Religion Before Patients? How One Orthopaedic Surgeon Observes Ramadan

A patient groans in agony lying atop a rigid spine board, carried by paramedics into the ER, his neck in a protective collar. The paramedics shout a succinct summary of the accident. Monitors are attached to the man, flashing and beeping the familiar cadence of vital signs. Nurses and physicians swarm. Gloved hands check his head, combing through brown hair to find bumps or lacerations. They remove his clothing and shoes, feeling for pulses in the neck and limbs. They press his belly, strap a blood pressure cuff to his arm, and ask him to move fingers and toes. IV fluids are given, X-rays are taken, and calm reassurances are repeated to assuage the patient’s angst. Each member of the trauma team has a specific role. I press along his arms and legs, noting obvious deformities to his forearm and shin. I don’t need an X-ray to know they are fractured. I call the orthopaedic tech, emphasizing the urgency and what splinting material we need to stabilize his limbs. This all occurs in rapid succession, a seemingly chaotic yet well-versed sequence that is all too common at a large trauma center.

I glance at the digital clock in the trauma bay: 8:10 p.m. I smile. Only a few minutes till Iftar, the evening time to break the fast.

Ramadan is the Islamic fasting month, when adherents abstain from food and drink during daylight hours. Fasting is mandatory on healthy adult Muslims; but if one is ill, older, dependent on medication, pregnant, or traveling, they are pardoned from the fast. Muslims believe it was during this holy month that the Quran, and other religious texts like the Torah, Psalms, and Gospels, were all revealed by God to His different prophets throughout history. Thus in addition to forgoing food from sunrise to sunset for those that are healthy, general self-discipline and reflection are exercised. One is encouraged to give more charity, increase prayer, and abstain from sexual relations, impolite speech, and other such activities during daylight. Naturally, food plays a large part in the communal spirit of Ramadan. Sharing Iftar with family and friends is common, and varies by culture. For me, this means dates, spicy samosas, kabobs topped with chutney, juicy mangos, and a refreshing yogurt drink called lassi. And right about now – standing in the trauma bay with my green scrubs already caked with white splinting plaster – the shear thought of food and water is invigorating.

Yet I know better than to hope for any grand meal tonight; I’m the on-call orthopaedic trauma resident. There are already three patients in the ER waiting for me to see them. I had only spared a quick glance at their charts and X-rays when I was interrupted and rushed here.

The familiar vibration had gone off at my right waistband, followed a second later by the inexorable “beep-beep” of the pager clipped to my scrub pants. I thumbed the button, silencing the cacophony. The screen flashed a short phrase: “TRAUMA ALERT / MCC / 40M / ETA 5 AIR.” Translation: A 40-year-old male was in a motorcycle accident, with suspected injuries serious enough to warrant complete trauma team evaluation, arriving in five minutes via helicopter.

Now waiting in the trauma bay, I think back to those three patients in the ER queue and create quick mental plans for each. 1) Wrist fracture, displaced: needs to be reduced and splinted. 2) Ankle fracture-dislocation with open wound: needs to be reduced, splinted, put on antibiotics, and added to the surgery schedule. 3) Deep hand laceration: needs full nerve and tendon exam and possible surgery. As I ponder this, my pager goes off again, yanking me from my orthopaedic reverie. A four-digit extension blinks on the screen. Likely a nurse calling about a patient having pain or a discrepancy in medications. I also hear the periodic chime of unopened text messages on my phone, hopefully from orthopaedic device reps confirming that we have the correct plates, screws, and rods for the coming morning’s surgeries.

Needless to say, the orthopaedic surgery department at a large trauma center is busy. With as many as twenty or more such patient consultations in a night, it is imperative to be sharp mentally and physically. And it’s Ramadan. So how does one fulfill the religious obligation to fast without hindering his/her care for patients? How does one reconcile religious beliefs with the ancient oath of Hippocrates, a promise to place the patient first?

