Ramadan And Over-Crowding Hospitals In Saudi-Arabia

The Holy month of Ramadan changes the daily rhythm drastically in Saudi hospitals. Basically the hospital, just like the rest of the Kingdom of Saudi Arabia, becomes alive at night and quiets down for the day during the Muslim fasting month. Read more here on how the Saudis usually visit the sick at hospitals. 

Needless to say the amount of visitors during Ramadan will at least double, especially during the last ten days. Visitors will come late and stay until early morning which is allowed because of the changed visiting hours. Visitors will bring along vast amounts of arabic foods to break the fast with like sambosa, all kinds of tiny pastries, cookies, dates, chocolates..

Large Saudi families come to the hospital to join in Iftar together with the sick family member.  It's not uncommon to find the entire family eating with their hands, on the bedsheets spread out on the floors! Saudis will generously give the nurses a taste of everything, sometimes offering huge trays full of different sweets or salty snacks.

Another peculiar thing that happens during Ramadan is handing out money to nurses. Patient or relatives might slip Riyals into the nurses pocket or openly offer money anywhere from 10 to 1000 riyals at a time. The gesture usually makes nurses feel somewhat awkward and because of cultural differences might be misinterpreted to be some form of bribing. Nurses are naturally not supposed to accept the money very few will reject it every time especially because the person offering the money will become very upset if rejected and they can be extremely pushy and just stuff the pockets with the money. The reason behind this is Saudis wanting to give 'charity' and do good deeds during Ramadan and the families wanting to show their gratitude and appreciation to the nurse.

Only a few patients will be observing the Ramadan fast, and if they do, they will also abstain from all medications including injections and intravenous drugs during daylight hours. That makes it a bit difficult to accommodate the medication regime to the fasting timetables. Basically it means that the medications normally given around 8-9 am will be given at fast breaking time around 6:30 -7 pm. The next dose will be at midnight and finally just before the morning prayer at 4 am. This can cause problems with the efficiency of treatments with antibiotics and pain killers.

For some patients it's fine to fast (health-wise) and it will not make their condition worse. Every once in a while there will be a patient who insists on fasting even if doing so will severely adversely affect their health. The patients don't want to miss out on the blessings of fasting. Some are diabetic which means their blood sugar levels will be uncontrolled and it might put the patient in risk of coma, or they will refuse insulin injections resulting in sky-high blood sugar levels. Patients with bowel problems might get complications like obstructed bowel, liver patients may suffer irreversible consequences that may even need surgery and then there is the odd patient who will even refuse to be operated on.

Toward the end of Ramadan the emergency room usually begins to fill with patients suffering from bowel obstructions, liver coma, severe dehydration and so on. Many are elderly patients needing full time hospital care meaning that the hospital will be full to its maximum capacity and often patients are left to wait for an available bed in the EMS. Patients suffering from gastrointestinal diseases and disorders, diabetes, metabolic disorders and other diet controlled conditions further crowd the ER beds making it the busiest time of the year in the hospital. Nurses and doctors are often exhausted from the workload this month brings along.

The Muslim medical personnel will often opt to work night shifts to make fasting easier or alternatively if they wish to work days they can work shorter hours. The total amount of working hours during this month for Muslim nurses, doctors and other muslim personnel is also cut down. Generally there will not be any operations other than the most urgent ones.

The patients' sitters will all usually be fasting and the hospital kitchen provides food for them as well as the fasting patients in the early morning hours. A three course 'breakfast meal' called sohoor will be distributed at 2 am well before the Fajr prayer.

The iftar meal, complete with dates, laban (buttermilk), soup, vegetables, rice and meat, dessert and juice will be distributed to the rooms at 6 pm. Even if a patient is not fasting, they will usually be up all night chatting with relatives, reading Quran or watching Arabic soap operas or the live televised show from the grand mosque in Mecca. This makes the night shifts exceptionally busy and hectic while the day shifts are slow paced and quiet.

