Crozet Annals of Medicine: In the Gardens of the King

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Emergency Medicine physicians wear many hats, as Dr. Sudhir and I discussed last month. This versatility leads to some interesting opportunities to practice in different venues. Cruise ships, for example, are always looking for ER docs to staff the ships. While I have yet to try out cruise ship medicine, emergency medicine has been a magic carpet for me, allowing me to practice medicine around the world and thus open windows into other cultures.

In the 1990s the Kingdom of Saudi Arabia was awash with oil money and anxious to modernize its healthcare system. The government had built state of the art hospitals stocked with the latest and greatest medical equipment and technology, but they were short on people to staff them. They were particularly short of doctors and nurses. Stiff cultural restrictions meant that Saudi women could not be nurses nor would men consider it. The nursing shortage was easily and economically solved by recruiting nurses from the Philippines as guest workers. There was no such cultural prohibition against Saudis becoming doctors, however, and so the Saudi government looked to the U.S. academic medicine infrastructure to help train young Saudi physicians. That’s where I came in.

I was teaching at Yale in 1995 when our faculty was approached by a representative of the King of Saudi Arabia to staff an academic emergency department in Riyadh, the capital of Saudi Arabia. Riyadh means gardens in Arabic. Sounds nice, right? The deployments were for three months but you could bring your family if you wanted. Well, that’s nice too. Of course my wife would have to wear an abaya, a head-to-toe shawl, when in public. Hmm, that might be a tough sale at home. Like Henry Ford’s Model T, you could get an abaya in any color you wanted, as long as you wanted it in black.

The Kingdom provided very nice housing, which included a harem. I thought that might be interesting, although also a tough sale at home, but it turns out a harem is just a part of the house forbidden to male visitors.

It seemed like an adventure, so of course I jumped in without too much thought. We packed up the three young kids, gave the cat and dog to some semi-willing family members and flew off around the world.

We hopscotched through Europe, seeing some sights along the way and finally arrived in Riyadh. It was 105 degrees outside and it was midnight. I did not see any gardens. In fact it was a desert.

I was anxious to inspect my harem, so we found our hospital-provided driver and left the airport. We rode on modern super highways in air conditioned comfort and all along the roadsides were families who appeared to be picnicking at two o’clock in the morning in the desert. This was a custom we would come to see as normal. The days were so hot (110 degrees average) that many people slept in the daytime and socialized at night. Visitors to the hospital began arriving at nine p.m., always with lots of food in baskets, and streamed in all night. Everyone was wide awake and alert in the wee hours of the morning. Well, everyone except me, who could not let go of my day-night cycle.

I was a little nervous on my first day on the job. I did not speak the language, I did not understand the culture and I did not know what the expectations of the patients and the other doctors were of a western physician. But I settled in, practicing medicine in the Kingdom of Saudi Arabia.

Much about medicine is standard throughout the world, but each country has its own fascinating variations.

One of the first patients I treated had sickle cell anemia. I have treated a lot of “sicklers” in my practice in the U.S., particularly at Yale as we were an inner-city hospital serving a large African-American population. Sickle cell anemia (sick as hell anemia some call it) in the U.S. strikes almost exclusively African Americans and it is extremely painful, so much so that opioid medications (narcotics) are almost always required. No one would think of not using narcotics to assuage the pain.

In Saudi Arabia sickle cell anemia is more widespread in the population so I was going to see a lot of it, I thought, and I was anxious to share my expertise with the Saudi staff. I approached my patient to take a history and of course the history was severe 10-out-of-10 pain in his chest and abdomen and legs. Because of a genetic mutation in his hemoglobin molecules, his red blood cells were being deformed into a sickle shape from their normal smooth oval shape, and they were thus blocking his micro-circulation, causing agonizing pain as the downstream tissues were deprived of blood flow and oxygen.

While this was obviously a severe case, it was like child’s play for a seasoned doc like me. I called for an IV and morphine, causing a small crisis in the ED staff. After some muttering and head shaking between my interpreter and the nursing staff, the chief of the ED was summoned. He patiently explained to me that narcotics were strictly forbidden in the culture. I got the feeling he had had this conversation with other western physicians over the years.

“Yes, but how am I to treat his pain?” I asked.

“Try Motrin,” he said.

I could hardly believe my ears. We had a somewhat heated conversation that ended in a compromise. I would start with Motrin, but if that didn’t work (how could it?) we were going to the head of the hospital to discuss obtaining some morphine. They had it, but just did not like to use it.

To my surprise my patient thanked me for two Motrin and said he thought he could manage at home with some Tylenol.

“Inshallah,” he added, meaning if God wills it, he will be better.

I learned a lesson from that patient and that culture about the subjective nature of pain and the degree to which faith can affect outcomes. I also learned how shaky the foundations of some of my medical certainties were. And I never saw another sickle cell anemia patient during my time in Arabia.

Well, my Saudi education was beginning, and so I approached my next patient a little more humbly.  She was covered head-to-toe in a black abaya and her face was obscured by a dark veil. It was not hard to decipher her emotions, though, as she began the encounter with an obviously angry diatribe to my translator.

“What did she say?” I asked.

The translator winced and reported, “She says the parking is inconvenient, the wait time is too long and the facility is dirty.”

I had to smile a little. I felt like I hadn’t even left home.

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