Hajar Ahmed AlBinali, MD

On the 24th of November in 1978, Abdulla, a 75-year-old Qatari man, was brought to Rumailah Hospital due to recurrent fainting spells at home. He complained of dizziness and his pulse was 40 per minute. I admitted him to our two-bed CCU room. He was lethargic. The diagnosis was quickly and easily discovered with an electrocardiogram: complete heart block. To survive, he needed a permanent pacemaker, a solution that was not so easy in 1978 because Qatar had no pacemaker, catheterization laboratory or mobile fluoroscopy machine.

I contacted the American commissioning team for the new Hamad General Hospital to search for a pacemaker among the newly arrived equipment in storage. They found a temporary external pacemaker in a crash cart in the storeroom. I inserted the pacemaker lead into the old man’s heart through his arm, pacing him at 70 per minute. In a few minutes, he became more alert and very talkative. The problem was solved temporarily.

 

 

 

 

 

 

 

 

 

 

 

Abulla

I called the Qatar medical attaché in London urgently.

“Buy one pacemaker with its lead from any company and send to Doha as soon as possible”, I requested. Three days later the life-saving pacemaker arrived in Doha.

The following day, I asked the Chairman of Surgery to arrange for my use one of the operating rooms and requested him to assign a surgeon to stand by to assist me in controlling bleeding, if needed. He recommended a visiting British general surgeon. The surgeon was reluctant.

“I have not seen a pacemaker insertion”, he said.

“Then you will see one today,” I replied.

“OK.” He laughed.

At 11 AM, with the precious pacemaker in my hand, I accompanied Abdulla to the operating room. I was handling the pacemaker and the lead like pieces of jewelry. Since we had no mobile fluoroscopy machine, we wheeled in a portable x-ray machine to enable us to repeatedly check the position of the wire inside the heart. We prepared and draped Abdulla for the procedure. Nasal oxygen was attached to his nostrils and a sterile drape covered his face, but he did not mind because his eyesight was poor. He told me that he kept his eyes closed during the procedure. I infiltrated the skin below the left shoulder blade with a generous amount of xylocaine. We monitored his rhythm with a portable defibrillator machine equipped with a monitor screen. The ECG leads kept falling off his chest during the procedure, but I knew Abdulla was all right because he never stopped talking. He was comfortable. His temporary pacer was working well. He was busy telling me about his recent trip to Dubai, while I was making the incision for the pacemaker pocket in his chest. I encountered minor bleeders, which the surgeon quickly ligated with skill and speed. Abdulla did not complain of any pain during the procedure.

In 25 minutes, the permanent pacemaker was pacing Abdulla’s heart and the temporary one was off. When I explained to Abdulla that the new pacemaker was functioning well and it was time to remove the temporary pacer, he objected.

“I want them both, two are better than one.” He said.

“No, Abdulla, the one in your arm will ruin the important one in your chest, and you may get dizzy again,” I told him.

“Well, all right. You are the doctor, I do not want to feel dizzy again.” He finally consented.

My assistant surgeon nicely sutured the pocket wound. A plastic surgeon would not have done a better suturing for the old man.

Back in the CCU room, Abdulla was happy and was excitedly planning another trip to Dubai after discharge. He told me that he had a wife and children in Dubai. At lunchtime, Abdulla refused to eat the hospital food. His family delivered a tray with plates of rice and lamb to his room and he invited the patient sharing the room with him for a feast. At that time, there was no hospital regulation prohibiting families from bringing any food desired by in-patients. Once, I saw four men carrying a large tray filled with rice and topped with two whole baked lambs to a VIP patient in Rumailah Hospital.

During the night, a nurse called to inform me that Abdulla could not pass urine. I went to the hospital to see him. His bladder was very distended. He was not comfortable. I requested the urologist on call to see him. Abdulla had severe prostatic hypertrophy.

“Did the machine you put in my heart close my urine?” Abdulla asked me while the urologist was inserting the Foley catheter with difficulty.

“It might be related,” I replied. “The pacemaker made your heart more efficient in pumping blood to your kidney. Therefore your kidney is making more urine. But because of your age, your prostate is large and caused an obstruction when too much urine filled your bladder. This could be corrected with surgery later.”

The urologist explained to him the procedure. He did not like it. He was not keen on having surgery on that part of his body. “I want to have more children”, he said.

The news of the pacemaker in Doha hit the press. Newspaper reporters came to see Abdulla. His story was published locally and taken up by the Arabian Gulf and Egyptian newspapers. It was something new for the laymen in the region. Abdulla’s picture appeared in newspapers and magazines (see picture). He became an instant celebrity. The newly established Cardiology Division, including myself, shared in his glory. Through him, our Cardiology section became known in the area. Patients came to us for treatment from other Gulf states.

In one of his numerous interviews with reporters, Abdulla claimed that the only things he was missing in the hospital were “good honey and bokhoor (incense)”. The following day, he received several gifts of honey and bokhoor from family, friends, and sympathizers. He burned bokhoor in his room daily, filling the whole ward with the fragrant smell of incense. Everybody passing through his ward would sniff the air, murmuring with wonder, “incense?” The hospital maintenance department objected to his burning bokhoor in the hospital.

“What is wrong with bokhoor? Even the Prophet Muhammad used it”, he responded defiantly, while passing his ghattra (Arab headgear) over the smoke of the incense.