I personally enjoy working during Ramadan, patients and relatives are in good spirits and it's nice to spend some extra time with them in the rooms having some arabic coffee and sweets. Generally the atmosphere is more laid-back and patients are not complaining as much as usual :)

P.S this post is a revised edition of a previous Blue Abaya article about Ramadan in Saudi hospitals from 2010.

Saudi Hospitals, Bureaucracy And Bullying

A colleague I used to work with recently asked me, don't I miss work? My first reaction was yes in a way I do miss it. I miss the patients mostly. I miss interaction with them and the opportunity of meeting so many different Saudis from all levels of society and learning about the culture and customs. Especially I miss having the Bedus as patients and seeing those smiles on the pediatric patients faces.
Read more about quirky bedouin patients here: :http://blueabaya.blogspot.com/2010/06/bedouins-as-patients.html
And more about why I love working with Saudi patients here: http://blueabaya.blogspot.com/2010/11/thank-you-my-dear-saudi-patients.html
Learn about the amazing Saudi hospitality I experienced with patients here: http://blueabaya.blogspot.com/2011/12/saudi-hospitality.html

Patient care was always the best part of the job. Naturally I miss some co-workers as well. Many, many awesome people from all over the world I was lucky to meet along the way. I made some great friends and found many like-minded people during the years. I miss the social aspect of work and of course the extra money, who wouldn't!

What I don't miss in particular however is the bureaucratic nature of the hospital. Everything is just so DIFFICULT. Things don't work anything near to how they do in the west although the hospitals claim to be run by the American model. This is 100% a Saudi model complete with a mix of discrimination against sex and nationality, pecking orders, red tape, complicated policies, gross incompetence, random unfairness, cosmetic campaigns, some unprofessional management and so forth.

I don't miss that one bit. If I could just interact with the patients and not have to deal with the rest of the load, I would be running back. But in the end I think, is it worth the stress and hassle? At the moment I feel it isn't but I might change my mind in the future, who knows.

Let me give you an example of making simple things complex. Say I have a patient complaining of headache on night shift. I assess her pain and want to give her a mild pain reliever. What I would do in Finland:  Go check her computer file for any allergies, previous medications, current medications and illnesses, then proceed to medicine cabinet, open it with the keys I have to get the pain relief of my choice based on my education, knowledge and experience and then go give it to her and document it. Taking about 3 minutes in total.

For comparison lets look at how this simple procedure in Saudi-Arabia turns into something so complex and frustrating it will have you pulling your hair out in no time. Same scenario, patient with headache. I go check her file in the automated medicine dispensing system called PYXIS and find she doesn't have a pain killer on her list of approved medicines. Then I go to her paper files to double check if there's any written orders by the physician for a Tylenol (also known as paracetamol, the only drug a physician in a Saudi hospital will write as telephone order) that has been missed by previous nurse. No luck.

Next I have to page the correct doctor. I need to check which team my patient is under and find out who is the on call doctor. If I'm lucky I find it relatively quickly but it might be under a service i'm not familiar with and I will have to do a computer search. I page the number and wait for a reply. If I'm lucky he might actually call back within minutes. According to policy I have to wait 10 minutes. The time goes by and I call again, no reply. Another 10 minutes and finally a reply, the doctor was busy (in some cases, he was sleeping).

Next I have to explain to the doctor the whole history and current condition of this patient just to get this simple medication that anyone can purchase by the truckload at any Saudi pharmacy no questions asked. He finally gives the telephone order and I write it down in the file. Another nurse has to come sign it with me as a witness. The order is STAT meaning the pharmacy should prioritize and activate it right away.

Next I have to fax the order to the pharmacy. The pharmacy staff may or may not be helpful. Usually the latter. I wait for a while next to the machine tapping my fingers on it and then decide to log in to check if the pharmacy has activated the medicine in the machine yet (nothing comes out of this machine without it being on the patients list, not even hand cream). Naturally sometimes nurses take the same drug out under other patients files but this is not the correct way to do it.

