Emergency medicine in Saudi Arabia: an expatriate’s perspective

International EM

CJEM 2000;2(2):125-128

You get off the plane and wonder, “What am I doing here?” It’s halfway around the globe, it’s stifling hot and you’ve heard horror stories about the difficulties of living here. Others warned you to be prepared; you could be turned around at any time — tonight, next week . . . Thankfully you were here on locum and know most of the stories are exaggerated. The advice, although well intentioned, reflects the restlessness or dissatisfaction of others. You also know many expatriates have been here for years, if not their entire career. Your emergency physician mentality kicks in: "If they can do it, so can I."

At first, expatriate life in Saudi Arabia is a combination of mystery, adventure, attraction, frustration, puzzlement and desire to leave. New arrivals go through a honeymoon period — from 2 weeks to 3 months — during which the positives outweigh the negatives. After the honeymoon, though, it’s best for all concerned if the individual takes a leave to relax, collect his or her thoughts, and weigh the pros and the cons. We have never lost a physician after the first leave; they all come back. But why?

Saudi Arabia is not a tourist haven. For non-Muslims, it’s a difficult if not impossible country to visit. You need family or a job to get an entry visa. Within the Kingdom there are many sites worth visiting — the Red Sea for its splendid diving, the cosmopolitan city of Jeddah, the Abha Mountains, and the ruined Nabatean city of Madain Saleh — but expatriates don’t usually discover these attractions until they have arrived to work. So, if not tourism or religion, what is the drawing card?

Fig. 1. Camel, dressed for the dessert.

The medical scene

At the King Faisal Specialist Hospital & Research Center (Fig. 2), the emergency department (ED) is a small part of a huge operation. The hospital has 500 beds, and over 200,000 outpatient visits annually. There is one satellite hospital and another coming online. Our ED sees 42,250 patients per year — 60% adult, 45% urgent or emergent. The hospital’s mission is to treat tertiary care cases that cannot be managed in any other part of Saudi Arabia; therefore, we see many cancer-related emergencies, complex cardiology cases and rare metabolic illnesses right out of the biochemistry books. A significant number of our patients come from the hospital community (15%) and from the Royal Family (11%). These patients tend to have more typical "general hospital" ED problems.

Fig. 2. King Faisal Specialist Hospital and Research Center. Main entrance, commissioned in 1975 by King Faisal.

Patients must meet certain criteria to be "eligible" for treatment in the hospital. Those who present to the ED are registered and undergo a screening exam in the Patient Assessment Room or PAR. (There is no COBRA “law” here, but the approach is similar.) PAR serves as a filter, allowing only the sickest and truly eligible into the core department. The core consists of 21 rooms, including 12 general purpose rooms, 4 private rooms for VIP examinations and a resuscitation room for high-level VIPs. The floor space is small but functional, and there is excellent support from pharmacy, diagnostic radiology and the lab. A bonus is the continual presence of a hospital administrator in the ED whose role is to handle the administrative problems of patient care. Physicians make the medical decisions, and the administrator deals with any administrative issues that arise.

There are no emergency medicine (EM) training programs in the Middle East, either for physicians or nurses, so the ED staff is largely expatriate. The nurses are mostly North American. They are required to have ED experience and training, and they work 12-hour shifts. Our physician roster is large by North American standards. We have 34 positions (8 pediatric, 1 administrative and 12 on special assignments with highly placed Saudi Arabian VIPs). Core department physicians work 8- to 9-hour shifts with double or triple coverage. The best part is that nights are double-covered.

Departmental obligations are similar to those in North America. Most of our time is spent providing patient care; however, we have an active academic program, a total quality improvement program, morbidity and mortality rounds, continuing medical education, departmental meetings, elective EM resident programs and departmental representation is hospital affairs.

Understanding your patient's culture

What makes Saudi Arabia different and exotic? It is the heartland of Islam (Fig.3). This is evident in every aspect of your day. Almost all the patients are Muslim. The men dress in a long white garment (thobe) (Fig. 4). Their heads are covered with a red checkered or plain white cloth square (ghutra), held on by a black rope (igaal — once used to hobble camels). The woman wear a black coverall (abaya) (Fig. 5). The more fundamental women cover their hands and feet also. Most often, when evaluating females, you can see only their eyes.

