SPECIAL SECTION

CHAIRMAN’S REFLECTIONS
Part 12

Looking back at the first few years of working as a cardiologist at home in Qatar, is like watching an old movie. The scenes are clear, the events exciting, the struggles intense, and the heroes real. Some characters are still around; some are no longer with us.                                                                                            

                                                                                                     Hajar A. Hajar, MD*

Salim 

Twenty-four years ago, I attended the fune- ral of an old woman who died due to old age. After the burial, I stayed behind to read some verses of the Holy Qur'an over the grave. A white-bearded man whom I had seen on several occasions in my father's living room came to shake hands with me. Salim was his name. He looked sad. He appreciated seeing me reading the Qur'an on the grave. I was sure he was curious why I was doing that. He did not expect that a young man like me would stay behind to read verses from the Qur'an over a grave. He told me that the deceased was his relative.

"Hajia had told me stories about you when you were a child in Ras Al Khaima", he added. She had moved from Ras Al Khaima to Qatar after my family did. Hajia is a respectable term. The term is applied only for a woman who had gone to Hajj (pilgrimage to Mecca). After I shared with Salim the reason, he thanked me, praying that God may prolong my life.

In January 2002, almost a quarter of a century after that funeral, Salim became my patient when I became aware of the tragic last days of his life.

I was born in Ras Al Khaima, UAE. Hajia was not a relative but when I was a child, she was my babysitter. She was a poor widow who lived with her blind brother. I used to follow her everywhere in town as a child. When I was five years old, my parents sent my sister and me with Hajia to a lady, Amina. Hajia's house was next to Amina's house. Both houses were made of palm tree branches. Hajia could hear us reading and reciting the Qur'an. Amina was a private Qur'an tutor for my sister and me. She did not know how to read or write! But she knew how to read the Qur'an! This may sound strange. However, many people who are illiterate could read the Qur'an but not any other book. They actually memorize the Qur'an by repetition through phonetic association with the Arabic alphabet. I demonstrated this to my children once by giving the Qur'an to our gardener, a non-Arabic speaking Moslem, to read. He read it in "good" Arabic but he did not understand what he read.

Every Thursday morning the tutor expected me to memorize the assigned verses. She would hit me with a stick if I had not memorized the verses. Hajia would rush in to rescue me from the stick, if she heard the angry voice of the tutor. In retrospect, I do think that those two ladies may have purposely made such an arrangement between them secretly to scare me while avoiding the physical punishment. I was not hit except two or three times during the two years with the tutor.

Some health care practices are imprinted in my memory from that old environment. They are so strange when I think of them nowadays. I must mention them for history's sake. 

Once, the tutor's baby was crying and could not sleep. She thought the baby had stomach ache. There were no medical doctors or pharmacies in town or any place in Ras Al Khaima then. She gave me a rupee (an Indian coin used in the Arabian Gulf then) and sent me to a neighborhood shop to buy one-rupee worth of"tiriak". The shop owner cut a black-looking piece of stick from a small cylinder, which he handed over to me. The tutor brewed a small piece of that tiriak with tea and forced the liquid into the baby's mouth. The baby slept quietly in a few minutes. The same material was once used to kill the pain of scorpion sting on my father's foot. The tiriak was heated and applied to the site of the sting. I learned later that tiriak was opium. Opium abuse was not heard of in our society then. The fact that people sent children to buy it was proof 

that it was safe to have it in the local market. The government did not interfere with its sale because it was considered medicine.

One year later, the same baby had whooping cough. The tutor sent me with a cup to a specific family to get urine from their son. She forced her child to drink the urine! An old woman had told her that the urine of a child who was half-white and half-black could cure whooping cough! That myth did not do anything for her son. Several years later, I read about an Indian prime minister who used to drink one glass of his own urine every morning to stay healthy!

Hajia's brother was a poor blind man. I saw him once in the street with bleeding toe after he stepped over a broken glass. He had no shoes. The wound was covered with sand and blood. I offered to lead him to his house. He declined the offer but asked me to urinate on the wounded toe, which I did. Then he cut a piece of his head-cover cloth and tied it over the wound. So, that was the first time in my life to treat a patient. Urinating on wounds was common therapeutic practice then. It makes sense when no medication is available. The urine of a healthy person is sterile. It is like washing and irrigating a wound with sterile saline using god-made syringe. It removes sand and debris from the wound and reduces contamination and infection. People learned such therapy over centuries of experience.