Abdulla did not show up for his clinic appointment after discharge, but he sent me his greetings through patients. Almost a year later, going to my office at noon to rest. I found a thin, white-bearded Bedouin wearing a pair of dark glasses with a crack in the right lens. He was banging the door with his thin stick, and calling my name loudly.

“Hajar! Hajar! Open the door!”

I placed my hand on the man’s shoulder.

“Where is Hajar?” He asked, turning to me. He was Abdulla. I realized that his poor vision had deteriorated further.

“You mean Dr. Hajar,” I said jokingly.

“I want the doctor.” He said. He meant, “the doctor.”

“I am Hajar,” I said as I opened the door for him. He entered my office and started exposing the pacemaker site, talking all the time.

“I just came from Dubai in a jeep. We drove for more than seven hours. The road was rough and bumpy. I suspect that the heart machine fell out during the jeep ride.”

He had no symptoms. The pacemaker was well secured and his pulse was 70 per minute and regular. The ECG showed that the pacemaker was functioning well. I reassured him and advised him to come to my clinic on a regular basis.

“No. The hospital is for sick people, why should I come if I am not sick? I will only come when I am sick.” I gave up on him and let him go. I did not see him for a couple of years or so.

In 1982, four years after the pacemaker insertion, Abdulla resurfaced in my clinic at the new Hamad Hospital. His only complaint was difficulty in passing urine. He was seen again by a urologist. He agreed to transurethral resection of his prostate, and we cleared him for surgery.

One week later, to my surprise, I found Abdulla walking near the hospital parking lot. He was looking for a taxi, carrying his urine bag in one hand, and his stick in the other. The stick, a thin flexible wood, was a part of his dress. Once, he came to the CCU to visit a relative. On entering the CCU, he tapped a short nurse on the shoulder with his stick, asking about me. The nurse was so startled and terrified that she complained about the incident.

Carrying a stick is an ancient tradition among Arab men and until a few decades ago, the practice was still prevalent in the Arabian Gulf. Many men in Oman and the United Arab Emirates still carry a stick. “He laid down his stick” is an old Arab terminology, which means that a person had stopped his journey or settled in a place. According to the Qur’an, God asked Moses, “And what is in your right hand, O Moses?” Moses answered, “It is my stick: on it, I lean; with it, I beat down fodder for my flocks; And in it, I find other uses.” (Sura XX. 17-18).

Al J’ahid, a famous Arab writer in the 9th century stated that an “Arab speaker may wear any dress but he must have a headcover and stick in his hand while speaking.” He devoted a full chapter on the uses of Al Asa (stick) among the Arabs in his book Al Bayan was Attabin. According to Al J’ahid, the “other uses” of Moses’ stick were “to hit snakes, scorpions, wolves, camels, etc.” He mentions a man who enumerated what his companion did with his stick during their travels together:

So, when I saw Abdulla walking in the parking lot, I stopped my car and offered to take him home. He got in the car and thanked me for helping him. He neither recognized me nor asked my name. He described the location of his house in Al Rayyan. When we reached his house, he insisted that I should go inside for coffee.

I asked him if he recognized me.

“No.” He said, but added, “You are a son of good people.”

I told him that I was his doctor.

“Hajar?” he exclaimed.

“Yes. It’s me.” I replied.

“I was thinking that I have heard this voice before.” He said.

I assisted him out of the car and helped him with his urinary bag and catheter. He complained that the Foley catheter was coming out. I went inside the house with him. I repositioned the urinary catheter and taped it well to his leg. Then he called for coffee. A 12-year-old boy came with Dhalla (Arabic coffee pot) in his left hand and finajeen (small Arabic coffee cups) in his right hand.

“This is Hajar.” He informed the child. Again he did not use the “doctor” title. I was not offended because I knew that it was not natural for the old man to use titles. Even though Abdulla was a city-dweller, his dress, character, and manner of speech were those of a Bedouin. The old generation of Bedouins never used titles. They call or refer to a King or Amir by his first name. The nomadic Bedouins never had kings or doctors living with them in the desert. Wilfred Thesiger, the English adventurer, and explorer, narrates in his book, The Arabian Sands, the incident of a Bedouin whom he heard address the late King Abdul Aziz of Saudi Arabia simply as Abdul Aziz. “‘Why did you not call him King Abdul Aziz?’ He asked. ‘There is only one King and that is Allah’, replied the Bedouin.”

Over coffee, Abdulla told me that when he was a young man he used to live with his relatives in the desert with their sheep and camels during the winter season, but during the summer he joined the pearl divers in the sea. He claimed that he was a good diver! This surprised me because Bedouins used to be scared of the sea. They even avoided traveling in a ship. Indeed, Abdulla was a unique and unusual person.

One week later, I was informed that Abdulla had told people in his neighborhood that I gave him a ride to his house, fixed his falling urinary catheter, and saved his life again!

The last time I saw my old patient was in 1983, during one of his sporadic visits to the cardiology clinic. He told me that he had not traveled to Dubai for a long time. His pacemaker was functioning well and his cardiac status was stable. He was almost blind. His only complaint was difficulty passing urine.

Sadly, one year later, the old man, Abdulla Bin Hamad Al Mihshadi Al Ma’dady, the first patient to receive a pacemaker in Qatar, died. He was an innocent instrument of fate, marking a milestone for the history of cardiology in Qatar. He was one of my favorite patients. I will always remember Abdulla – a pleasant, colorful, and lively Bedouin, from the time I paced his heart until he rested in peace. Peace be upon his soul