In 1991, Mohammed Abdulla Hardan (Figure 1), a 78 years old man was packing boxes in Ras Al Khaimah (RAK), UAE, when he developed severe chest pain with shortness of breath and diaphoresis. He felt very fatigued and dizzy and was on the verge of syncope. He did not go to a hospital but waited at home until the pain resolved in 15-20 minutes. He did not have the energy to do anything that day. He had recurrent chest pain on exertion for several days after and he flew to Doha seeking my help.
The above story of a patient with chest pain is not out of the ordinary for cardiologists. That patient, however, was not an ordinary patient with coronary artery disease that we see frequently. He was a man with an unusual history and character. He was also an old sailor who provided me with a fascinating history of sailing in the Gulf during the first half of the last century.
As a seaman, he spent most of his life on ships and in the sea. Like most of his companions, the seamen, he smoked tobacco using a small water pipe made of coconut shell (Figure 2). He quit smoking 40 years prior to admission (PTA). Both his father and mother died while he was a small child. A kind woman took care of him and her rich husband trained him to take care of horses.
Fig.2: Water pipe
He had a mild case of smallpox as a child. He fell down from a tree during childhood resulting in loss of some frontal teeth and a cut wound bisected the lower lip. The wound was treated with ashes. There was no medical doctor to suture the gap in the lip. The scar and disfiguration of the left lower lip were noticeable throughout his life (Figure 1). Another accident that he had during childhood was caused by a horse. He washed a horse in the sea, the road on its bareback while both he and the horse were wet. The horse ran fast heading home after the nice sea bath. It suddenly came across a well in its path and successfully jumped over it. Mohammed could not hold on to the horse’s slippery back during the sudden jump. He slipped and fell on stones surrounding the well. He was lucky that he did not land inside the well. He suffered multiple lacerations, ecchymoses, and bruises but no obvious fractures that he could remember. His foster mother made the herbal paste and applied it to his wounds. He could not walk for over a week after the fall because of severe muscle ache all over his body.
Over the last two years prior to admission, he was treated for hypertension with nifedipine and atenolol.
I admitted him to our cardiology department in Hamad General Hospital for evaluation on July 20, 1997. It became clear that for two years, he had angina on exertion and relieved by rest. His EKG revealed LVH with strain. He was reluctant to undergo coronary angiography. I discharged him two days later. But I continued to follow him up by phone and convinced him to return to Doha for angiography. Ten months after the first admission, he came back for coronary angiography.
The coronary angiography revealed stenosis of his coronary arteries: 90% proximal LAD, 50% proximal circumflex and 40% 1st obtuse marginal (OM1). During the injection of the dye in the left main coronary artery, he developed ventricular fibrillation and lost consciousness. We defibrillated him within one minute successfully. He regained consciousness but seemed confused when he saw not only me but also other staff surrounding him. I reassured him. His case was discussed in our cardiology and cardiovascular surgery conference. It was felt that at the age of 79 years the risk of surgery was high, therefore we treated him medically. I discharged him from the hospital and took him home with me.
Mohammad was not a relative but I grew up considering him as an uncle. He was the business captain of my father’s ‘Sinbook’, a large sailing ship. He lived in an isolated separate room in our house during my childhood. He used to carry me on his shoulder to the seashore. I enjoyed going with him in a small boat to the ship, while it was in the harbor. I used to look forward to the return of the ship from Africa or India to receive the gifts Mohammed brought me such as toys and clothes. I still remember the best gift he brought me from India. It was a large flashlight. It was very useful at that time when we had no electricity yet. With that flashlight, I overcame my fear of darkness when I walked alone at night. The first night I used my flashlight, it was very dark. I went to the seashore in front of our house to see how far I could see with it. I pointed the flashlight toward the sky and admired the beam line as moisture and particles in the air reflected the light creating a strong beam like a laser. A nasty old man ruined my fun when he approached me and asked sarcastically: “Are you looking for angels in the sky?”
As a child, I learned a lot about sail shipping, by osmosis so to speak, from Mohammed and the seamen working in our ship. In the summer, the ship was pulled out to the seashore in front of our house. I still remember the hard effort of the seamen pulling the ship to land using ropes, wood and primitive winch (Figure 3). The winch was turned manually by sheer force of the seamen.
