SPECIAL SECTION

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 Albinali, MD*

The Palm Tree Doctor

“Honor your aunt, the palm tree, it was created from the same clay as Adam.” Prophet Mohammad, PBUH.

Moslems consider the palm tree blessed. They believe that Christ was born under a date-palm and that the date-fruits relieved the labor pain of Mary, his mother. In ancient times, the Sumerians worshiped the palm tree. In the Sumerian version of the story of Adam and Eve, the snake tempted them to eat from a palm tree and this was illustrated 2300 years ago in an ancient Sumerian drawing. The date-fruit was the most important source of nourishment among the Arabs for thousands of years. The Arabs say, “A date is the food of the poor, the dessert of the rich, and the traveler’s food.” Nutritional analysis has shown that dates have a high iron content as well as appreciable quantities of proteins, fats, vitamins, and mineral salts. They are also a high-energy food as they are 50% sugar. Moreover, the entire tree was put to use. The trunk was used to construct supports and roofs for huts. The branches were transformed into shades and walls; the fiber into ropes. The leaves were, (and still are) made into useful and decorative mats and baskets. It is no wonder, then, that the Arabs, especially the Gulf Arabs, love palm trees. The Arabian Gulfs the original home of the date-palm, according to an Italian palm tree scientist, Odarado Beccari.

The Gulf Arabs consider the palm tree man’s close relative and it is not unusual for them to attribute human qualities to the tree: It stands erect; the body [trunk] is covered with fiber similar to human hair over the body. There are males and females; female palms do not bear fruit unless fertilized. The palm sticks are not like branches of other trees but more like human extremities – If cut off, they do not re-grow. The tree has an edible white structure called “heart” located in the middle of the tree’s green branches [sticks]. The palm heart is well protected and hidden between the sticks just like the human heart is protected under the ribs. If its heart goes into “shock”, it dies. The palm heart dies if injured, suffocated by drowning under water or subjected to freezing temperature. The palm tree dies if its head is chopped off. Over the last few years, a destructive palm tree insect entered Qatar probably with imported palm or fertilizers. That insect barrows large holes in the tree trunk and kills the tree. The mortality of infested trees is over 95%. I lost four out of 54 palm trees in my garden. I saw a botanist injecting the diseased tree with specific insecticide using a special large syringe. The port of entry for the injection is a tunnel hole in the tree made by the insect. On September 5, 2001, Dr. SS, the Indian botanist, who treats my garden palm trees and keeps them healthy, came to my office requesting to see me. Dr. SS has been working for the government agriculture department in Qatar for the last 15 years. He has BS, MS & PhD in Agriculture. I valued his recommen-dations and treatment of the plants in my garden. When my gardener says “the doctor” he always means Dr. SS. He is a good doctor but the sight of blood makes him faint, as he told me. He is also an interesting character. He does not smoke; he does not drink alcohol, tea, coffee, or milk. He does not eat red meat. Dr. SS looked grim when he entered my office. He appeared very serious when he shook hands with me. He was not smiling. I immediately assumed that he had bad news. He may have discovered new spread of the insect infesting my palm trees. “Doctor”, he said, “I came to ask your opinion.” “What is the problem?” I asked. “I am suffering from difficulty in breathing”, he said. He had been hospitalized for shortness of breath (SOB) and recently discharged from Cardiology on August 10, 2001. The shortness of breath had started one week before admission when he was supine in bed and his symptom had prevented him from falling asleep easily. During that period, he occasionally woke up from sleep because of SOB. He had no associated chest pain, cough, dizziness or diaphoresis. He complained of easy fatigability and difficulty of breathing on climbing one flight of stairs, associated with general weakness. He could walk without difficulty on flat level. After three days of such recurrent symptoms he went to a health clinic. His BP was found to be 160/100. He was advised to continue his anti-hypertensive medication. He was given a muscle relaxant. He thought his symptoms may have improved slightly. On the day of admission, he went to the ER in Hamad Medical Corporation because a friend had suggested to him that he should get checked in the hospital. He went to the ER without distress. “I went walking to the emergency room for check-up only”. He said. After registration, he was told to sit in a wheel chair to be taken for examination. “I could have walked by myself but I was not allowed” he added. He claimed to have been “fully relieved with oxygen.” He was scared when told that his BP was 200 mmHg. He did not understand why he was admitted and kept for six days in the hospital for work up. However, before his discharge, he was told that his heart valve was not normal. He was also scheduled for coronary angiography but he did not show up for it because he was worried. He denied any history of asthma but he had SOB for 2-3 days whenever he had a cold since childhood, usually in winter. He had no history of diabetes. He denied allergy to plants, animals or dust. He had a history of hypertension for 3 years, treated with Tenormin 50 mg daily. He had never been admitted to a hospital except for renal stone in India The sight of blood makes him dizzy. The medical record indicated that he was seen in the ER for SOB and dyspnea. He was described as lying flat in bed without distress. The clinical impression was heart failure, mitral regurgitation, and asthmatic bronchitis. He was admitted to Cardiology and treated accordingly.