Meanwhile the patient has rang the call bell every three minutes. Because I didn't have time to go to their room and none of the Asian colleagues sitting nearby gossiping in their own language are offering help to resolve the issue, the angry relatives have now ventured out of the room to the hallway demanding for pain relief. I have a reassuring conversation trying to explain the procedure to the shouting male relative and they may or may not calm down and go back to the room.

After waiting another 10 minutes I call the pharmacy and in the most polite way possible (knowing the night shift person is usually in the worst of moods) remind him of the missing STAT order. He goes nuts on me and slams the phone on my ear. I take a deep breath and go back to the machine. Someone is using it so I have to wait until they finish. The relative is breathing down my back looking at me like I'm the most incompetent, lazy nurse in the world.

Finally I get the medicine out and can go give it to the poor patient who has had to wait in the worst case scenario for over an hour for this basic medicine. For nurses the priority is always the patient and their well-being and not being able to help because of these silly limitations imposed on the nurses is very annoying.

The nurses in Saudi hospitals are treated as incompetent, unreliable and uneducated staff. Mere maids sometimes. At least this is how the western nurses often feel about it because they are used to something very different. The lack of independence in the nursing field is the single most maddening and frustrating factor for most western nurses here. It comes up in every aspect of a nurses work in Saudi, not just giving medications, but everything. A nurse has to have doctors orders to give water to the patient after surgery, sometimes to change her position or get her out of bed, or even for applying skin moisturizer (no joke people!) Sometimes it feels as if our whole education was a just waste of time.

So as we were chatting with this colleague she told me how things are still the exact same on the ward. The same problems still exist despite a cosmetic attempt to correct some issues. Such as the bullying. This is not only a problem specific to the ward I worked on, but this particular organization as a whole and in fact the entire Saudi-Arabia wherever there are mixes of nationalities.

The reasons behind the bullying problem are complex but ultimately it has to do with human nature and psychology. Regardless of our backgrounds, religion or nationalities, humans will start acting in certain ways and displaying negative behaviors if placed under certain circumstances. When one nationality is paid 10x less for the same job than another just based on their passport color, problems will arise. When the majority of the staff are of the lower paid nationalities and there are only a small minority of personnel getting the significantly fatter paycheck, more problems arise. If management is under-educated and lacks skills to deal with workplace violence, more issues arise. If the organization and system favors bullies and allows them to easily climb the ladder to higher positions, obviously the problems worsen. And when there are no set rules or policies against bullying, the problem not only persists, but gets worse by time.
This is the sad equation in many Saudi work places, particularly hospitals where people work under extremely stressful circumstances.

The typical Saudi way of doing things at the workplace is having things appear as if something is being done, but in reality it was just for show. Posters, campaigns and workshops against bullying can be issued to make it seem as if the problem has been dealt with. Behind the scenes however if a victim of bullying steps out, or someone exposes the problem or dares talk about it, he or she will in fact be facing denial or brushing off of the issue from most of the management. In other words problems are best swept under the carpet and the people who speak out better silenced.

Now this is typical for most workplaces around the world, bullying will always be a problem and management usually won't know how to or want to deal with it. In Saudi-Arabia the issues however become more severe and the victims more vulnerable. For one the staff is mostly a mix of expats, all or most far from the support of their families, working in a land with strange culture and customs, perhaps suffering from culture shock. They work under pressure to perform and sometimes using a foreign language. The mix of nationalities can be rewarding in many ways but it can also back fire if there's a significant imbalance and one nationality feels spite for another because of the differences in treatment and salaries.

I could go on about this problem but I will leave that to another post.

So after talking to my colleague and thinking it over, I don't miss the hospital and the problems that lie within it but I DO miss the patients!

The Princess And The Pimple

Believe it or not, based on a true story..

Once upon a time in the Magic Kingdom lived a young Princess called "Abeer". She lived in a huge palace with her parents and had a Pink Hummer driven by her private chauffeur.

One morning Princess Abeer woke up and upon looking in the mirror screamed: "Noooo! Yaaa Allah this can't be happening to me! Tomorrow is Fatima's wedding party!"