During that period of Qur'an reading I had fungus infection on my left temple. It ulcerated and became infected. Nothing helped to cure it over two months. My mother applied the best treatment known then, which was called "MB." They were white tablets sold in the local market with "MB" written on it. That tablet was well known by the old generation in the Gulf after World War II. While I am writing this article I became very curios to find out what was that miracle tablet. From the way it was used it must have been antibiotics, but what kind was it? I asked the pharmacy department in our hospital if any of the old pharmacists could help find out. They could not find any information. It is no longer available in any local pharmacy in Qatar. I inquired at the old shops that still sell old herbal medicine. The tablet was well known to them but it is no longer produced. An old man was able to find a similar tablet. It had MB # 693 engraved on it. We solved the mystery. MB stood for May & baker, now part of Aventis Company. The tablet MB #693 was sulfadiazine. The tablets were crushed and the powder applied over the ulcer. When that did not help my skin infection, my parents sent me with Hajia to an old man who lived near my tutor's house to see if he could do something for me. The old man took an old piece of leather and burned it until it became like charcoal. He crushedthe burnt leather into powder. He took me to the sea and cleaned the ulcer gently with seawater. He used a feather to rub the ulcer under the water. While the ulcer was wet, he covered it with his burnt black leather powder. The old man and I made the therapeutic trip to the sea daily. The ulcer dried and healed in one week. My father gave him a reward for his success.

During those days we had no piped water in our houses. Most houses had wells but the water was brackish because we lived by the seashore. The water was used only for animals and washing. Drinking water had to be brought from a far away place on donkeys by the "water man". Each donkey could carry four large tins, two hanging on each side. The capacity of each tin was 20 liter of water. Our family used to buy one donkey load daily. It was stored in large clay pots. Poor people like Hajia could not afford buying water from the water-man. She had to walk to a well, two miles out of town, to bring water. She carried a clay pot full of water over her head back to her house. Once, on a Friday afternoon, I accompanied her, as a child, on such a trip. She entertained me with children stories during such a long walk. During that trip she made a request: "I wish you read verses from the Qur'an over my grave when I die. Will you?" I said: "Yes I will." She was so happy with my promise. She did not seem to have any doubt that I would do it. And so thirty years later, I fulfilled my promise to that kind old woman. Peace be upon her soul.

Two years ago, while making rounds in our CCU with cardiology residents and registrars, I saw my old tutor Amina. She was admitted with heart attack. She looked so old but was not in distress. She was recovering well. She told me that she regretted hitting me when she taught me Qur'an as a child. She pleaded for forgiveness. She asked me if I had any ill feelings toward her. Of course I did not. I felt sorry that she felt bad about the old days. I decided to lift up her morale. I said to her: "I always remember you as the teacher who installed the first seeds of knowledge in me. You hit me not because of hate, but because of love. You wanted to make me successful. Your stick made a man out of me. You deserve to be thanked for it". The old woman smiled and tried to kiss my hand but I saw some tears in her eyes. She is still doing well on medical therapy and had no recurrence of her heart attack.

I must go back to Salim's story. I got carried away with the story of his relative who used to be my babysitter. Salim had a business transporting people going on pilgrimage. He had busses taking people on roundtrips to Mecca.

Salim had two wives. In 1985, he brought his older wife to my clinic. She was his cousin but seemed much older than he. She was diabetic with hypertension, osteoarthritis, and severe coronary and vascular disease. She was in very poor health. She did not last long after I saw her. She died the following year.

Salim himself was also suffering from coronary artery disease, diabetes, hypertension, peripheral vascular disease, hyperlipedemia, and chronic obstructive lung disease. His medical record in 1999 indicated that he had a history of acute anterior myocardial infarction, aortic sclerosis, mild aortic insufficiency and "hypertensive nephropathy" manifested by elevated urea. He was also a heavy smoker.

On January 17, 2002, he was admitted to the CCU with a new heart attack. He was advised to have coronary angiography before discharge. He called me and requested me to perform the angiography. I told him that my colleagues are doing more procedures than I did these days. Therefore, it was better for him to let my colleagues do it. He refused and insisted that I do the procedure. I understood why he insisted. He thought I would take care of him better than others because I knew him more than my colleagues did.

On the fifth day post myocardial infarction, he insisted to go on pass to attend the wedding of his daughter. Twenty-four hours later he returned to the CCU with recurrent angina and new ST-T changes on his ECG. He was managed with intravenous nitrate.