Transthoracicand transesophageal echocardiography revealed: Flail mitral valve, severe mitral regurgitation, severe pulmonary hypertension (RVSP 100 mmHg.), left atrial enlargement, left ventricular hypertrophy, normal left ventricular dimension and ejection fraction. Transient segmental wall motion abnormality was noted during the study. After I evaluated Dr. SS I told him that he had severe valve disease and severe pulmonary hypertension and that further evaluationwasrecommended.The echocardiography was also suggestive of coronaryarterydisease.Coronary angiography was a must. He told me that he was afraid to undergo the test. I told him that I would personally perform the test and that I would take good care of him. He agreed. OnSeptember 8, 2001, three daysafter seeing him in my office,I catheterized him and found 90% lesion in the 1st diagonal and 60% mid right coronary artery lesion. Before discharge the following day, pulmonary function test was performed, which showed mild restrictive type of ventilation impairment, that did not respond to bronchodilator. After discussion with my surgical colleagues, we recommended mitral valve surgery. We did inform him that in his case the surgery was risky but necessary. He decided to go to the USA for the surgery as advised by his brother-in-law who is a vascular surgeon in the USA. I said good-bye to him and wished him a safe journey and successful surgery. On November 5, 2001, two months after his discharge, he was readmitted because of progressive shortness of breath, dyspnea on exertion, increased fatigability and lower leg edema, as well as chest pain on exertion. His symptoms had deteriorated over the last two months. He was willing to accept my old advice to have the surgery in Doha. When I asked him why he had not gone to the USA as he had planned, he said that he had applied for a visa to go to the USA for medical treatment but then came the attack in New York on September 11, which delayed the processing of his visa. He waited and waited but finally his request for visa was rejected by the US embassy. “I do not know why they refused”, he said while stroking his long beard. His beard might have been the reason for the rejection. In the aftermath of September 11, an Indian Moslem with a long beard and cap on the head may look like an Afghani from Al Qaeda or Osama bin Laden to many Americans. On November 9, 2001 he underwent mitral valve replacement. His post-operative course was complicated, which was not unexpected. It was difficult to extubate him and he was on ventilation for three days. He also developed temporary heart block post operatively, which required a temporary pacemaker. He did not ambulate until the 6th post-operative day because of feeling of fatigue. On the 11th day post op, he developed mild depression and confusion. This was attributed to intensive care unit environment, which improved when he was transferred to the ward. On the 13th day post op, he developed atrial fibrillation, which required cardioversion. On the 22nd day post op he developed painful Herpes Zoster (shingles) over the left chest which was dealt with successfully by the dermatologist, but It delayed his discharge from the hospital further. He was finally discharged well and happy, 38 days after his surgery. He decided to take sick leave from his work and went home to India to relax. He came back to Doha three months later and visited me. This time he entered my office with a big smile. He brought me a gift, a pack of three slim ball pens, made in India. I noticed that his beard was shorter. I asked him why he trimmed his beard. He laughed but did not answer.®

Dr. S.S.