Fig. 3. Prophet's mosque in Medinah (note minaret in background).

Men accompany all women from their family, and everyone has a rank. The correct approach is to address the highest ranking man, even before acknowledging the woman patient. (Germaine Greer is unknown here.) Undressing for an exam is not a problem, as long as the woman's face remains covered, and gynecologic examinations on married women are acceptable if the husband gives permission. Children are dear, as in any culture, but you must not stare too directly or comment on how cute the child is, for fear the "evil eye" may invade the child. Any such interaction must be followed with a quietly spoken "Mas'allah," which serves to protect the child from evil.

Fig. 4. Saudi man in traditional garb, holding a shisha (water pipe used to smoke fruit-flavored tobacco).

Communication is generally easy. For those of us who don't speak Arabic, an interpreter is provided. The Saudi people respect your education, knowledge and professional commitment, and in 5 years I have not been called the names I was on many Friday and Saturday nights in Canadian EDs. There are, however, aspects of communication to take note of. First is the Arab propensity to stand closer, lean in tighter and speak louder when making a point. Most expatriates relate these behaviours to unhappy, aggressive patients just before they take a swing at you. It takes time to unlearn the "fight or flight" response that emergency physicians have developed in these situations.

Fig. 5. Woman dressed in tradional abaya.

A second tendency is for patients to withhold part of their history. Although many of these patients have been seen elsewhere and have detailed medical reports available, the patient and family do not always offer this information. It is as if they are testing you — or perhaps testing the previous medical teams. If both assessments concur, then both parties must be right and the diagnosis accurate (unless, of course, you both got it wrong). My practice now is to ask for medical reports very early in the interaction.

Another tendency is for families to protect patients from bad news. Many of our patients have complications of advanced cancer (for example, uncontrolled pain). Family members often request treatment for the pain, but ask that you not reveal the diagnosis to the patient. It seems illogical to me that patients can deal with their situation without knowing the facts; however, Muslims put their faith in Allah and in their families, and believe that illnesses will be adversely affected if the "truth be told."

Dealing with death is another cultural difference. In Saudi Arabia, death is in the hands of God. All of us are headed there, and Allah is the "traffic controller." Therefore, when someone dies it is Allah's will and not to be questioned. There is little public display of grief. The main focus for ED staff is to verify death and to mobilize the body so that it can be washed, taken to the mosque, prayed over and buried before the next sunset.

The pillars of Islam

To appreciate why Saudi Arabia is different and challenging for expatriates, it helps to understand the 5 pillars of Islam: shahadah, salah, the hajj, sawm and zakat.

The first pillar, shahadah, the profession of faith, refers to the belief that "there is no God but Allah, and Mohammed is his prophet." The second of the pillars is prayer, or salah. Muslims pray 5 times a day, at fajr (dawn), dhuhr (midday), asr (afternoon), maghrib (sunset) and isha (evening, about 1.5 hours after sundown). Prayer times are coordinated with the sun, not the clock, and therefore vary according to the times of the sunrise and sunset. These times are published in the daily newspapers. During prayer, everything shuts down. Stores close and restaurants dispel their clients. All Muslims are expected to go to the mosque, where prayer is called from a minaret, or tower (visible in Fig. 3), by a muezzin, who nowadays has a microphone and no longer has to climb to the top of the tower.

The ED pace also slows. Patients who are mobile leave the examination rooms and the waiting room to attend one of the hospital's 3 mosques, where non-Muslims are not permitted. You cannot assume that a patient is "AWOL" if he or she is missing from the ED during prayer. When prayer is done, ED activity returns to normal.

The hajj or month of the pilgrimage is another pillar of Islam. Muslims are required to go to Mecca (Fig. 6) at least once in their life, to re-enact the devotions of Mohammed. Annually, when the hajj arrives, 2 million Muslim pilgrims from around the world converge on Saudi Arabia to perform their religious obligations. Because pilgrims typically arrive in Jeddah, which is nearer to Mecca than Riyadh, the hajj has little effect on our ED. An occasional patient may present, having recently returned from his pilgrimage (the telltale sign is the shorn head that marks male pilgrims), but our ED volumes are essentially unchanged.