On January 26, 2002, I proceeded with the procedure. He came to the catheterization laboratory smiling. When I felt for his femoral pulsation I lost my smile. It was difficult to feel the pulse on both sides but he had pedal pulses. He had a history of intermittent claudication for several years. Finally, I convinced myself that I felt a pulse. I successfully punctured the right femoral artery without difficulty. There was good blood flow out of the rear end of the needle. Such blood pumping out when the chance of puncture was small was better than the sight of oil or gold for a cardiologist. The sheath was placed smoothly but when I tried to feed the angiography catheter, I faced a roadblock, so to speak. I manipulated the guide wire under fluoroscopy but it coiled at the right iliac vessel. I used a catheter and injected dye in the right iliac artery. The artery was almost totally blocked but there was a small medial opening the size of the 5 French catheter. Using a very flexible wire and with more luck than skill, I was able to sneak into the common iliac and up to the heart. I covered the patient with heparin to prevent clotting.

His coronary angiogarphy revealed severe critical three-vessel disease involving the proximal left anterior descending coronary artery, the circumflex and right coronary artery. It was obvious that he would require coronary bypass surgery. The surgery will be risky because echocardiography revealed severe left ventricular dysfunction with ejection fraction of 22%. The septum and anterior walls were described as akinetic with dyskinetic apex. The surgeon may need to know the status of his femoral and iliac vessels because an intraortic balloon pump (IABP) maybe required to support him. I took a picture of the common iliac vessel. He had severe stenosis in the common iliac and in both branches. It would be a disaster if he required IABP support. I prayed that he might not.

Salim left the catheterization laboratory as smiling as when he came, but with poorer prognosis. On leaving the laboratory the patient was greeted by his large family. He had 12 children, seven boys and five girls, all from one wife. They all wanted to talk to me about their father's heart. When his wife said hello to me, he signaled to me with his eye and asked jokingly: "Doctor, is my heart good enough to have another wife?". I said: "Yes, but not today". His wife laughed, as she understood the humor of her husband who was also her relative.

One of the well wishers by the door was his son Ahmed. He shook hands with me while one of my colleagues was whispered in my ear that Ahmed was also a cardiac patient. Ahmed was admitted with unstable angina last year at the age of 33. He was a heavy smoker like his father and had elevated cholesterol. He ended up with stents to the LAD and RCA. Ahmed was not Salim's eldest child; there are others older than him. Salim's stated age in the file was 65 but the family told me that he was 10 years older than that.

Salim was given 4 days to stay home with his family and was electively readmitted on April 2, 2002 for cardiac surgery. My surgical colleague told me the rest of the story.

On February 5, 2002, the patient underwent coronary artery bypass with three grafts using LIMA and two veins. The cardiopulmonary bypass was discontinued without a problem and the patient was transferred to the intensive care unit (SICU).

Salim's recovery in the first 24 hours was uneventful. The problems started in the afternoon of the following day when he was noted to have reduced urine output, thus he was started on a furosemide infusion. He was subsequently extubated and was able to breath spontaneously. At this stage several members of his family came to visit him. The nurse noticed that his respiratory effort was becoming gradually compromised. The

blood gas showed that he had become severely acidotic in association with severe oliguria.

Salim was subsequently reintubated and followed by major resuscitative measures to support the kidneys and myocardial function. He might also have suffered a myocardial infarction as his blood pressure required inotropic support. Unfortunately, an IABP was required. It was initially inserted into the left femoral artery, but due to severe stenosis of the left external and common iliac the balloon catheter did not pass up into the aorta. The balloon pump catheter was successfully inserted through the right femoral artery. His condition improved gradually with better blood pressure, but still he did not pass urine. He was dialyzed on the third post-operative day with excellent results in terms of acid base balance and blood chemistry. However, during the same evening the right leg showed some signs of ischemia as anticipated due to the severely stenotic iliac arteries.

The next morning, the right leg was examined carefully and it was apparent that the leg would not withstand further ischemic insult as it was becoming colder and bluer. The balloon pump catheter was therefore taken out. The patient at this stage was in a relatively stable condition and remained so for about an hour. But he suddenly developed cardiac arrest. Cardiac resuscitation commenced, the IABP was re-inserted and cardiac massage was started. This went on for about an hour with very little response.

I certainly felt sad when my surgical colleague informed me one hour before Salim's death that he may not survive. The following day, I visited his family to express my condolence while an Arab poetry verse by Ibn Nabata echoed in my brain. I may translate the verse as follows:

If death is not caused by the sword,
it will be caused by other means.
Death's causes are numerous,
but there is only one death on the scene.

 

Pearl-Oyster Sculpture, Corniche, Doha, Qatar