July 3, 2009

Last night, my husband Din Merican and I attended a private dinner hosted by Dato Lim Say Chong and his wife, Datin June, in our honour. It was for me an opportunity to meet some of Din’s close PFS and University of Malaya (Class of 1963) classmates. I was moved by stories about their days in public service and business. They recounted them with great humour.  There was solidarity and camaraderie among these Malaysians unseen today because Malaysians of the 21st century are very conscious of their religious and racial background and economic status.

These men embody the idea of service before self. Each and everyone of them have had an illustrious career. What is amazing is that they continue to be very intellectually, physically,  and socially active even that they are all approaching the the autumn of their years. Their wives too were charming and extremely intelligent. I have chosen to post this thread on my blog in memory of Michael Jackson, the Peter Pan of the Modern Era. Although this is not about dentistry, I think that it is good to remind all of us that we need to be  always in good health, and to enjoy our lives with family and friends. Din and his friends continue to lead productive lives. —Dr. Kamsiah

By Carol Krukoff

this article is dedicated to Din Merican and his friends from Penang Free School and their wives.

The pain struck suddenly in his chest as George Fickus filled a vending machine with sodas. A gleam of perspiration broke out over his body — but then, all at once, the pain was gone.

I’ll go home and rest, thought the 57-year-old Baltimore man. Shaken, he walked slowly back to his van to tell his assistant he was taking the rest of the day off. But Blaine Pierce took one look at his boss and said, “No way — I’m taking you to the hospital.”

Pierce, 27, recognized the pained look and pale, sweaty sheen on Fickus’s face because several years earlier his father had died of a heart attack. “My dad was perspiring like that and had chest pain, but he wouldn’t go to the hospital,” Pierce told Fickus. “Before we knew it, he was dead. I’m not going to let that happen again.”

Fortunately they were near Baltimore’s St. Agnes HealthCare. This community hospital has the world’s oldest chest-pain centre — a special emergency service for patients with suspected heart attacks. Within minutes of his arrival, Fickus was hooked up to a heart monitor, an intravenous line and an oxygen tank. A pulse oximeter (a small clip that looks like a clothespin) was placed on his middle finger to measure the oxygen reserve in his blood.

Dr. Raymond Bahr strode briskly through the door. The gentle, white-haired physician peered at the heart monitor and studied the patient’s electrocardiogram. He saw that Fickus was experiencing the “stuttering presentation” of intermittent chest pain, likely to mean a heart attack in progress. Bahr instructed a nurse to administer tissue plasminogen activator, a drug that dissolves clots and prevents damage from occurring. “You’re lucky,” he told Fickus, laying a reassuring hand on the patient’s arm. “You arrived within the first ‘golden’ hour when our therapies are most effective. You should be fine.”

Farfetched Dream

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Working in an ordinary community hospital, not a major academic centre, Raymond Bahr is an unlikely hero in the war on heart attacks. Yet he has pioneered a program that enables people to recognize and take action when faced with the early warning signs of America’s — and Canada’s — No. 1 killer. According to Bahr, half of the 500,000 heart-attack deaths in America alone each year could be prevented if people sought help right away. In addition, his creation and promotion of chest-pain centres in hospitals are dramatically changing the treatment of people with suspected heart attacks.

Born in 1935, Bahr grew up in Canton, Md., a working-class section on Baltimore’s East Side. Life became tough when Ray’s father, a factory worker, died suddenly. Ray was only six. His mother, pregnant with her fourth child at the time, supported her family by scrubbing floors and cleaning houses.

As a teenager Ray got a job after school at Kaminski’s drugstore to help pay for his parochial-school education. Ray always assumed he would work at the area’s brewery, steel mill or tin-can plant. With owner Felix Kaminski’s encouragement, however, the youngster set a higher goal for himself: He attended pharmacy school while working at the store nights and weekends. After graduating first in his class of 52 students, he stayed on at Kaminski’s.

