Of all possible times, it happened during Ramadan. The test of faith would be extreme.
Azka was the first of four children born to Persian parents in a small town thirty miles outside of Tehran, Iran. Being devout Muslims, her father chose the name Azka in part because it meant “pious”. His wife later revealed to Azka that he also liked how the name rolled off the tongue when spoken in Farsci. When she heard this news, Azka, twelve years old at the time, spent the next several days purring her name to her father whenever she had a chance. Her father, red faced with a combination of embarrassment and affection for his daughter, chuckled each time before giving his daughter a bear hug. Father and daughter had the same playful personality and good humor, but their distinctive big, brown eyes were their most obviously shared trait.
By the time she was twenty-one, Azka was married to a man who was a member of the Artesh, the name for the Persian Army. After his conscription period had expired, her husband had decided to stay in the military. During their twenties, the young couple went on to produce four children. Then came the Islamic Revolution of 1979, and in a violent street battle, Azka’s husband was killed. Suddenly, at the age of twenty-nine, Azka was a widowed mother of four. Within a year, accompanied by her children and seven other family members, including her mother and father, she immigrated to the United States. She never returned to Iran.
With the help of extended family and a network of Iranian friends, Azka raised her children without a partner. She never remarried and, in fact, never even considered it. Her husband was her true love and she honored him by remaining alone. She filled her life with family and Allah-that was more than enough for her.
Ramadan, the month-long period of fasting and abstinence, was strictly observed in Azka’s household. Ramadan is intended to teach Muslims about patience, spirituality, humility and submissiveness to God. Azka could never imagine how those virtues would undergo the ultimate test later in her children’s lives.
Azka enjoyed excellent health throughout life and even when she turned sixty-one, her only medical problem was high blood pressure, easily controlled by a single medication. Her daughters marveled at her vitality and positive energy. Daily, she cared for her nine grandchildren without ever seeming to tire. Like her father, she loved to make the children laugh. It was not unusual to find the grandchildren gathered closely around her, listening intently to another amusing story, nine little heads rocking back with laughter. Her supply of funny anecdotes and jokes seemed endless.
Now in her sixties, Azka approached Ramadan with fresh enthusiasm and gratitude for the blessings in her life. The first three weeks were like any other Ramadan; nothing to eat or drink during daylight hours followed by the family coming together each evening to prepare and eat dinner together. Then one day near its end, Azka rose before dawn to eat a hearty breakfast and drink plenty of fluids in preparation for the next fifteen-some hours of abstinence. Around four in the afternoon, she was feeling particularly tired and so decided to take a nap. Several hours later, one of her daughters, surprised that her mother was still napping, went to check on her. Just as she walked into the room, the mother was getting out of bed. Her mother smiled warmly and nodded in assent when her daughter asked if she was okay.
Azka then followed her daughter into the kitchen where six family members were preparing the evening meal. Soft Persian music was playing in the background, the outside light was growing dim. Azka sat down at the kitchen table, flanked by her her two oldest daughters. They were cutting vegetables and Azka asked one of the daughters to pass her a knife so that she might help with the preparation. As her daughter placed the knife in her mother’s right, upturned hand, Azka suddenly dropped her hand and knife, as though the knife was too heavy to hold. She simultaneously slumped to the right with her head lowered. Immediately, the daughters laughed at yet another one of their mother’s practical jokes. But after several seconds, her mother hadn’t moved. Her face was expressionless and it looked like she wasn’t breathing. Her daughter reached over and shook her mother’s shoulder but there was no response. Remarkably, and with great calm and presence despite the circumstances, the daughter checked for a pulse at her mother’s wrist and upon finding none, quickly instructed her sister to call 911. With a gasp, the other daughter picked up the phone and dialed 911.
The sisters placed their mother on the floor, speaking to her in Farsci, saying anything they hoped would bring her back. But she was dying, perhaps already dead, right there on the kitchen floor. The paramedics arrived in less than ten minutes and upon discovering that Azka was not breathing and did not have a pulse, immediately began trying to save her life. Within several minutes, they had placed a breathing tube in her trachea, an IV in her arm, and defibrillator pads on her chest. When the heart rhythm was noted to be ventricular fibrillation, they shocked her three times, each shock causing the characteristic heaving of the chest into the air as the electricity arced through her.
