and thought that it is alive. His behaviour also changed to be inappropriate and disorganised. Some things he does are purposeful, other things can be inappropriate. His thought process is linear at times but can be tangential at other times. He loses insight that he seems to be out of what he normally is.

It reflects about psychological disorder we call psychosis or craziness. It is bizarre and has been a mysterious subject until the last 50 years when research enlighten us a bit about this still mysterious subject. This patient out of sudden developed aberrant belief secondary to his frontal lobe determination and perception that people are against him. This is further strengthened by auditory hallucination from activation of temporal lobe that people are talking about him. Without going in depth about different types, we learn to understand automaticity of brain function without external stimuli from the surrounding can induce a “perceived world” in which these kind of people interact and form their judgment, reaction, logic and etc. It is made worse when these people lose their insight losing perceptual attachment from what perceives by others making them not understanding us and us not uderstanding them. In short, the physical present is there but these people are in fact in a “different world” from us. This is in-line with what mentioned in Harun Yahya quoting verses from Quran about the fact and the reality of this world. The world is but a perception that we perceived from our sense organs and brain interpretation. From time, the essence of physical being and many things around are what we perceived from senses we are given with. At the end of our life time, these senses will definitely shut down and we will move from this “perceived world” into another dimension of eternal life, as perceived by us, Muslims as Hereafter.

In medicine, there are several conditions that mimic formation of “perceived world.” In children , we have a condition we call Autistic Spectrum Disorder, in psychiatry we have psychotic disorders and in different cultures and beliefs, we have meta-physical influence. All these will be discussed in my next writing – Sanity, a gift that reminds part 2. Stay reading and may knowledge leads us to be grateful and thankful, God Willing.

Abu Asr

11/1/12

Medical Questions : 

1) Why can anti-psychotic cause development of galactorrhoea and parkinsonism?

2) What is the cardiovascular condition that can be trigerred by anti-psychotic s and how do we manage patient that develops this?

3) What are the two groups of anti-psychotics and which trigger more anti-cholinergic effect but less extra-pyramidal side effects?