One day Bahr was busy behind the counter when Jake, the neighbourhood tailor, came bustling into the pharmacy. There was something about Jake’s skin — its paleness and sweaty gleam — that spurred Bahr to ask if something was wrong. “I’m not feeling quite right,” Jake admitted. “I think I have indigestion. It woke me early this morning, then went away. Now it’s back.”

“You should see a doctor,” Bahr told him. Then Bahr became distracted with other customers, and Jake left. Hours later the tailor was found dead of a massive heart attack.

Bahr then realized that Jake must have been in the early stages of a heart attack and should have got immediate medical help. He didn’t have to die. Feeling awful, the 22-year-old pharmacist wished he could spare others the same fate.

One night Kaminski brought up an idea that ignited his protégé’s thinking. “You know, you don’t have to stop at being a pharmacist,” Kaminski said. “You can go to medical school and work here on nights and weekends to pay for it.”

Medical school — now that’s a farfetched dream, Bahr thought. Yet the idea appealed to him. Fuelled by a sense of responsibility for Jake’s untimely death, Bahr enrolled in the University of Maryland School of Medicine. He soon discovered he had a natural affinity for internal medicine and a special desire to help patients through life-or-death struggles.

Shifting Focus

Bahr served his last year of residency in the intensive-care unit at St. Agnes, across town from where he’d been raised. At the time, a new type of facility was being pioneered: the coronary intensive-care unit, which closely monitored people who’d had heart attacks and were at risk of sudden death. So when administrators asked Bahr to develop such a system for them, he jumped at the chance.

Over the next several years, however, despite the state-of-the-art unit Bahr had set up, he still saw countless premature, unnecessary deaths. Generally one third of heart attacks proved fatal; half these people died before reaching the hospital. Those who survived often suffered irreparable damage to the heart. Relatives would tell the doctor that their loved ones had felt chest “pressure” or “tightness” for several hours but passed off the discomfort as heartburn or muscle strain. Too stoic or embarrassed to seek help, they waited until their symptoms became unbearable before getting medical care. By then it was often too late — they’d had a heart attack.

“If only they’d come in when they first experienced symptoms,” Bahr said. He felt discouraged each time he lost a patient. On one such frustrating occasion, he thought of Jake, who had ignored the chest discomfort preceding his heart attack. If I knew then what I now know, I could have saved him, he thought. At that moment he was struck by a simple truth: Jake’s symptoms were like a smoke alarm sounding at the start of a fire. Heart attacks have beginnings! Why are we focusing all our energy on the time during and after the heart attack? he wondered. We should be shifting our focus earlier.

Bahr launched his first public-education campaign to alert people to the little-known symptoms of an impending heart attack. Nurses spread the word at schools, churches and community organizations. Unfortunately the medical establishment was skeptical. “We don’t want to create heart-attack hysteria” was a familiar response. Many health professionals worried that telling the public about early warning signs would flood emergency rooms with people suffering from indigestion.

Undaunted, Bahr continued piecing together feedback from patients and their families that would help persuade his colleagues. One common reason people frequently dismissed all but the most severe pain was a misperception that they should “tough it out.” Typically, patients told Bahr, “I really didn’t think my nausea and sweating were an emergency.”

Part of the problem, too, came from the hospitals. Busy emergency-room personnel weren’t always responsive to people who didn’t have the classic elephant-standing-on-the-chest pain. Then one day Bahr had an idea: What if we start a facility with a less threatening name, such as chest-pain centre? It could be staffed by nurses and doctors trained to help people with all kinds of chest discomfort.

Red Carpet Treatment

Bahr proposed his plan to the St. Agnes Board of Trustees in 1977, but the administrators turned him down. Their refusal merely propelled him to intensify his efforts, however. Twice in the next two years, Bahr presented his proposal to the trustees, each time offering more data and doing a more persuasive presentation. And each time the administrators turned him down.

