History of Coronary Care Unit in Qatar
A brief history of the Coronary Care Unit
Between 1920 and 1960 the mortality rate for acute myocardial infarction (AMI) was between 40% to 50% because there was nothing to offer patients except bed rest. The real progress in treating patients with AMI occurred only in the last 40 years.
In 1956, a 65-year-old physician with AMI developed ventricular fibrillation. He was rushed to the operating theater where open chest massage and defibrillation resulted in full recovery. This extraordinary medical feat was reported in JAMA by Beck et al (1956;161:434). That was the first time that a life-threatening arrhythmia after AMI was successfully treated. In 1960, closed cardiac massage and defibrillation were accomplished.
To exploit these new techniques of cardiac resuscitation, victims of AMI were admitted to a special ward, equipped with ECG monitors and defibrillators, hence the coronary care unit (CCU) was born. The first such CCUs were born in Kansas City, Toronto, and Philadelphia in 1962. (Day HW: History of CCU Am J Cardiol 1972;30:405) The 1960s was a decade of rapid progress in cardiopulmonary resuscitation (CPR). With the use of anti-arrhythmic drugs and defibrillators to treat tachyarrhythmia, and pacemakers to treat bradycardia, a death of post-AMI patients with arrhythmia in the CCU became uncommon, in the absence of severe myocardial damage.
The second phase in the treatment of AMI in the CCU was the treatment of heart failure. Swan-Ganz catheters, inotropic and vasodilator drugs, and mechanical support devices became popular in the 1970s when the concept of CCU became widely accepted by most major hospitals in the USA and Europe.
Even though I had my internship training in 1973 in one of the major hospitals in the city where the first CCU was born, i.e. Kansas City, I was not exposed to a modern CCU until 1974 in Portland, Oregon where I had my medical residency and fellowship training.
In 1978, when I was struggling to create a CCU in Doha, most hospitals in the Middle East, and many hospitals in the USA did not have CCU. Cardiac patients were cared for in medical intensive care units.
My first round in Doha
In August 1978, having completed my cardiology fellowship, I returned to Doha. I was young, full of enthusiasm, and eager to implement new and innovative techniques into practice.
At the time of my return home to work as a cardiologist, there was only one intensive care unit in the country - a surgical intensive care unit at Rumailah Hospital. I knew that fact one year earlier when I came home for summer vacation in 1977. During that summer, I discussed with the administrators the need for a CCU. I made a list of equipment that would be needed. I mailed the list to the hospital administrators of Rumailah Hospital in December 1977. Unfortunately, no action was taken.
On my first working day, at 7:00 AM, wearing a black suit and a necktie, I went to Rumailah Hospital, the only general hospital in Qatar then. I entered the room allocated for cardiac patients. It had two empty beds. There was no patient in the room. An old and dusty Seimens cardiac monitor sat on a small table in one corner of the room. I asked the nurse about the monitor. She said that she did not know what the machine was for, but she had seen doctors attaching the machine’s wires to patients for a few minutes, then remove them. I realized that the monitor was used as EKG for a few minutes to detect arrhythmia, not as a continuous monitor. The nurses were not trained in arrhythmia recognition. I also noticed an ancient, red-colored defibrillator in the room, covered with dust. It was out of order even though it was never used.
I informed the nurse that I was a cardiologist and that I will be looking after cardiac patients. “I thought that you must be a doctor. No one has informed us that you were coming.” She said. A file of one patient was on the table. “Where is the patient?” I asked her. “You will find him in the corridor. Do you want me to call him?” “No,” I said. “I will review the record first.”
I picked up the file. I did not find a proper history and physical examination in the file. There was only a very short note in the file with a folded strip of ECG and laboratory reports of CBC and CPK. He was on nitroglycerin as needed and persantin. The CPK was elevated and the ECG was compatible with acute myocardial infarction. Obviously, the patient was supposed to have been admitted for AMI the night before.