After the quiet dinner in my house, I brought a small one-meter wooden ship that was an exact replica of an old Gulf sail ship. I asked Mohammed to name for me the Arab Gulf terms for each part of the ship. In order to stimulate his memory about his sailing experience, I told him what I read about the heritage of ship sailing in the Arabian Gulf.
I mentioned that the Gulf Arabs mastered the art of shipbuilding and sailing over many centuries. Certainly, there were famous sailors centuries before Islam. The Gulf Arabs are credited to be the first to invent the triangular sail. The Mediterranean sailors borrowed the concept of the triangle-shaped sail from the Gulf Arabs. The Arabs never used metal ships then. All their ships were made of wood (Figure 4). The Portuguese Vasco de Gama, who is credited in the west for discovering the Cape of Good Hope, was led by Ahmed Ibn Majid, a famous Gulf Arab sea pilot. He showed Vasco de Gama the route from Africa to India. This fact is well known among the Arabs but not in the western world. Ahmed Ibn Majid was born in Ras Al-Khaimah around 1421. Mohammed became very interested in the topic. He told me that some elderly men in Ras Al Khaimah had told him that they had seen a palm-tree farm that originally belonged to Ahmed Ibn Majid.
Fig 4: Wooden Gulf Ship (Boom).
I asked Mohammed if it was fun to sail in the ocean. “No, it was not” Mohammed answered and adding, “The sea is treacherous, disloyal and is never safe.” Those descriptions of the sea were actually Gulf Arabs’ proverbs that reflect their knowledge of sailing and their long experience with the sea. I asked him to tell me why he felt that way about sailing. He started narrating the problems he faced over 60 years of experience in the sea.
“Sailing in the old days was not a pleasant occupation,” he said. “It was hard, tiring and risky. When we said goodbye to our loved ones, we never knew if we would see them again. We faced numerous problems in the ocean.” He continued, “During our time sailors did not have meat, chicken, vegetable or fruit while in the ocean. Bread and dates were the main diets. We caught fish for meals by trolling while the ship was sailing. We also ate preserved salted fish if we did not catch fish. In Basra, when the merchant loaded his commodity (mostly dates) it was customary to give the seamen a bull or a cow if the ship was big, and a lamb, if the ship was small.”
Fig. 5: Route map for Gulf sailing ships.
Mohammed explained that the ship would sink if water that accumulated in the bottom of the ship was not carefully drained manually. Some water always leaked in through the boards in the base of the ship. Seamen worked hard to remove the water manually with buckets. Occasionally the leak was so bad that they had to work day and night during the whole trip scooping the water out with buckets until they reached land to repair the ship.
There was no medical help in ships then. If a seaman got sick during sailing, he may either spontaneously recover or die. The crew carried with them some minerals and herbs to try in certain conditions. It was not common to find an expert in the ship who had experience in cautery or bloodletting. When a seaman died in the ship they wrapped the body with the cloth, tie it with a piece of stone or metal, and dropped him in the sea. It was considered improper to have a dead man floating on the surface of the sea.
Mohammed told me that they could never exactly tell when their ship would reach their destination harbor or city. The time to reach from one harbor to another depended on the wind. If the sailing is in the same direction as the wind, then the ship sailed relatively fast.
From Basra (al-Basra) southern Iraq to RAK, UAE for example, the journey would take only two days if the sailing was in the direction of the wind. But going back to Basra against the wind may take a full month (Figure 7). They could not sail directly north to Basra, because of the predominant northern wind, so they would sail in a zigzag pattern, toward west and east to gain a few kilometers each swing until they reached Basra.
The trip from RAK to Muscat took two days; from Muscat to Mombassa, Kenya or Zanzibar, Tanzania, 12 days; and from Zanzibar to Muscat 20 days. Crossing from Africa to India took 2 weeks on average (Figure 7).
If the wind was very strong during a journey, they would raise a small sail, but if the wind was less, they would use a larger sail. With a very weak wind, they raised four sails on the ship. They navigated using a compass at daytime but at night, they knew their direction from the stars.
