Death in many guises

By Dr Upul Wijayawardhana

We are not sure whether Andare is a legendary figure or a ‘Matara Man’ born around 1742 in the village of Udamalala, who went all the way to Kandy to serve King Keerthi Sri Rajasinghe. But we can be pretty sure that the exploits of this famous court jester will not cease to entertain for generations to come. Only Andare could get away with daring antics but, unfortunately, on one occasion he went too far, greatly annoying the King who, in a fit of rage, condemned Andare to death. In desperation, he pleaded, “Your Majesty, considering that I have been your humble servant for so long please allow me to choose the mode of death”. The good King did not have the heart to refuse and agreed to this request, under the impression that Andare would choose the mode of his execution but when Andare quipped “Your Majesty, I like to die when I am old”, and the King burst out laughing! Like Andare, we all would love to live to a ripe old age to die. But then, we do not want to drag on with a life of infirmity. Perhaps, the best way to leave this world is with a sudden death in old age!

Death comes in many guises: some die in-utero, others in childhood, yet others in the prime of youth and the lucky live to a ripe old age. Some have a long-drawn out deaths whilst others die suddenly. As I wrote in a song, during my medical student days, “Andagena upanne, andawa merenne, me sansare oba kohida yanne” (we are born with a cry, make others cry when we die, do not know where we go in this cycle of life).

Although sudden death is a nice way to go, if it does not happen too early, it can create huge problems the dear ones of the deceased. Sudden deaths often necessitate a post-mortem examination but, in some instances, even the PM examination may not show the exact cause of death although it would help to exclude foul play. Someone living alone, who dies suddenly, may not be found for days leading to decomposition, which makes the job of the pathologist doing the PM examination even more difficult. This was highlighted by the recent unfortunate sudden death of Zacky Jabbar, the Deputy Editor of this newspaper. Three months ago, a regular contributor to this newspaper, Rajeewa Jayaweera died under tragic circumstances; unfortunately, he took his own life: yet another guise of death. We live in an era of uncontrolled social media and the irresponsible, baseless rumours spread that these two deaths heralded a killing spree by the government, added to the distress of the families.

Sudden deaths are often due to problems of the heart although, on some rare occasions, they can happen as the result of a massive stroke or the rupture of a main blood vessel, usually due to weakening of the wall and dilatation forming an aneurysm. Sudden deaths due to heart problems are referred to as Sudden Cardiac Deaths (SCD) and result invariably from abnormal heart rhythms, the most common being ventricular fibrillation (VF). The main pumping chambers of the heart are the ventricles, which pump blood to arteries by coordinated contractions of muscle fibres but in ventricular fibrillation the muscle fibres contract in an irregular discordant manner like a ‘bag of worms’ without any effective emptying. VF can be caused by the ventricular muscle not getting enough blood due to narrowing of the coronary arteries, the vital arteries that supply blood to the heart muscle itself, sometimes made worse by a blood clot developing on the narrowed vessel, causing complete obstruction: Coronary Thrombosis. VF also can occur due to abnormalities in the ‘wiring system’ or the electrical activation system in the heart.

Very rapid heart rate, tachycardia, too can cause sudden death. Blood that returns from various parts of body is taken by the venous system to the right side of the heart to be pumped to the lungs where replenishing of red blood cells with oxygen, oxygenation, takes place. Oxygenated blood returns to the left side of the heart to be pumped around the body. If the heart beats too fast there is no time for the pumping chamber to fill, so that even if effective contraction occurs, there is no blood to pump out resulting in collapse. These rapid rates can occur with significant underlying disease but in some instances occur on a structurally normal heart, due to electrolyte disturbances, drug interactions etc.

Too slow a heart rate is also detrimental and the heart rate needs to be around 60 – 70 beats per minute at rest. In addition, the rate needs to increase with increased activity, to keep pace with the metabolic demand. For this, as well as to give electrical signals for the synchronised working of the various chambers of the heart, there is an electrical conducting system with built in pacemakers, buried in the tissues surrounding the heart muscle. When there is a block in this circuit, heart block occurs. This block in the electrical circuit of the heart causes slow heart rates or bring the heart to a complete standstill resulting in death. In such deaths, there are no PM findings unless detailed microscopic studies are done on the conducting system but this laborious process is hardly ever done.

Fortunately, in heart blocks there are warning symptoms like fainting, blackouts, sudden and transient giddiness, etc. When patients present with these suggestive symptoms Cardiologists arrange monitoring of heart rhythm using various devices. Once confirmed, heart block is one of the easiest and the most cost-effective conditions to treat with a permanent pacemaker. In fact, I set up the permanent pacemaker programme in the Cardiology Unit [Colombo] way back in late seventies.

There are many rare and perplexing rhythm abnormalities that occur in a structurally normal heart, some of which are brought about or exaggerated by chemical and electrolyte imbalances. The trigger for contraction of the heart muscle is an electrical impulse, very tiny in strength, which depolarises the muscle. For the next contraction to occur the cardiac muscle has to repolarise and this period of repolarisation is vulnerable to many factors. Some genetic abnormalities affect this period causing syndromes like ‘Prolonged Q-T syndrome’ and ‘Brugada syndrome’. A dangerous rhythm could be precipitated in susceptible individuals by drugs which affect depolarisation. By regular monitoring of drug reactions and interactions we are able to avoid prescription of drugs that may cause potential harm. Unfortunately, various preparations used in alternative medical systems like Ayurveda contain multiple plant-based derivatives whose safety has not been tested adequately. The argument that plant based products are harmless is fallacious as plants have many toxic compounds. Further, compounds that may not have direct harmful effects may interfere in the repolarisation process of vulnerable individuals. An expert eye may detect subtle ECG changes in these conditions but for confirmation, specialised invasive tests are needed. Deaths due to these conditions are impossible to detect in PMs, as the death was due to a functional abnormality, not structural.

Another cause of sudden deaths is cardiomyopathies: abnormalities of the heart muscle itself. There are many types, the commonest being dilated cardiomyopathy associated with heart failure. In this condition the chest x-ray shows an enlarged heart and an echocardiogram (ultrasound examination of the heart) would confirm poor function. However, the lethal variety is hypertrophic cardiomyopathy, where there is unnecessary and unregulated thickening of the heart muscle, to varying degrees. Sometimes the thickening of the muscle is so great that it obliterates the ventricular cavity but more commonly what it does is to obstruct the outflow. Patients with hypertrophic cardiomyopathy are liable to have sudden deaths, especially when they undertake sudden, severe unaccustomed to exertion: they virtually drop dead. The cause of death is easy to establish in these cases as there are obvious structural abnormalities. Hypertrophic cardiomyopathies are often inherited, and once an unfortunate case is detected what is important is family study: to identify family members who may be affected and treat them appropriately to prevent sudden death.

The realisation that someone who had sudden cardiac deaths had hearts that are ‘too good to die’ gave rise to the concept of cardio-pulmonary resuscitation, which has saved innumerable lives around the world. It has evolved over time and is much simpler now. Pressing the breast bone down against the spine, about 50 times a minute, could imitate the pumping action of the heart, though to a lesser degree, but that could enhance the survival of the brain for some time and has saved many lives. This was coupled with mouth-to-mouth breathing, at the beginning, but it was later shown that this step, which some found difficulty in complying with, does not make a significant difference. Thus, the present CPR technique is simple and should be taught to all upper school children. Even the young can have sudden deaths and a simple procedure like CPR coupled with prompt treatment in hospital has the potential to save many lives.