Then in 1980, when the hospital was finishing an addition, Bahr again proposed that a chest-pain centre be included in the new area. The administrators finally gave him the go-ahead. Soon the journal Medical World News was trumpeting Bahr’s innovation, noting that the pioneering physician wants “red-carpet treatment” for patients who may be having heart attacks.

Warning Signs of a Heart Attack

Pressure, aching or burning — not necessarily pain — in the chest. Often it increases with activity and subsides with rest. Discomfort, tightness, squeezing or fullness in the chest, usually lasting longer than two minutes. Mild discomfort that may come back sooner, last longer or feel more severe each time. Discomfort in the teeth, jaw, inner arm (often the left) or back. Dizziness, fainting, sweating, nausea, shortness of breath or weakness. If you’re not sure whether discomfort is from heartburn or a heart attack, ask these questions: Is the discomfort located in the centre of the chest? Does it recur? Does it increase in intensity? Does it become more intense with exertion, then go away with rest? If the answer to any of these questions is yes, take an aspirin, call 911 for an ambulance, or have someone drive you to an emergency room. Don’t drive yourself.

Improving hospital care solved only part of the problem, however. People still needed to learn about a heart attack’s “soft symptoms” so they could get to the chest-pain centre early enough to be helped. At that time cardiopulmonary resuscitation was getting great attention, and Bahr and his staff taught it to people in the community. He soon added a program to educate the public about heart-attack warning signals, dubbing it EHAC, for Early Heart Attack Care. “EHAC is the message,” Bahr would say, “and the chest-pain centre is the delivery system.”

A breakthrough came in 1987 when Bahr received a grant from the National Emergency Medical Association, which thought EHAC had potential. Bahr spoke of his two-pronged approach to combat heart attacks at annual conferences of cardiologists, critical-care nurses, paramedics, emergency-room physicians and any group willing to hear him.

Slowly, but then with gathering momentum, the concepts began catching on. And despite skeptics’ fears, “cardiac chaos” did not occur. Instead, an estimated three million people a year are evaluated quickly and effectively in the 700 chest-pain centres currently operating around the United States.

The word spread to Canada, where all emergency rooms now have cardiac-care units which are geared to chest pains. Last January the University of Ottawa Heart Institute became one of the first major health centres in the country to open a chest-pain unit.

Bahr predicts that by the year 2000 virtually all of America’s 4,400 emergency rooms will be equipped with chest-pain centres. The EHAC program is now taught in 1,000 hospitals, and half a million people have learned about EHAC through Bahr’s public-service tape, available free at some video stores, baseball stadiums, high schools, colleges and libraries.

EHAC Oath

Still, it was only last year that the remaining resistance in the medical community began to crumble. Despite Bahr, many health professionals thought early heart-attack symptoms were rare. Then in January 1996, renowned Boston cardiologist Eugene Braunwald reported in the New England Journal of Medicine that about half of all heart attacks have such early warning signals. Other doctors also began to agree with Bahr’s message.

“Early on, Ray Bahr recognized the important truth that time saves heart muscle,” says Dr. Henry McIntosh, medical director of the Preventive and Rehabilitation Centre at St. Joseph’s Hospital in Tampa, Fla. “If we can treat a patient within 60 to 90 minutes, we can salvage heart muscle and prevent damage. That’s a message my generation wasn’t taught.”

In February 1996 Bahr was honoured by the American Heart Association — Maryland Affiliate. When the crowd rose to give him a standing ovation, Bahr surprised everyone by asking them to remain standing and be deputized as Early Heart Attack Care Givers. Audience members raised their right hands and repeated the EHAC oath: “I hereby solemnly swear that when a person in my presence is experiencing the early symptoms of a heart attack, I will make every effort to get that person to go to the nearest hospital emergency room to get those symptoms checked out.”

Bahr told the crowd with glee, “I’ve been waiting 30 years to do this.” And from this heart doctor’s record, it’s clear he won’t stop deputizing people until he has completely disarmed this killer.

DATA PROVIDED BY DR. RAYMOND BAHR