A gigantic red pimple stared back at her form the mirror. Worse yet it was in the middle of her forehead. "I look like a freak! Yaa maamaa!" she shouted in panic as she ran downstairs into the palace courtyard to find her mother.

"Mother what shall I do now, look at me I am so ugly! Tomorrow I must look my best because Prince Mishaal's mother will be at the wedding to check me out! He won't propose if I look like a three-eyed monster!"

"Yaa Rabb, poor girl. Don't worry dear Beero, we will go to the hospital and tell them to give you some medicine for the pimple."

So the Princesses left to the emergency room with their maids in tow. In the car Princess Abeer instructed the driver "Yalla ya Munir I am in great pain! Drive faster! Remember to use the royal entrance to the hospital so we don't have to queue!"

On arrival at the ER the poor Princess was so weak she needed a wheelchair. The driver fetched the chair for her and they rushed her into the VIP section of the ER. A nurse and a royal officer immediately attended to the Princess and she was whisked past the overcrowded side of the ER full of  the ordinary patients.

The Princesses had both thrown the black scarves over their heads so that their true identity (and the protruding pimple) would remain hidden. The nurse apologized and told the them to wait because she was busy with a very ill baby in the other room. The Princess got extremely upset.

"Sister don't you know who I am?! I am Princess Abeer bint so and so bin so and so bin so and so bin AbdulAziz Al Saud. You must attend to me first!"
"But your Highness, the baby might die!"
"I don't care! This is an emergency situation! she exclaimed, sister get me the doctor NOW!"

The nurse ran off to fetch the doctor, she knew not to mess with the royal family members after some of her colleagues had been "dismissed" and sent on the next flight home after criticizing the VIP status of some patients. A Saudi male doctor specializing in royal medicine arrived to examine the royal patient and asked her to remove the veil. The Princess whimpered in pain and exhaustion as she lay on the bed and finally removed her scarf.

Her mother with a stern voice advised the doctor: "Doctor we have imboortant event tomorrow and Abeer needs to be a beerfect condition. Blease doctor we need a medicine." "And I'm in pain!" the Princess added.

The doctor looked at the pimple for a moment and then gave his orders to the nurse: "Take her vitals, do blood tests, insert IV line and start her on intravenous Ceftriaxone. Give Pethidine 100 mg I.V. Apply Bacitracin ointment on the pimple Q.I.D.
"Don't worry your Highness we have it under control. The antibiotics will take care of the infection in no time and you will receive a pain killer now."
"Thank you doctor! Now sister, call the kitchen we want to order some food!"

The nurse went off to follow the doctors orders shaking her head in disbelief of such vanity and the unnecessary medical interventions. The VIP kitchen staff arrived at bedside to take their order. "Freshly squeezed orange juice, chicken burgers, fries..oh and cupcakes and kahwa please! Yalla besurah!" the young princess instructed.

The nurse returned to insert the I.V. line and the Princess shuddered. "Please sister I want the cream first!"
"But it's only for children your Highness and it won't hurt really, I will be very quick." "No, mama I want the cream!" "Sister, blease ze cream now." the mother Princess confirmed nodding her head.

The nurse applied the numbing cream to the princesses hand. "Sister blease, put ebra here so tomorrow mafi mushkila at wedding" the mother demanded. "But your Highness, placing the cannula high on her arm on the inner side will cause her great pain and it is not per policy either." "What is zis bolicy sister? Yalla but ebra now sister!" the mother Princess looked annoyed so the nurse forgot about reasoning and proceeded.

Despite the cream she screamed in pain from the injection. "Shweia shweia sister, shweia shweia!" The mother disapprovingly clucked her tongue. The nurse then proceeded to apply the antibiotic cream on the pimple. "Shweia shweia sister!" Cluck cluck cluck.

Finally the antibiotics were hooked and the Princess dozed off from her narcotic painkiller. She and mother princess spend the night in the ER on I.V fluids watching movies from the flat screen TV and calling the nurse to run different errands for her throughout the night. The maids massaged their feet.

