WISDOM FROM TWO WORLDS
An exclusive excerpt for members of the TAIK Health community
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We're excited to share a short excerpt from Dr Hosen Kiat's latest book, a guide to healthy ageing which brings together clinical insight and peer-reviewed research to explore how daily choices shape the way we age.
As it gets closer to beating its last, the dying heart stiffens into a clenched fist of muscle and blood. It can, with assistance, be forced to perform its vital pumping function but, with each beat, it weakens further. The fist of muscle becomes stiffer and stiffer until it becomes more like a lump of clay than living tissue.
For the doctors and nurses in the room, the stiffening heart becomes an unmissable sign that the patient will not recover. The attending nurses keep working, in three- to four-minute rotations. Under the bright surgical light hovering above, sweat drips from their brows as they pump with intertwined hands on the patient’s chest. They persevere, even as the body stiffens under their hands. We always hold on to the hope that the patient will be pulled back from the brink at the last moment, but this is not a Hollywood script full of dramatic reversals. The heart is an incredibly strong organ, but it has its limits, and once those limits have been reached or surpassed, the curtain falls.
Even for the most experienced doctors, these moments never get easier. Watching a life slip away is always hard. And then comes that final word – the one no one wants to say but knows must be spoken. Stop. The room falls silent. Just like that, it’s over. We tell ourselves we did everything we could but that doesn’t make the weight any lighter. And if we knew the patient, if there was a connection beyond the charts and scans, that weight can feel almost unbearable.
I have led countless resuscitations in the hospital – moments where life teeters on the edge, and every second counts. One summer night at Monterey Park Hospital in Los Angeles, I was in that role again, standing at the head of a crashing patient, leading the team. It was a scene I knew by heart. I moved without thinking, calling out orders, focused on the rhythm of saving a life. But this time – this time was different. So familiar, yet completely foreign.
Because the man on the gurney wasn’t just another patient.
It was my father.
I went numb. The cardiologist in me took over, steady and clinical.
The son in me? He had to disappear.
A father’s fate
In the bustling streets of Jakarta, a love story unfolded between a humble teacher and the daughter of a pharmaceutical company owner. Their union marked the beginning of a journey that would see my dad transition from a teacher to corporate director, climbing the rungs of success in my mom’s family business.
My dad’s roots traced back to Cianjur, a quaint little town just a few hours outside Jakarta. Losing his brother young, he grew up an only child in modest surroundings. Neither of my parents got past high school, but what they lacked in education, they more than made up for in grit.
My father was 33 years old when I was born, and while he was relatively active during his youth, he gradually put on weight and became notably sedentary into his middle age. His lack of exercise and a diet typical of our Asian heritage – salt-laden and often fatty – contributed to his declining health. Although he prided himself on eating a lot of fruit, his high fructose intake likely exacerbated his already elevated blood pressure. By the time I left home at 15, he was managing this high blood pressure with medications.
During the 1960s and 1970s, particularly in Indonesia, the concept of preventative medicine was virtually non-existent. Doctors, often unaware of the strong connection between lifestyle choices and heart health, were as susceptible to heart disease as their patients. They might have casually suggested weight loss to their overweight patients, but meaningful lifestyle changes were rarely supported. Medical professionals were trained and worked to treat diseases, not prevent them.
Despite having a family history of health issues – my father’s father suffered a premature death from an untreated heart condition, and his mother passed away after a routine eye surgery likely due to a heart attack – my father failed to recognise the urgency of his situation. He believed he was healthy and ignored the alarming signs driven by his genetics.
When he retired in 1984, my parents opted to join my sister Tien and her husband Charles in Los Angeles. They chose Monterey Park, a suburb of Los Angeles with a significant population of residents from Hong Kong and Taiwan where many local shops were Chinese-owned. The move initially brought excitement to my father’s life, giving him a brief surge of energy. Yet, the consequences of his decades-long unhealthy lifestyle and diet followed him across the ocean.
The first heart attack
In the spring of 1985, I was completing my cardiology fellowship in Sydney when a frantic phone call from my sister shook me. She had called from the Kaiser Permanente Hospital emergency department in downtown LA. My dad had woken up at home with severe chest pain. While en route to the hospital, his heart had stopped. Resuscitation efforts successfully revived him, but he was critically ill.
The next year, when I completed my cardiology fellowship, Vicky – my then wife, six months pregnant with our first child – and I left Australia to join the rest of my family in Los Angeles. The move was partly to be closer to my father, but I’d also been offered a prestigious research fellowship at Cedars Sinai, one of the world’s foremost medical institutions and a flagship hospital for the UCLA School of Medicine.
I’d always known Cedars-Sinai had a formidable reputation. But it wasn’t until I began working there that I truly understood its reach, and the weight of its expectations. The place buzzed with brilliance. You were surrounded by colleagues whose clinical acumen and academic achievements constantly pushed you to think sharper and aim higher.