The nurse had no idea about the care of heart attack patients. She took the patient’s vital signs three times daily and gave the patient his medicines. If the patient could walk, he was free to roam around the hospital. If he was too sick to leave the bed, she would visit him and take his vital signs according to the orders of the physician.
I went looking for the patient in the corridors. I was not surprised to see cardiac patients mixed with general medical patients. Months later, on visiting the several Gulf States, I found no proper CCU in any of them except in King Faisal Hospital in Riyadh, Saudi Arabia where I was a locum cardiologist for one month. Even that CCU was not designed as such. The nurse station was in the far end of a long corridor and was not facing the unit. Unlike other major Gulf hospitals, Rumailah Hospital had no medical intensive care unit. It had only a surgical intensive care unit, which opened a couple of years earlier.
At the time of my return, there was no trained cardiologist in Qatar. A geriatrician was recruited and assigned the responsibility for cardiac patients just before my return. The medical department staff was composed of two general internists, a chest physician, one “specialist” and a handful of house officers.
Most Qatari citizens and non-Qatari government employees with cardiac problems were sent abroad for care at the expense of the government. Those who were very ill were sent with medical escorts – a doctor and a nurse. Cardiologists from abroad were flown to Doha to help manage VIP patients who were not willing or could not travel.
Dr. Gelal El-Said, a well-known Egyptian cardiologist narrated to me the following story:
In 1977, A VIP patient was admitted to Rumailah Hospital for chest pain with ST-T changes on ECG. A cardiologist from London was requested to come to treat the patient. He was not able to travel and no other cardiologist could be found willing to travel to Doha at that time. The cardiologist recommended to the local doctors, over the phone, to use nitrate and IV heparin. The patient did not improve on this treatment for 3 days and the chest pain became worse. I was requested to come to Doha from Cairo for urgent consultation. I received the call in the morning and by evening, I was on a plane to Doha. I was told my visa will be waiting for me at the airport. On auscultation, I heard a very loud friction rub and the ECG was not compatible with AMI but was typical for pericarditis. I stopped the nitrate and heparin, which were very inappropriate and dangerous for his condition. I started the patient on NSAID. The following day, the patient was better. He was discharged a couple of days later.
“Treating patients over the phone several thousand miles away is not good medicine” Dr. El-Said added. The memories of my first working day in Rumailah Hospital are still fresh and clear in my mind.
As I wandered through the corridors, looking for the patient with AMI, I noticed that most rooms had two patients. Some 2-bedded rooms had only one patient, presumably VIP. There were also 4- and 6-bed patients’ wards. Some patients were cared for in the corridors on makeshift beds due to overcrowding and lack of hospital rooms.
I asked one of the Indian cleaning boys to help me look for the patient.
“There is your patient”, he said, pointing to an Indian man sitting on a wooden bench and smoking a cigarette while socializing with other patients. I informed the patient that I was a new doctor and asked him to put out his cigarette. He complied without any hesitation. I asked him to return to his room, where I took a detailed history and physical examination. The nurse was also Indian and translated for me.
The nurse was very amused that I spent almost an hour with the patient. She thought that I was cruel when I said that heart attack patients should not be allowed to leave the room for the first 5 days even if they could walk. That patient did well and was discharged one week later without complications.
I did not get that patient attached to the monitor even though I had the impulse to do so. I realized that I had to train nurses in arrhythmia recognition and teach them the technique of cardiopulmonary resuscitation.
From the first day on duty, I realized that I must roll up my sleeve and start the difficult task of establishing a cardiology department and a proper CCU.
The first CCU in Rumailah Hospital (1978).
Cardiac Nurses and cardiology house officers
The first member of my team was Hassan a Somali nurse, who was transferred from medicine and whom I trained to be my ECG technician.