In the morning the doctor came to check the patient. "Your highness the infection is improving. We can discharge you but continue your antibiotics at home for a week and keep applying the cream."

The pimple had indeed disappeared over night. "Thank you doctor! Sister, we want leave now so remove ze ebra and give us a medicine, besurah besurah!"
Upon leaving the hospital the mother Princess made a complaint of the nurses rude behavior to the Patient Relations Officer.

The Princesses returned to the castle and all was well in the Magic Kingdom.

And the Princess lived happily ever after, without the pimple.

Read more about how VIP patients get treated in Saudi hospitals:

http://blueabaya.blogspot.com/2010/10/saudi-arabia-and-vip-patients.html

Vocabulary
Ebra= Needle
Besurah=hurry
Mafi mushkila=no problem
Sister=what all Saudi patients call nurses
Shweia=little, carefully
Pethidine=Extremely addictive narcotic painkiller
bint/bin=daughter/son of
Rabb=Lord

Saudi Men and the Pressure to Perform

Picture an 86-year old bedridden man. He has recently married a 16-year old girl, his third wife. He feels the need for a little "boost" to his manhood to fully enjoy the marital life and satisfy his new bride. Viagra no longer works for him. What can he do? 


The man is fortunate to be a Saudi. He can easily get help with a penile prosthesis, inserted free of charge at the government hospital. If one hospital rejects his request, he will just keep looking until he finds a physician willing to operate on him. Lucky for him it does not matter that he is nearing 90, cannot walk and that his new wife could be considered a child by some. Saudi medical ethics are exceptional in his case. The man is entitled to have some fun after all. At least one limb should be working!

At the hospital the surgeons will pat the mans back and congratulate him on the new wife. Of course the old man needs to be able to perform! Surgery will be planned and an implant inserted to enable a constant "state of readiness" for him. After the operation the room fills with curious male relatives congratulating the man on his new upgrade popping up from under the blanket. He will leave the hospital with a new cane but this one is not meant to assist in walking.

The sensitive issue of erectile dysfunctions are relatively common in Saudi-Arabia. Contributing factors are often social like multiple wives, arranged marriages, consanguinity and lack of sexual education before marriage.

Many of the cases are young newly married men presenting with "honeymoon impotence". Sometimes those men were not able to consummate their marriages simply because the social pressure was too heavy on them. The problem can be so severe it leads to divorce. Unconsummated marriage is not seen as a valid marriage and impotence is a just cause for the woman to file for divorce.

Then there are the 70+ men that seek for a cure for erectile dysfunction. They too feel the social pressure of being a virile and active husband.
Elderly patients with this problem are not a Saudi specific occurrence of course. What makes it different in the Kingdom is the fact that many of the old patients will end up having surgery despite the risks.

Elsewhere and in the western world performing such invasive surgery would be seen as unethical and down right dangerous due to old age and higher complication risks. Penile prosthesis surgery is usually performed on young men with certain medical conditions and older men will be treated with medicine such as sildenafil (Viagra). But in Saudi the lack of medical ethics as we know them and the "gentleman's club" attitude enable these old babas to have their way.

The culture in Saudi-Arabia does not frown upon very old men wanting to enjoy marital life. It's seen as their right. Same does not apply for older women though, after the women reaches menopause she is not seen as a sexual being anymore.
The elderly man of the above story was an extreme case but nevertheless such cases do sometimes occur. And they are viewed as perfectly normal. A new young wife is seen as an acceptable indication for surgery!

Elderly men, regardless of their underlying medical conditions or even their mobility in the most extreme cases, will be granted the implant if they so wish. These old Saudi men will happily continue their marital relations and keep their social status with their eternal erections. Only in Saudi-Arabia!

Some interesting research from the Middle-East region on the matter:

A urologist I used to work with concluded in his study conducted in Saudi-Arabia that patients with penile prosthesis had a 92% satisfaction rate.