Every day brought patients with complex, often extraordinary conditions, the kind only seen in a major tertiary and quaternary centre. It was the sort of environment that stretched you in every direction, both clinically and intellectually. I arrived unprepared for it all – but somewhere in that intensity, I found my rhythm. And with it, a deeper appreciation for what true excellence in medicine really means.
Cardiac cachexia: the devastating impact
It had been a few years since I had last seen my father. I remembered him as strong, tall and handsome. But when we arrived in LA in August of 1986, I barely recognised him. Though he survived it, the massive heart attack just over a year ago had weakened him. It had stripped him down. Cardiac cachexia had taken hold, a brutal form of unintentional weight loss and muscle wasting that comes with advanced heart disease and heart failure. The skin sagged over his bones. He was frequently short of breath. Even short trips from the couch to the kitchen often left him struggling for air. His heart was swollen and weak, and beyond repair. The devastating impact of cardiac cachexia in my dad was unmistakable.
The heart, once a powerful and reliable pump, can be severely damaged by a massive heart attack, leaving it struggling to circulate life-giving blood throughout the body. This inefficiency sets off a vicious cycle, where the body begins to waste away due to a lack of essential nutrients and oxygen. Imagine a garden that depends on a water pump to stay lush and green. If the pump breaks, the plants won’t get the water they need – they will dry up, wilt and eventually die. Your heart works the same way. When it is severely damaged, it can’t pump enough blood to nourish your body’s tissues. Without that steady supply, muscles shrink, weight drops and vital organs like the kidneys start to fail.
My father’s experience taught me a valuable lesson: the importance of prevention. Just as regular maintenance is crucial for the water pump in your garden, taking care of your heart is essential to avoid catastrophic breakdowns. By prioritising heart health, we can prevent the sudden and irreversible damage that can lead to further heart attacks, complications, suffering and, ultimately, loss of life.
This personal experience sparked my passion for understanding the importance of preventative measures. I have come to realise that taking care of our hearts is not just a matter of avoiding disease, but also about nurturing our overall wellbeing. By making conscious choices to maintain a healthy heart, we can avoid the devastating consequences of cardiac cachexia and ensure a longer, healthier life.
But what if we gave him a new heart – a transplant? Back then, the cut-off age for a heart transplant was 60. My dad was 67. Still, I managed to get approval to put his name on the list. When we sat down to talk about it, I laid everything out for him – the risks, the process, what it would mean for his future. Heart transplants in older patients carry serious risks. Surgery itself can lead to bleeding, infection, stroke or kidney failure. The new heart may not work properly or be rejected, and over time, its arteries can clog, increasing the risk of heart attacks. Lifelong medications to prevent rejection can weaken the kidneys, raise blood pressure and increase the risk of infections and cancer. After a long conversation, he decided to decline his spot on the waiting list for a transplant.
We did everything we could to keep him going in those final years. He was in and out of the hospital, struggling with heart failure – fluid building up in his lungs, making it harder and harder to breathe. His coronary arteries were a mess, clogged with cholesterol plaques, starving his heart of blood. I knew another heart attack was just a matter of time, and the next one would likely be worse. Still, we hoped the right mix of medications could buy him a few more years.
The call in the night
On an evening in May of 1989, it was a night like any other. Then the phone rang. On the other end, my mother’s voice trembled. ‘Your dad has collapsed.’ A chill shot through me. An ambulance was already there. They were working on him. Just hours earlier, he had been laughing over dinner, playing a few songs on the electric organ. Now, he lay unconscious, his life slipping away as my mother desperately tried to rouse him.
I grabbed my car keys. The 30-kilometre drive to Monterey Park felt unreal. The world outside blurred, my hands gripped the wheel, but I was detached, moving on autopilot. When I arrived, paramedics were wheeling my father out of the house, their movements urgent yet controlled, performing CPR with unwavering focus. Inside, my mother knelt on the floor, tears streaming down her face, clutching a small bottle of Anginine – her desperate attempt to save him. She had tried to push the tablets into his mouth as he collapsed.
We followed the ambulance in silence for the entire 15-minute drive, my mind blank, my body numb. The ambulance tore through the night, rushing my father to Monterey Park Hospital – the closest facility with an ER. Although it wasn’t my hospital, at 1 am, as a cardiologist, I was the most experienced among the team gathered and swiftly assigned to coordinate the resuscitation efforts to afford the best chance for a positive outcome. Just like that, I became a conductor, not leading music but orchestrating a high-stakes battle between survival and loss.
My father lay motionless on the cold, sterile table. Tubes snaked in and out of him, leads strewn across his chest. Monitors beeped, their blinking numbers broadcasting his body’s silent struggle. The ventilator hissed, forcing air into his lungs – a reminder that even breathing was no longer his own. Nurses, paramedics and staff moved with practised efficiency. It seemed like the entire Emergency Department had converged on this moment. I felt detached and focused, my medical training subliminally clashing with the raw fear of losing the patient, my father.
‘100 mg lignocaine. Prepare for another shock – 200 joules. Another bolus, 1 mg adrenaline, followed by magnesium. Ready for re-shock – 300 joules.’