Fig. 6. Prophet's mosque in Mecca.

The Hajj Authority organizes medical care on a monumental scale. In the past, medical disasters, including flood, fire, heatstroke and epidemic infection, have been handled. This would be the ultimate training ground for ED physicians interested in disaster medicine. However, such physicians would require more than interest: they would have to be Muslim because only Muslims are allowed into the Holy cities of Mecca and Medinah. These cities house 2 of the 3 holiest mosques in the Islamic world, thus the King of Saudi Arabia is known as the Custodian of the Two Holy Mosques.

The four pillar of Islam, sawm (fasting), is incorporated into the Holy month of Ramadan. During Ramadan, all healthy adult Muslims are required to fast during daylight hours. At sundown, or ifhtar, the fast is broken with prayer, a celebratory meal and family gathering. During the midday, many people rest or sleep and, for a large number of Muslims, the workday is split into an early morning and a late evening shift.

This behavior has a substantial effects on the ED. Patients do not want to come to the hospital until after their fast is broken; therefore, the evening and night shifts become busier. Strict fasting deters patients from taking their medications; as a result, diabetics present at the ED with hyperglycemia, heart patients with unstable angina, and metabolic patients with high ammonia levels and acidosis. For some of these people, the entire month is a series of ED visits for temporary control. Admission is an unpopular option, because patients usually wish to be with family and attend the community mosque.

From an ED viewpoint, Ramadan poses unique challenges; adjusting to different daily patient peaks, allowing Muslim staff time off to pray and break fast, and modifying treatment paradigms to allow patients to meet their religious obligations. Non-Muslims are expected to respect the fasting of others; it is not appropriate to eat or drink in the company of Muslims. Even chewing gum in public is prohibited. The cafeteria remains open for non-Muslims, and our coffee room is safe territory to which we can retreat for snacks, bag lunches or drinks.

The final pillar of Islam is zakat or almsgiving. All Muslims are expected to contribute a percentage of their current wealth to the community, which results in the building of many mosques, close together and readily accessible. Although zakat has little direct effect on the ED, it is a time of kindness, hospitality and charity. Everyone is greeted with a traditional, "Salam allaykum" (God be with you). There are handshakes all around, coffee and dates, tea, the favoured seat, and the best of available food.

Why stay?

Sound exotic? It is! At times. Sound bizarre? It is! At times. Sound difficult? It is! At times. So why stay? There is no single answer; it is as personal and unique as the reasons for coming here in the first place. For most expatriates, the reasons for staying include at least on of three factors: travel, money (Fig. 7) and social life.

Fig. 7. Dera Gold Souq in Riyadh: a sponge for many expatriates' disposable income.

Travel and money are often the reasons for coming here, but the longer you stay, the more you are bound by tight social ties. Social life is a bit like living in a college dorm, with the exception that most physicians have family. You are part of most social events, you know your neighbours, holiday with them, drop in unannounced, your kids sleep and eat over, and you actually see your family on a regular basis. With trips to plan, people to socialize with, and an ever-increasing bank balance, it is hard for many to leave. Expatriates are likely to tell you that the decision involves 2 bags: one labelled "money" and the other labelled "bullshit." When either one is full, it's time to go.

It has been said that Saudi Arabia attracts bad doctors, bad investors and bad spouses, but this is generally not true. I know of a new arrival who was being introduced at a party. An old-timer asked him if he was here because he was a bad doctor, a bad investor or a bad spouse. Before the new arrival could answer, his wife interjected: "He's a good doctor!"

It is true that the job is a challenge and that Saudi Arabian living is exotic and demanding. It is also true that the people are the best part of the experience. They are not "bad" in any manner. This place attracts the brave, the adventurous and the strong of character. These are collectively the most impressive people with whom I have ever worked and interacted. A colleague has described the attraction to the place as the "X=2X Plan" You arrive on the X plan, planning to stay for X numbers of years. The X-patriate experience grabs you and the plan becomes the 2X Plan. It happened to me, and it could happen to you.