The link between low sexual desire and consanguinity: http://www.ncbi.nlm.nih.gov/pubmed/15672966

Study from Iran about the pressures of the wedding night: http://www.ncbi.nlm.nih.gov/pubmed/19090943

Researchers found that in "240 cases, unconsummated marriage was due to being under social pressure to have a quick intercourse while relatives waited behind the door to confirm and celebrate coitus by checking a handkerchief that was placed beneath the bride to become bloody by hymen perforation."

Research from Turkey concluded that 67% of honeymoon impotence cases were of psychogenic origin.
http://www.ncbi.nlm.nih.gov/pubmed/11306399

Alarmingly high rate of honeymoon impotence among Saudis due to severe performance anxiety: http://www.partal.com/mares/sexologies/angles/arxius/47/sommaire2.html

American Bedu discusses the popularity of use of Viagra among Saudi men:
http://americanbedu.com/2011/09/10/saudi-arabia-popularity-and-use-of-viagra/

The Eternal Veil

Imagine a man that has never seen the face of his wife, ever. How about a son or a daughter that does not know how their mother looks like?

Such men and women still exist in Saudi-Arabia.

Recently in the news was the story of a Saudi man that had never seen his wife's face. After 10 years of marriage the man had become too curious to control his desire to look at the woman he married. He had made the mistake of trying to sneak a peak under the veil at night. The wife had however woken up and now wanted a divorce. She had "lost face" so to say.

The women that practise this custom of never revealing their faces come from a very small majority from certain tribes of the Najdi region.

What's most peculiar is that some of these women refuse to remove their veils even in the company of female relatives including their own daughters, sisters and mothers!
How does this effect the child?

This reminded me of how I found out about this custom through a patient of mine.
She was being treated for cancer and was on the ward with her two daughters who acted as her sitters (caretakers). The daughters were perhaps 7 and 15 years old, hard to say because of the veil.

I remember going about my normal routines measuring her blood pressure and asking her some questions and making a note to myself that I had not yet seen their faces. I wondered why the patient and daughters all sat in the room eating in their colorful dresses without abayas but they hadn't removed their niqabs (face veils).

I then requested for the patient to remove her veil for me to check her and made a gesture with my hand indicating she lift her niqab. She went ballistic!
She shouted "haram" at me and I could see I had upset her but I still didn't realize what I had done.
On the side note, some Saudi patients might be a "bit" demanding or like some nurses say "crazy" so I just thought of her behavior as the norm, smiled and left her.

Later on a female physician told me that these bedouins (she referred to them as nutters) never removed their veils, not even in presence of women. She said it has nothing to do with Islam, it's just their tribes that have these weird traditions of hiding the women's faces. The permanent veil imposed a huge problem as to how to treat this woman and it was driving the doctor crazy.

The patient had demanded an all female medical team and none of the male doctors were ever allowed to enter the room. The major issue was that she needed surgery and it didn't look like it would be possible to accomplish with her remaining veiled the whole time.
The veil would of course be in the way of surgical procedures and it would be an infection risk but the patient insisted she keep it on.

The next time I saw the patient I asked her why she always kept the veil on. At that time my arabic was still very basic and I was not able to understand her funny accent either. She kept repeating "lazim" which means "have to". So I never really understood what were the reasons behind it nor was I able to find out at what age they started veling the daughters. Did they actually veil babies?

The woman and her daughters seemed very comfortable with the veil and at night when I entered the room all three had them securely on. I wondered do the veils come off when they are in the bathroom or shower? It was as if it was a part of their bodies.

In the end the patient was discharged with her eternal veil and no procedures were done. She had refused life saving surgery rather than removed the veil.

Saudi-Arabia and VIP patients

Saudi-Arabia still has the outdated practice of VIP status, even in hospitals. To me as a Scandinavian this term of a "Very Important Person" just seems so antiquated and even ridiculous.

VIP as a concept does not exist in our society (exception some nightclubs VIP sections). Finland has always been a reformer and a pioneer in medical ethics. Back in 1964 the Declaration of Helsinki was developed and it is regarded as the cornerstone document of human research ethics.
If someone would declare themselves a VIP in Finnish society (which is highly unlikely) they wouldn't be taken seriously and it would be seen as nothing but a joke.