My voice was steady, clinical, as if it weren’t my own. Another blood draw – ‘pH, lactate, potassium, base deficit, anion gap’. Orders spilled from my mouth, each one a desperate attempt to wrestle him back from the brink.
Beside me, the young medical resident moved fast, relaying orders, hands steady, voice firm. A nurse logged every action with mechanical precision – every drug, every shock, every desperate attempt to pull him back. Time warped. Fifty minutes collapsed into a single moment. I stayed locked in, absorbing every number shouted across the room, every reading from the machines. Heart rate, oxygen levels, acid-base balance – my mind processed them all at rapid speed. My fingers pressed against his femoral artery, searching. My eyes scanned his face, his cyanotic skin, the rigid movement of his chest under the compressions. The team worked with unwavering focus. Every second felt like the edge of something – teetering between hope and the unthinkable.
Despite everything – the shocks, the adrenaline, the relentless effort – his heart refused to hold on. We brought him back nine, maybe ten times, but each revival was shorter, weaker. He was slipping away. Minutes stretched as his heart stiffened, locked in its final grip. Just after 2 am, I made the call. Stop. The nurses stepped back. The scribe noted the time. The beeping sounds gone. The ventilator switched off. The rhythmic hiss that had filled the room for the past hour fell silent. The fight was over. Silence. Just stillness, thick and absolute. I stood there, caught between duty and loss.
I walked out, down the hall, into the waiting room – moving on autopilot. My mother and sister looked up, their eyes clinging to hope. I gave them the news. They crumbled. My sister wept into my brother-in-law’s arms. My mother wailed. I stood still, expressionless. Years of training had taught me to hold it in, to stay composed. That night, sleep never came – not from grief but the adrenaline still coursing through me. Not a single tear fell. That would come later, when the walls finally gave way. For years I found myself replaying that night of resuscitation, wondering if I could have done something differently – another drug, a different dose, a better sequence of shocks and medications.
Lessons in prevention
Medical science has progressed considerably since then – but catastrophic damage to the heart is as permanent today as it was 40 years ago. Once interrupted, the delicate dance of the heart and the rest of the body loses much of its grace. Though the patient who has suffered a large heart attack might survive the ordeal and live longer than my dad did, they will likely experience a major reduction in quality of life, for the remainder of their life.
This prospect often comes as a shock for patients, who, having come out the other side of a heart attack, begin to take much better care of themselves. They make dramatic changes to their lifestyle and diet, but their cardiovascular function remains severely impaired. I have seen heart attack patients go on to achieve incredible things, but they do these things despite their cardiovascular impairment, which is with them for life. They can expect to live considerably longer than those who go back to the same high-risk diets and lifestyles that got them in trouble in the first place but must make do with the damaged equipment they have.
When a heart attack damages the heart muscle, part of the heart essentially dies and turns into scar tissue. That damaged area can no longer contract or pump blood. It’s a bit like a six-cylinder car that suddenly loses four cylinders – the engine still runs, but very poorly. And unlike a car, you can’t replace the broken parts. Those cylinders in your heart are gone for good.
From that point on, your body relies on whatever healthy heart muscle remains. The heart keeps beating, but with less strength and efficiency. While we can’t revive what’s already lost, the goal is to help the remaining cylinders do their job as well as possible – for as long as possible.
Indeed, with today’s medical advancements, my father might have lived longer and with a better quality of life. Implantable defibrillators, advanced cardiac devices, improved procedures and innovative medications now help patients like him extend their years and stay out of the hospital. These treatments can slow the progression of heart failure and may improve longevity for selected patients under specialist care. Although it is true that with modern medicine my father may have lived longer, longer doesn’t always equate to better.
There is a crucial difference between a long life and a full life. We can keep the heart beating, but those extra years often come at a cost. A heart patient who might have died in their sixties decades ago can now be kept alive into their seventies, but the final stretch is often fraught with limitations – frailty, hospital stays and a body that is failing despite medical intervention. More time doesn’t always mean more living. The best time to do something for my father would have been decades before his first heart attack. He knew that he was at risk for heart disease thanks to his family history. (I too have an elevated risk based on my family history.) My grandfather’s premature death in Indonesia should have been a wake-up call for him.
Like so many of us do when we are still in our twenties or thirties, or forties, my dad either didn’t recognise his heart risks or chose to ignore them. Through his forties and fifties, my dad’s health declined. He gained weight. He didn’t exercise consistently. His risk factors piled up. Even if you don’t have a family history of heart disease (but especially if you do), the best time to start prevention may have already passed, but the second-best time is now. Later may be too late. If a long, full life is the goal, prevention is the most powerful treatment. And the numbers prove it. Large studies from Germany and the US show that over 10 years, adopting healthy habits – like not smoking, eating well, staying active and maintaining a healthy weight – can reduce heart disease deaths by over 80%, stroke risk by 50% and cancer deaths by 65% compared to those with unhealthy lifestyles. Prevention is investing in your future.
If you enjoyed this excerpt, you can learn more about Wisdom from Two Worlds here.