Then, I selected 6 nurses from the medical ward for training and called them “cardiac nurses”. I conducted an intensive cardiopulmonary resuscitation (CPR) and arrhythmia course for them. They learned fast because they were enthusiastic and eager to learn. They scored over 90% on their first arrhythmia quiz.
One month later, with those “trained” nurses, I converted the room assigned for cardiac patients into a temporary “CCU”, before we established our first proper CCU in Rumailah hospital. It was a 2-bedroom with two old monitors connected to patients, ECG machine, a crash cart filled with emergency drugs, and a new defibrillator machine, which I requisitioned from the storage room of Hamad General Hospital (HGH). At that time, HGH was still under commissioning. I assigned a cardiac nurse to watch over the patients round-the-clock. After a few weeks, the number of CCU admissions quickly increased and we added another 2-bedroom to our CCU. The need came when a lady with atrial fibrillation was admitted. Although the second room was in the same ward, it was not adjacent to the first, which was a distinct disadvantage, because we had to put one nurse in each room.
We did not label the rooms as male CCU and female CCU because the rooms were used for men most of the time.
In the beginning, I assumed the role of an intern, resident, fellow, and consultant. By September of that year, I had a full-time cardiology house officer and a month later, I had three residents devoted to cardiology service.
Cardiology separates from Internal medicine service
The survival of cardiac arrest patients after CPR was news in the hospital. Doctors came to watch us when we resuscitated patients. One morning, after we had successfully resuscitated a patient, one of the doctors who had never seen CPR, stopped by to watch, and commented: “How do you bring back patients from death?” “Only God could do that”, I answered. “But with His help, we can save lives.”
After training nurses and doctors in CPR, the second step was the formation of CPR teams to cover 24-hours. The team consisted of a cardiology house officer, cardiac nurses, ECG technician, anesthesiologist, and myself. We had a special tone for the team bleeps. We would rush to the hospital even after midnight when our bleep “cried”. Once, I had to leave guests in the middle of dinner at home to rush to the hospital.
After observing our nurses in CPR, I became confident in their ability to recognize ventricular fibrillation, ventricular tachycardia, and asystole. I wrote on the standard CCU order in the files that a nurse might start full CPR until a physician arrives. But one evening, a cardiac patient had ventricular fibrillation. Our cardiac nurse had put the defibrillator paddles on the patient’s chest when a head nurse from medicine held her hand and prevented her from defibrillating the patient. “This is a job for doctors, not nurses”, She told our nurse.
She ordered her to call the medical doctor on duty. At that time, doctors on night duty stayed home. No doctor stayed at night in the hospital. When the doctor arrived at the hospital, the patient was dead. The following day, after discussing the incident with the Minister of Health, I declared to the administration and nursing department that “cardiology is an independent division and that we will not accept interference from any section in the care of cardiac patients.” The death of that patient convinced everyone in the hospital to respect our patient care. After that incident, I made the cardiology house officers rotate on 24-hour duty in the hospital. The hospital superintendent issued a memorandum to all departments that the cardiology service was independent.
A dream come true
By the end of the year, we made another move. We took a 6-bed ward and converted it to a CCU, using portable monitors mounted on crash carts. The new cardiology division consisted of 3 full-time house officers, one specialist and myself. A well-trained American cardiac nurse, Carol Schneider, joined the division as head nurse. We were lucky to have somebody like her join our team.
The number of cardiac patients increased from 10 admissions per month before August 1978 to 30 admissions per month by December 1978. The number of female admissions was also increasing. We used to keep myocardial infarction patients in the CCU for one week.
But I was not satisfied with the new CCU. We started planning for a proper CCU in the new extension ward with a central monitor station, wall-mounted monitors connected to the nurse station with arrhythmia storage capability, pressure recording, a sophisticated alarm system, and a step-down unit. On September 1, 1979, we moved to our new proper CCU in the new extension ward of Rumailah Hospital. Most of the equipment came from the new hospital. We also created a 2-bed female CCU to accommodate the increasing number of female admissions. Our old CCU became the first medical intensive care unit in Qatar, which also opened on September 1, 1979.
