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Dr. Judith Tintinalli on visiting Saudi Arabia, investigating the Kingdom’s EM infrastructure and on being a female emergency physician in a Muslim country. 

I didn’t know what to expect. I was excited, curious, but also somewhat apprehensive about being a woman in Saudi Arabia. The reason for my visit was the ‘2nd Up to Date Emergency Medicine Practice’ conference, sponsored by the King Fahad Medical City in Riyadh.

Several western women with their families were in the customs line, and they had put on their Abayas – the traditional, black overgarment worn by Arabic women – before leaving the plane. I was a bit uncomfortable because I didn’t have one yet. But Dr. Abdullah Al Sakka greeted us and expedited our passage through customs. I had met Dr. Al Sakka several times before at international meetings. I had to switch my mental image of him from an emergency physician in western clothing to my host in the thobe, ghutra, and egal (the white, traditional ankle-lenth garment and headpiece worn by men in many Arabic countries).

The conference organizer, Dr. Mohammed Alnabi, is the director of the King Fahad Medical City arm of the Saudi Emergency Medicine residency program. Mohammed arranged a personal session with a group of Saudi emergency medicine residents. Although at this session and in the conference, women and men sat on separate sides of the room, both sides were inquisitive and active participants in our discussions.

There were many questions – how could only three years of training result in a skilled emergency physician? How are journal clubs organized? How can Saudi residents get more medical students interested in emergency medicine? Do American EM residents have mandatory rotations in psychiatry and anesthesia? Residents described their training likes and dislikes as very similar to those in the United States. Their assignment to medical duty to Hajj – the massave annual pilgrimmage to Mecca – was reported by all as a culmination of their training as emergency physicians. Medical duty at Hajj consists of  extremely intense 12-hour workdays, with no translators, no common language, and the need for pointing and gestures to identify chief complaint and obtain a history.

Saudis are magnificent hosts – excellent conversation, warmth, and lots of congeniality. I must say I was treated like ‘one of the guys’. It was only after my return to the United States that I realized I often was the only woman in the room, or the only woman at the dinner table.

By the second day I was wearing my abaya – a loose robe-like overgarment – which was gifted to me by Dr. Amal Yousif, a pediatric emergency physician on the faculty of King Abdulaziz Medical City and the National Guard Hospital. The abaya does become part of you, and western women that I passed going down the stairs quietly said ‘be careful going up and down stairs, make sure you lift up the hem so you don’t fall’.
There were a few shocks during this trip, the first being the 114°F weather. Saudis accommodate to summer heat by moving quickly from one air-conditioned environment to another. The crush of traffic in Riyadh was a surprise as well. It could take hours to move short distances in the city.  

As an emergency physician, the highlight of my trip was the visit to the National Guard Hospital, hosted by Dr. Ra’ed Hijazi, the Department Chairman. Dr Hijazi, who is pro-basketall tall, is notable for his wit and his charming, engaging smile. He has organized an efficient department – census at least 1,000 patients/day – has tried every trick in the book to decrease access block and ED overcrowding, and has now convinced the hospital that the next needed step is decreasing hospital length of stay. I saw an ultrasound machine in every ED bay, electronic medical records, white boards tracking patient advancement through the system, and men and women physicians seeing all types of patients. There was even a sophisticated pediatric ED, run by pediatric emergency medicine specialists. It was hard for me to keep from grabbing a chart and stepping right in!

The reality of health care and emergency medicine in the Kingdom of Saudi Arabia is complex. The government provides national health care services through a number of government agencies, but the private health sector is growing. In 1970 in the Kingdom, the population was about 5.7 million and there were 74 hospitals with 9039 beds. By 2005 the population was nearly 28 million and there were 350 hospitals with 48,000 beds. The Ministry of Health (MOH) operates 62% of the hospitals and 53% of the clinics and centers; other government agencies, including the Ministry of Defense, the National Guard, and the Ministry of the Interior, operate facilities for their employees; and private facilities, including the Saudi ARAMCO Hospital, and the German Hospital serve other groups of individuals. Three Mothers University Hospitals (King Khalid University Hospital In Riyadh, King Abdulaziz University Hospital in Jaddah and King Fahed University Hospital in Alkhobar), and now King Fahad National Guard University Hospital in Riyadh, focus on research and the training of medical students and residents.

The Saudi Red Crescent Authority provides prehospital care in all five administrative regions of the Kingdom. Large MOH or Ministry Hospitals also have their own prehospital ambulance systems for their own patient populations, but can also serve the surrounding geographic area. The Kingdom also has 8 medical helicopters for transport to University or other tertiary care hospitals.

Emergency medicine in Saudi Arabia began in 2000 after a group of young Saudi physicians, trained in the USA and Canada, returned to the Kingdom and established the Saudi Board of Emergency Medicine. Professor Musaad Alsalman was the first chairman of the first Scientific Council of the Saudi Emergency Medicine Program at SCFHS (Saudi Council For Health Specialists). The first emergency medicine residency program started in October 2001 at the King Fahad National Guard Hospital in Riyadh with 7 residents, and Dr. Abdullah Alhudaib was the first residency program director in Saudi Arabia. As of 2011, 60 residents have graduated and are board-certified, and there are currently 120 residents, men and women, in the residency program. The residency program itself is shared by multiple hospitals, and there are discussions about separating the current large program into several separate hospital/university programs. Currently less than 5% of the emergency physicians in Saudi Arabia are trained in the field, and there will be a long journey before the Kingdom’s need for emergency physicians is met.

Emergency Medicine training begins with a one year rotating internship, followed by a 4-year EM residency, with 25 months in adult and pediatric EM, 16 months of rotations in major subspecialties, EMS, and research; and 7 elective months. One half day each week is dedicated conference time. There is a yearly in-training examination and an oral and written board examination.

I learned once again that the principles of EM training, practice and administration are similar worldwide. Emergency physicians adopt practices from other countries to meet their patients’ needs, and adapt to meet challenges. In western societies, the individuality of clothing, how people dress, is a major determiner of identity. Traditional Saudi dress was an eye-stopper for me, but I quickly learned that the individual himself or herself, not the ‘wrapping’, was what was important. The eyes. The face. The personality. It seems to me that Saudis are bridging the gap between the time-honored customs of culture, religion, and family (which many western societies have lost) and the global society in which we all live together. Our participation in International Emergency Medicine provides support and resources for our colleagues who are just starting to establish Emergency Medicine in their countries. It is even more important for us as physicians and as people to work with our international colleagues, because it opens our mind, eyes and hearts to other cultures, and allows us to see the world as it should be. We are a band of brothers and sisters practicing in the most exciting specialty there is!

This article originally appeared in issue #7 of Emergency Physicians International. Read more at www.epijournal.com

 

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