By the third shock, the paramedics could feel a pulse. They rapidly bundled Azka into a collapsible gurney, carried her downstairs and into the back of a waiting ambulance whose siren began wailing as soon as the driver accelerated out of the driveway and into the night.
I was walking down the hallway of the county hospital ER when Azka was whipped into the department by the paramedics. I rounded the corner just in time to see her flowing, black hair hanging over the rapidly moving gurney. I followed the commotion into a cardiac room. A respiratory therapist quickly took over administering air to Azka by squeezing a stiff, rubber bag connected to the endotracheal tube in her windpipe. A blanket covered Azka’s body and when I removed it, I could see that her dress had been cut away to enable the placement of the defibrillator pads. Telemetry leads were placed on her chest and the monitor showed Azka to be in normal sinus rhythm. An automated blood pressure cuff attached to her arm showed that the blood pressure was excellent. From a cardiovascular perspective, Azka was stable, which was reassuring.
But then I began the neurologic examination, and the manifestations of ten minutes without oxygen to the brain were immediately apparent. Azka was displaying odd movements of the arms, called decerebrate posturing, which consists of fully extending and inwardly rotating both arms. It is a characteristic sign of significant brain injury and suggests a poor prognosis. And then I examined her pupils and when I shined a light upon them, her big, brown eyes appeared lifeless. This was more evidence of brain damage, and after several minutes I pulled away from Azka so that I could speak with family that had already congregated at the hospital.
I quickly rehearsed what I was to say to the family as I took the fifty foot walk to the family conference room in the emergency department. Eight of them were waiting there, all seated around a long table, none speaking, everyone predictably apprehensive. I began by telling them Azka had experienced a cardiac arrest from which the paramedics had heroically revived her. I reassured them she was stable and that we would be taking her to the ICU shortly. They immediately asked for the cause of the cardiac arrest and I told them at that point we weren’t sure. I then ran through the possibilities and the tests we would be conducting to help us determine the cause.
Azka’s two eldest daughters identified themselves and asked most of the questions. I noted they had their mother’s eyes, and that caused me to pause to collect myself before starting the most difficult part of the conversation. Slowly, I began telling them my concerns about likely brain damage from the arrest. They were crestfallen and began weeping quietly. The men in the room simply stared down at the floor, shaking their heads. I waited for questions, but none came and so I excused myself so that I could return to caring for Azka.
The first night was a difficult one for Azka. Her heart repeatedly developed life-threatening arrhythmias which required various medications and several debrillations at different points during the night. The neurologist evaluated her on the second hospital day and rendered the opinion that Azka likely had severe brain injury. The prognosis appeared grim at that point. But then on the third hospital day, the odd posturing movements stopped; however there was still no evidence of meaningful neurologic functioning. In the meantime, the family held vigil over the patient, with at least two to three people with Azka at all times. They spent the time speaking to her, praying, and reading the Quran out loud. For no apparent reason other than faith, they were convinced she was going to get better.
When I walked into her hospital room on the fourth day and called out her name, Azka opened her eyes. I nearly dropped my stethoscope. As I proceeded through the neurologic exam, I noted that Azka was able to move her arms and legs and follow commands. The neurologist was stunned, I was puzzled, and the family ecstatic. By the next day, Azka was fully awake and so we removed her from the ventilator. Remarkably, she was able to communicate normally and would eventually have a full recovery of her cognitive functioning.
Azka remained in the hospital for another week. During that time, she underwent an coronary angiogram which revealed a partial blockage in the left anterior descending artery, which is one of the main arteries supplying the heart. This blockage, although incomplete, had caused a heart attack which lead to the arrest. A stent was placed into the artery to keep it open and, gloriously, Azka was discharged home.
Azka was clutching a copy of the Quran when she was wheeled out of the hospital, her faith clearly renewed. Showered in smiles, I wished her well, and she thanked me profusely, ending with “Allah is good, and he will guide you.” I nodded in affirmation, realizing what I had witnessed required at least that.
“The American Doctor” is a physician who blogs at his self-titled site, The American Doctor.
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