Mohammed told me that crossing the ocean from Africa to India was their most dangerous voyage due to frequent rough winds and storms. Many shipwrecks and seamen died along that route. They were helpless during such a sea storm. They lowered their sails and tried to maintain the ship in a parallel direction to the wind. The ship would capsize if the windstorm’s force hit the ship from its side or perpendicular to it. Every time they experienced such a storm, they thought they might not make it. They entrusted their fate in God with a lot of prayers. Mohammed lost many friends during such storms in other ships. He recalled that a sailor was thrown overboard from his ship during such a storm. It was impossible to turn the ship back for him. If did, all on board might drown. Fortunately, another ship was one kilometer behind their ship. They raised a flag, which was an unusual practice in a storm. A raised flag was a danger signal known by all seamen. The other ship’s crew looked carefully for the sailor and threw a rope for him.
Once, they encountered a storm in the Gulf while sailing in a medium-sized ship loaded with sheep. The wind tilted the ship to one side. All the sheep moved to the tilted side and the ship almost turned over. They had to throw the sheep in the sea to save the ship and their lives.
At this point, Mohammed asked me if I am still keeping the museum items from our old sail ship. I said: Yes. I went to my library and took a box containing the items he asked about. They were a compass, a telescope, and a pistol – the pistol that Mohammed used to keep with him in the ship. He stared at the pistol for a while, then picked it up and held it in his hand with some affection. It must have reminded him of the old days in the sea. He started wiping and cleaning the pistol. He showed me how the old pistol’s wooden cover could be fitted in the back of the pistol to be used as a rifle (Figures 6a, 8b). It was very amusing. I wondered aloud if the pistol was still working. He said he was sure it was but we had no bullet suitable for such a pistol. He suggested that he should go to the old market and look for bullets. The following day Mohammed came to my house with three large bullets. We took the pistol and drove to the beach out of town. He told me how to use the pistol. He fired one and I fired all the rest.
Fig. 6a: Old pistol and cover. Fig. 6b: The pistol mounted on the cover
We sat on the sandy beach in Qatar, watching steamships and boats passing fast. I asked him to tell me about the manpower and the order of authority in a sailing ship. He said that the ship’s captain is the overall manager of the ship. The front-man, “Mojjaddami”, acts as a foreman in charge of the sailors. The steerers (at least 3 in number), rotate in steering the ship. The teacher, “Moallim”, is responsible for map analysis. He works only at midday, using instruments to measure the sun’s angle and calculate the distance of harbors and islands along the way. Mohammed added: “We only needed the teacher for the difficult ocean crossing journey between India and Africa.” The rest of the ship’s staff were the seamen (workers) and the cook.
Mohammed told me that when he was a ship captain, he had to calculate the number of seamen in the ship he needed for a sea journey. To show me how he made his calculations, the old man made lines over the sand representing seamen then added them together. Using sand for counting is a primitive form of computing. I was amused but did not laugh at his primitive counting because our modern sophisticated computers use silicon chips. Silicon is basically an extract from sand.
I told Mohammed that the reason that he enjoyed a relatively healthy life was that he was physically active and that helped him stay fit into old age. Mohammed had a remarkable history of walking throughout his life. I asked him to tell me about his “walking stories.” He said that once, as a young man, he was in a harbor on the east side of the Gulf. He wanted to go to Kuwait but he had no money. He walked for 30 days, bare-foot, heading north. He had no money to buy shoes. He rested in mosques along the seashore towns until he reached the opposite side of Kuwait. He then crossed the Gulf in a small boat. He recalled the miserable condition of his feet on reaching Kuwait. He had wounds, blisters, and many scars.
He walked, once, the whole night alone, under the moonlight, starting after sunset from Khor Fakkan, UAE, where his ship was anchored, passing over some mountainous roads. He reached Dibba city at dawn to arrange for a shipload of goods such as preserved or dried fish and robes (Figure 7). They used to carry different goods from different cities. From Basra to Africa or India they carried dates and onion. They bring to the Gulf wood (“Candlewood”) and bamboo from Africa. From India, they carried building materials to Africa especially red clay roof tiles and rice to the Gulf. I still remember the fruits Mohammed used to bring us as gifts from Africa. They were coconut and tangerine. The tangerine was somewhat spoiled when the ship reached us. We enjoyed eating it anyway, because we had not seen or tasted fresh tangerine then.