All patients receive the same treatment in our free or low cost government provided hospitals. Even Bill Clinton recently commented on the Finnish healthcare and schooling systems, saying "America should be more like Finland". Well I would have to agree!

For americans VIP patients are a more familiar concept. I googled it and found many articles from the States about VIP patients and how to treat them. I guess that might be where Saudis copied the system from, but here its implementation is far worse.The VIP in Saudi can be royal family member, a high ranking government or military official, a diplomat or just a person from a very rich family with serious wasta.

VIP and patient just don't go together. It's against all medical ethics. But in Saudi it seems to be like a normal thing accepted by everyone. To me it's like living in the medieval times.
Actually it wasn't always like this, VIP syndrome is definitely a result of the oil boom, sudden wealth and feeling of supremacy it brings to some Saudis. In fact during the medieval times Muslim hospitals were institutions which treated patients of all ethnic backgrounds and financial statuses equally. Including patients who were male and female, civilian and military, child and adult, rich and poor, and Muslims and non-Muslims alike.

Muslim physicians were expected to have obligations towards their patients, regardless of their wealth or backgrounds. The ethical standards of Muslim physicians was first laid down in the 9th century by Ishaq bin Ali Rahawi, who wrote the Adab al-Tabib (Conduct of a Physician), the first treatise dedicated to medical ethics.Read more here.
So Muslims were way ahead of the west when it came to medicine back in the day and actually one of the features in medieval Muslim hospitals that distinguished them from their contemporaries was their higher standards of medical ethics.

As a Finnish nurse, dealing with these kind of VIP patients and their often silly requests needed some getting used to. I used to ask: Am I supposed to ramp up my quality of care as if I have multiple standards depending upon the prominence of the patient? Why is my job at risk if I choose to prioritize care according to my judgment leaving the VIP waiting for 10 minutes? How can I be genuinely compassionate to a person that treats me with disrespect and like a maid, not a professional?

I still do not to this day compromise the care of my other patients just because the VIP is requesting for a glass of freshly squeezed orange juice or his or her shot of whichever drug they are addicted to. However I know many nurses who have lost their job because they didn't succumb to the whims of their VIPs. Some have been sent home the next day if the upset VIP was a high ranking royal. On the other hand nurses of Asian nationalities seem to take the VIP "seriously" and seem to be intimidated and will never question even their most absurd requests.

From the minute the VIP steps into the hospital, their whole course of stay will vary dramatically from the "ordinary patient".
They have their own entrance, clinic, ward, doctors and in the ER, they have a VIP fast track. Which means they will be treated first in all cases, even if there is a dying baby in the next room, the princess with the pimple  will be first priority. And yes they have come to ER for treatment of a pimple!

In case the patient is admitted, regardless of diagnosis he or she will most likely go to the designated VIP ward. Needless to say the rooms are huge and glamorous and anything the patient wants extra will be catered to. The problem I see with this is that in fact the patients are not necessarily receiving the best possible medical care. When patients from all medical fields are combined in one ward including deliveries and babies, the amount of knowledge and experience the staff should possess in order to equal the quality of care on the regular wards is enormous, even impossible to achieve. Some VIPs have realized this and request to be assigned onto the specific wards and "suffer" the consequences of smaller rooms.

Another issue that diminishes quality of care and slows down the treatment process is that physicians are reluctant to make diagnosis without consulting a multitude of specialties first. They are so terrified of making a mistake and loosing their jobs, they will be hesitant to start treatments further worsening the prognosis of the patient in some cases.

They will also prescribe drugs and treatments of no benefit or even harmful to the patient, just because the patient requests them. This is the case with drug addictions, there is no such thing as weaning the VIP off the drug and upsetting the patient.