NO. OF CCU Admissions 1978-1981:
Admissions Before moving to Hamad General Hospital
The following month the local Gulf Times newspaper wrote a report on our unit:
NEW CARDIAC UNIT KEEPS UP PULSE OF MEDICINE M. Radhakrishnan
October 2, 1979
"A new Cardiac Care Unit (CCU) opened at the Rumaillah Hospital in Doha on September l marking another landmark in the advancement of Qatar’s free health care facilities.
The CCU and a cardiology clinic, opened a month ago, together form the cardiology department headed by a well-qualified Qatari cardiologist, Dr. H A Hajar.
The new CCU, in a recently constructed wing of the hospital, opposite The Guest Palace, was formally opened by the Minister of Health, HE Sayed Khaled bin Mohammed AI-Mana.
The new ward has four beds for critical patients. It will have four more for less serious patients next week. Very soon the total number of beds for non-critical patients will be increased to 16. The CCU now has the services of a cardiologist, one visiting cardiologist, one specialist, and three junior doctors. Out of 10 nurses, one is a Qatari and five more will join in a week. The CCU and the clinic together have three technicians. Dr. Hajar took over the cardiology department in August 1978 and has been building it up all these months.
Nurses had to be trained to care for heart patients and to handle sophisticated machines, which were ordered from abroad. In certain emergencies, the nurses are now capable of attending to the patient until the doctor arrives.
Each patient’s heart is monitored on a video screen and an alarm attached to the screen warns the nurse who constantly monitors it.
Other equipment includes a fluoroscopy machine which helps the doctor to see the movement of the heart and heart catheters which help determine pressures in the heart.
The cardiology clinic houses the Echocardiography and Stress Laboratory. The laboratory has a treadmill machine which helps determine a heart patient’s physical ability and an ECG service for the entire hospital. Soon to arrive is an echocardiography machine to help diagnose heart valve diseases.
There is also a small pharmacy at the clinic for the physically handicapped or the aged to save them the trouble of going to the Polyclinic several yards away.
The clinic serves those patients referred by the Polyclinic doctors and only by appointment. Open between 8.30 a.m. and 1 p.m., the clinic attends to nearly 20 out-patients a day.
Dr. Hajar has introduced a medical record system and the clinic now has files of 800 patients giving their heart histories".
The visiting cardiologist mentioned in the above news item was Dr. Keith Woollard from Australia. Soon after, he joined our team with his wife Janet, a nurse who later became CCU Head Nurse. When Keith returned to Australia for good, Dr. Bernard Hockings, another Australian cardiologist joined us. I shall always be grateful to Keith and Bernard for their valuable help and contribution during those early years.
When I realized that no CCU had been planned in the new Hamad General Hospital (HGH), I expressed my concern to the commissioning team. In 1981, in my capacity as Undersecretary of Health and Managing Director of HGH, we started planning a new CCU in HGH with 16 beds. We converted a regular ward to a CCU, which required only minor modification of the layout of the nurse station. We also modified an area in the radiology department and converted it to a cardiac catheterization laboratory. Likewise, a section of the Outpatient Clinic was modified to accommodate a Non-Invasive Cardiac Laboratory.
In February 1982, my dream came true when we moved to our well-equipped and well-staffed modern CCU at HGH. I was happy but anxious. I had to sleep in the unit the first night to be available for any unexpected emergency. It was not easy to sleep. I counted that in 4 years, from 1978 to 1982, we moved our CCU from one location to another four times, and expanded from 2-bed to 16-bed CCU. The cardiology department grew from single manpower to over 60 men and women. I still remember the first ray of sunshine seen from the CCU room at HGH. It was a beautiful, vibrant, and inspiring sunshine.
Hamad General Hospital CCU (1982)
© 1999 Hamad Medical Corporation.