Fig. 7: Fujairah Map
Mohammed narrated another walking story that happened in the 1950s. Our Sin book anchored in Khasab harbor of Oman near the Strait of Hormuz. The wind was not suitable for sailing to RAK. Mohammed walked with a younger seaman, Mohammed Matter, from Khasab to RAK, a distance of over 70 Km. (Figure 8). His companion could not continue walking because his feet became swollen. Mohammed rented a donkey from Sha’am, a small town along the way. His young companion rode on the donkey while he walked beside the donkey until they reached RAK.
Fig. 8: Ras Al Khaimah map
After my father sold our ship, Mohammed was hired to work in a Kuwaiti ship. He was a sailor in a Kuwaiti ship sailing to Calicut (Calcutta), India, forty years PTA. The ship was carrying a very precious metal – gold. At that time, India prohibited gold import. Smuggling gold to India was a very profitable but risky business. That ship had smuggled gold to India successfully several times. The smuggling attempt on that trip did not go well. Someone had tipped the Indian authorities to watch for their ship. As soon as they arrived, the Indian police raided the ship. They confiscated the gold and took all the sailors to jail. Mohammed with other twenty sailors stayed in jail for one year. They were frequently taken to a courthouse where a woman judge interrogated them. They made some money in prison from labor making ropes. Mohammed and his companions made 700 Rupees each over one year. The sailors were released after one year while the captain was kept for two years. They had to stay over in India after their release for several months waiting for the Arabian Gulf ships to reach India.
They were released at the wrong season to go home. The wind was not suitable for sailing from the Gulf to India then. They had nothing to do in Calcutta. They felt idle and bored. Most of the sailors got married to Indian girls while waiting for the ships. Mohammad married a young Indian lady that kept him company while waiting to go home. Most of the Arab sailors knew adequate Hindu language to communicate in the harbors and shops. The wives forced them to speak Hindu by necessity, and therefore, they gained more Hindu vocabulary. Those marriages did not last long for most of the sailors. Those who had children from the Indian wife kept the marriage and supported the wife and the children. Mohammed had no children from the Indian wife. He divorced her after returning to the UAE. But Mohammed’s wife at home in UAE, the mother of his four children, was unhappy with him when news of the sailors’ secret marriage in India leaked out in the community.
Three years after Mohammed came to Doha for cardiac evaluation and coronary angiography, Mohammed came to Doha on a social visit. He was reluctant to come to the cardiology clinic for evaluation. He said that he was an old man and happy with the level of his activities. He did not want to undergo another coronary angiogram. I convinced him to come for a non-invasive evaluation. His echocardiography revealed left atrial enlargement, left ventricular hypertrophy, mild mitral regurgitation, mild aortic insufficiency, and mild aortic sclerosis. The findings were consistent with hypertensive heart disease.
Two years later, I visited Mohammed in the UAE. He was doing relatively well. He could walk almost one kilometer before he had to rest because of chest pain. Occasionally the chest pain woke him from sleep. I suggested that he comes to Doha for the checkup and re-evaluation. I offered to perform coronary angiography for him, with consideration of stenting if needed. He reluctantly agreed to return to Doha a few months later for the procedure. He came one year later in early 2003. He was planning to travel to Sri Lanka. Even though he was not a rich man, he traveled almost every year for humanitarian causes to India and Sri Lanka. I learned from his friends that he was financing the building of a mosque in a poor village in Sri Lanka.
In late 2003, he had frequent episodes of angina. He called me once when he had severe chest pain while he was in Dubai. I advised him to go to a hospital in Dubai immediately. He was admitted to Dubai Hospital on 12th of December 2003 with unstable angina. His ECG showed atrial fibrillation with ST depression in V4-V6. Troponin test was negative. He was stabilized on medical therapy and was advised to undergo a coronary angiogram, but he refused the procedure.