People naturally are curious whether one can maintain energy and focus while abstaining from food. I have been asked, “Is it safe?” “Does it compromise your ability?” There are countless studies assessing the physiologic effects of fasting. They illustrate a myriad of health benefits such as enhanced neurogenesis, improved cognition and decreased impulsivity, decreased circulating TNF-alpha and C-reactive protein levels (1,2), improved insulin sensitivity, and increased human growth hormone production (shown to hold anti-aging benefits). There is also evidence showing that fasting during Ramadan improves liver function, decreases total cholesterol, and can lead to weight loss and decreased fat mass by burning fat as fuel rather than carbs.

There are many Muslims in the public eye that perform at the highest level while fasting during Ramadan. Basketball Hall of Famers like Hakeem Olajuwan and Kareem Abdul-Jabbar continued providing highlight-reel performances while fasting. Muhammed Ali, one of the greatest boxers of all time, also fasted. Current athletes like Portland Trailblazers center Enes Kanter, Liverpool forward Mohamed Salah, and U.S. Olympic fencer Ibtihaj Muhammad similarly continue to train during Ramadan. Celebrities aside, millions of Muslims around the world incorporate Ramadan into their daily lives and vocations such as accountants, teachers, firefighters, police officers, nurses, doctors, and many more.

What one must further realize is that Muslims who fast throughout Ramadan, like myself, have been doing it every year since before they were teenagers. The self-discipline of Ramadan continues to teach me perseverance, patience, and toughness. For me, these are translatable traits, and of themselves are integral to becoming a skilled and empathic surgeon.

Due to the daytime restrictions on food and drink, one can certainly become fatigued if not adequately prepared. To combat this and remain competent during Ramadan without compromising care for my patients, I prepare ahead of time. I wake up well before sunrise and eat a full meal, called Suhoor, ensuring adequate nutrition throughout the day. Eggs, yogurt, fruits, bread, nuts, and plenty of water. Additionally, before every night of orthopaedic call during Ramadan I pack full Iftar and Suhoor meals. I carry these unabashedly in my oversized red lunch box, stashed in the surgeon’s lounge fridge, ready to break the fast and then eat again before sunrise. I chose the medical profession, and orthopaedic surgery specifically, to help patients conquer their injuries, continuing to climb the ladder of recovery and regain their quality of life. It would be a disservice to my patients if I didn’t ensure that I was as mentally and physically sharp as possible to give them my best.

So I stand in the trauma bay, watching the digital clock and its slow minutes blink by. “Another motorcycle, huh?” The orthopaedic tech has just arrived at the trauma bay with the splinting material. “You know it. The night’s just getting started. Let’s get to it,” I respond. Once we finish, I promptly jog to the surgeon’s lounge, fling open the fridge, and extract my ridiculously large red lunch box. As I say a quick prayer and raise the Styrofoam cup of water to my lips, my phone lights up. A text from my wife, reminding me it’s Iftar time. I can't help but smile and then immediately gulp down the water. The coolness is so refreshing, a wave of energy washing over me. Then I quickly scarf down carrots, hummus, and a samosa, and grab an apple for the walk back to the ER. Yet I barely pass the door of the surgeon’s lounge when that the all-too-familiar vibration hits my right hip, followed by the pager’s “beep-beep” like a one-two punch. “TRAUMA ALERT / MVA / 66F / ETA 10 GROUND.” Here we go again.

Adil Shahzad Ahmed is an Orthopaedic Surgery resident physician at the University of South Florida in Tampa, FL. He is interested in offering a lens into the life of a doctor and surgeon, and the growth throughout the stages of education and training. He also runs MedSchool Declassified, providing advice and personal anecdotes to college and medical students on the journey to becoming a physician.

References

1) Mushtaq R , et al. (2019, January). The role of inflammatory markers following Ramadan Fasting. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/30881400.

2) Tello, M. (2018, June 28). Intermittent fasting:Surprising Update. Retrieved from https://www.health.harvard.edu/blog/intermittent-fasting-surprising-update-2018062914156.

Image by hayatikayhan / gettyimages

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