What the patient does acquire with VIP status in addition to the larger room is 5 star hotel like service. This is assumed to be delivered by all personnel, from housekeeping, maintenance, food services and of course, nurses. The patient can order any type of food from the VIP kitchen 24/7, the can get extra golden armchairs and sofas brought in for visitors, if they need service of hairdresser or masseuse the nurse wll arrange them, their rooms are filled with flower assemblies reaching to the ceilings and in addition to all this have private nurses and maids serving them.
If the patient is not satisfied with the service provided they have their own representative in the hospital who will arrange any arising problems.

I've had many wonderful and genuine VIP patients that don't seem to be bothered of their status too much and are not overly demanding. But there are patients with a bad case of VIP syndrome, which can be a hassle for the staff to deal with.
My conclusion is VIP status does not in fact benefit the patient from the medical point of view but it serves more of an egoistic purpose.

Ramadan in a Saudi hospital

The Holy month of Ramadan changes the daily rhythm drastically in Saudi hospitals. Basically the hospital becomes alive at night and quiets down for the day.
Read here how the Saudis usually visit the sick in hospitals. Needless to say the amount of visitors during Ramadan will at least double, especially during the last ten days. Visitors will come late and stay until early morning. They will bring along vast amounts of arabic foods to break the fast with like sambosa, all kinds of tiny pastries, cookies, dates, chocolates..

Large Saudi families come to the hospital to join in Iftar together with the sick family member.  It's not uncommon to find the family eating on the sheets on the floors! Saudis will generously give the nurses a taste of everything, sometimes offering huge trays full of different sweets or salty snacks.

Another peculiar thing that happens during Ramadan is handing out money to nurses. Patient or relatives might slip money into the nurses pocket or openly offer money anywhere from 10 to 1000 riyals at a time. The gesture usually makes nurses feel somewhat awkward and because of cultural differences might be misinterpreted to be some form of bribing. Nurses are naturally not supposed to accept the money very few will reject. The person offering the money will become very upset if the offer is rejected and they can become pushy and just stuff the pockets with the money! The reason behind this is Saudi families wanting to show their gratitude and appreciation to the nurse.

Only few patients will be observing the Ramadan fast, and they will also abstain from all medications including injections and intravenous drugs during daylight hours. That makes it a bit difficult to accommodate the medication regime to the fasting timetables. Basically it means that the medications normally given around 8-9 am will be given at fast breaking time around 6:30pm. The next dose will be at midnight and finally just before the morning prayer at 4 am.

For some patients it's fine to fast and it will not make their condition worse. Every once in a while there will be a patient who insists on fasting even if doing so will severely adversely affect their health. The patients don't want to miss out on the blessings of fasting. Some are diabetic which means their blood sugar levels will be uncontrolled and it might put the patient in risk of coma, or they will refuse insulin injections resulting in sky-high blood sugar levels. Patients with bowel problems might get complications like obstructed bowel, may even need surgery and then there is the odd patient who will even refuse to be operated on.

Toward the end of Ramadan the emergency room usually begins to fill with patients with bowel obstructions. Many are elderly patients needing full time hospital care. Patients suffering from gastrointestinal diseases and disorders, diabetes, metabolic disorders and other diet controlled conditions further crowd the ER beds making it the busiest time of the year in the hospital. Nurses and doctors are often exhausted from the workload this month brings along.

The Muslim nurses will often opt to work night shifts to make fasting easier or alternatively if they wish to work days they can work shorter hours. The total amount of working hours during this month for Muslim nurses and other muslim personnel is also cut down. Generally there will not be any operations other than the most urgent ones.

The patients' sitters will all usually be fasting and the hospital kitchen provides food for them and the fasting patients in the early morning hours. A three course 'breakfast meal' called sohoor will be distributed at 2 am well before the Fajr prayer.

 The iftar meal will be distributed to the rooms at 6 pm. Even though a patient is not fasting they will be up all night chatting with relatives, reading Quran or watching Arabic soap operas or the live televised show from the grand mosque in Mecca.

I personally enjoy working during Ramadan, patients and relatives are in good spirits and it's nice to spend some extra time with them in the rooms having some arabic coffee and sweets. Generally the atmosphere is more laid-back and patients are not complaining as much as usual :)