I talked to him again one week after his discharge from the hospital in Dubai. He told me that he was walking all over his town as usual. He had chest pain only if he walked fast. He was planning to proceed with his trip to Sri Lanka.
When I went to Ras Al Khaimah for a private visit, I went to see my friend and patient, Mohammed, at his home before his trip to Sri Lanka. A friend accompanied me to his house. After he embraced me and kissed me, he sat down for a serious talk. He told me: “If I get sick my family will contact you. You will decide what to be done for me. Your decision will be followed and respected. But I want you to know my will. Everybody will die sooner or later. I am an old man and my time may come soon. I am not afraid of death. As long as I could walk, I will take your medications. If I became crippled and could not walk or lost my mind, I do not want any surgery or heroic action to keep me alive. I do not wish to live in a vegetable state, like the state in which your father was. Let me die in peace, please.” I told him that I respected his wisdom and his wish.
Two months later, he had recurrent severe chest pain. He called me from Dubai while he had an episode of chest pain. He was wondering if it was safe for him to fly to Doha to see me. I told him no, it was not. I convinced him to go to the hospital immediately. I called my colleagues in Dubai and arranged for his admission. He was admitted to Dubai Hospital with a complaint of retrosternal chest pain. The medical record that I obtained from the Dubai hospital provided me with detailed information during his hospitalization. On arrival his blood pressure was 140/70 mmHg, pulse rate was 65 per minute. Chest examination revealed bilateral crepitations. ECG showed right bundle branch block with ST depression in V4-V6, leads II, Ill and avf.
He was offered coronary angiography but he refused. I called and advised him to accept the procedure. A coronary angiogram was performed on February 28, 2004, and showed: LMCA: Heavily calcified with 75% stenotic lesion, LAD: two lesions with 90% stenosis, Circumflex: Cut-off proximally with faint filling from collaterals, RCA: two stenotic lesions of 90% just before PD branch. The left ventricular angiogram showed an ejection fraction of 40% with mild mitral regurgitation.
An echocardiogram performed on March 1, 2004, which showed dyskinetic basal inferior wall, hypokinetic basal and mid-one-third posterior wall. Ejection fraction was 55% with concentric left ventricular hypertrophy and mild mitral insufficiency. Ultrasound of the carotids showed significant stenosis with more than 80% stenosis of the left common carotid artery.
He was advised to have coronary artery bypass graft but he refused and asked to be given a report to travel to Doha. I talked to my colleagues in Dubai Hospital, and then I called Mohammed. I convinced him that it was not wise to refuse surgery and stay suffering from recurrent pain. There was no good alternative medical therapy for his condition then. He must accept surgery even though it was risky. When the family heard my advice they pressured him to agree. He did.
Just before the weekend, on Thursday, March 4, 2004, he was prepared to undergo bypass surgery at Dubai Hospital. The surgery was scheduled for Saturday. Aspirin was stopped pre-surgery. Unfortunately, in the early morning of Friday, March 5, 2004, Mohammed developed severe chest pain with marked ST depression in V2-V6 and in lead I and avL. He was transferred to the coronary care unit and was started on Aggrastat and Heparin. Later he continued to have chest pain and repeat E.C.G. showed ST elevation in the anterior leads. His condition deteriorated and he went into cardiogenic shock and was intubated. He had cardiopulmonary arrest 2-3 times for which he received multiple D.C. shocks and was put on full inotropic agents. An intra-aortic balloon pump was also inserted, but unfortunately patient expired in the early hours of Saturday, March 6, 2004, at 05:00 hours.
Mohammed, the sailor, the seaman, was born near the seashore and spent most of his life in the sea. He loved and respected the sea all his life. He faced death during numerous sea storms but the sea did not kill him. He lived a productive and active life until the age of 91. He was like a brave soldier who fought so many battles and died at home without a scar or scratch on his body. When I catheterized him in 1992, I thought that the old man may not survive for another year, but he walked around for 12 more years. His only regret was that his father or mother died before he knew them. He lived by the sea and worked in the sea. The sea was his father and mother. He was truly a son of the sea.