After my experience seeing rural surgery, all day I hoped that we didn't have to go again to observe. To be honest, the residents hoped the same thing as well as the learning yield was low (he pimps us on random surgical/anatomy facts that I may have knew as a medical student on surgery) and the residents weren't going to be surgeons - they were primary care physicians!
Before clinic, we saw the two patients on the female ward of the hospital. These were the facilities, making UCH look a tons more modern and clean. There were holes in the screens making mosquito entry into the rooms very easy. No bedsheets; family had to bring sheets/pillows for the patients if they had any.
We also saw a patient in the maternity ward. Apparently, this first time mother had given birth yesterday morning but no one (i.e. physician) was called to assist. We think the nurses delivered the baby.
In the morning, we again saw patients in the walk in clinic. Patient flow was pretty low. Dr. Sanwo and I saw a couple of infants with failure to thrive. On our differential included HIV as the infants mothers both had died soon after childbirth under unclear circumstances and didn't receive much prenatal care. Malaria and decreased volume of feed (due to poverty) were also on the differential. One infant was being raised by her grandmother and uncle. The other infant was being raised by the first wife (the infant's mother was the second wife... polygamy is not uncommon esp in the rural areas). We didn't dare say HIV or even high five (the code word we use commonly in the US) as even despite the lower literacy and education level of the community, they knew what HIV was. HIV yet remained highly stigmatized. We instead referred to it as retrovirus as we had on the wards. In contrast to the toddler I had seen the day before playing in the dirt, these children were thin and gaunt and clearly underweight. Nigerian children as often swaddled in the back (as opposed to the front) of the caregiver. One infant's grandmother was so kind to let me take a picture as an example. She is wearing traditional Yoruba attire.
We also saw a few cases of confirmed and suspected malaria in a infant (with failure to thrive), in a middle aged woman and a young child. They all got blood smears which cost about 600 Naira (remember, they have to pay first to get it done) and only the infant didn't have malaria parasites seen on the smear (which didn't mean that the infant didn't have malaria). One common recurrent theme was that these patients, except the infant, were not using bednets. Before coming to Nigeria, I had read about the successes of international nongovernmental programs (NGOs) to distribute and educate on bednet use to eradicate malaria. In fact, there was even a recent NY Times article that discussed how some NGOs were going out of business/closing as they had achieved their goals; one example of such NGO was one pertaining to malaria and bednet distribution. Thus, I was surprised to see how bednets were not widely used by all. Perhaps it's a cost related issue? The pre-treated bednet I purchased was 500 Naira which by US standards is quite inexpensive (a little over $3 USD) but for those living in poverty, 500 Naira could mean feeding a family for a day or even longer. What I also found interesting was that the physicians I spoke to didn't feel that malaria could be eradicated as I read. I wonder if the presumptive cases of malaria that we have been treating without confirming diagnosis was even really malaria, perhaps contributing to the sense that malaria was more prevalent that it actually is?
After a short day of clinic, the residents and I went to do some grocery shopping at a local market to pick up red peppers, rice, tomatoes, spices and eggs for our next meal. This picture below is representative (different areas have markets each day; I had taken this picture the day before). As we were at the local market, it struck me how traditional gender roles (women cooking, men waiting for cooked food) seemed to prevail. We had all driven together to the market but only Dr. Sanwo and I were the ones shopping for food while the men waited in the car. After a while, as the merchants were snickering at us and perhaps driving up the prices, Dr. Sanwo even sent me back to the car to wait for her while she shopped. (As an aside, they mentioned to me how there are a good number of Nigerians who have never been to rural Nigeria or even seen such markets as below before. I was surprised.)
The male residents seemed to enjoy the fact that Dr. Sanwo was cooking for everyone as at home, one of the men never cooked or shopped for food. In fact, it was a big deal for him to recently had picked up more duties at home (i.e. bathing his children) as his wife was pregnant and no longer physically as able to do certain household tasks. In speaking with women residents, despite their high powered, respected positions in society as physicians, at home, they very much need to fulfill a traditional wifely role. Of course this varies person to person and family to family, but I get the sense that traditional gender roles are very much observed.
One other thing I have noticed is the lack of consistency regarding eating lunch. While at UCH, I never saw any of the residents or attending break for lunch during the lunch hour. At times, I would have to sneak away and get a snack from the guesthouse before the afternoon would start. As such, in my first night at Igbo Ora, we all didn't eat lunch (and I didn't realize how hungry I was until about 8 PM) and on my second day, we all ate a meal at 4 PM which for me was dinner and for others, was just lunch.
In any case, Dr. Sanwo made (I tried to help) white rice with a stew of red peppers, tomatoes and traditional spices. We also made fried plantains which I've come to like a lot; I'm going to try to make this when I return to Chicago. She also mentioned how every Nigerian meal should include at least a protein so we got eggs which were hardboiled as the meat was too expensive at the market (I was relieved because the meats were sitting out open in the sun with lots of flies swarming around them).
Here the satchel drinking water we used to cook with so as Dr. Sanwo said, "so I can be sure the food is clean".
Here is Dr. Sanwo and Dr. Fasasi while we wait for the stew to finish cooking.
Here is the yummy food. This meal had a nice spicy heat to it which made me naturally sweat even more.
Unfortunately, we were called by the surgeon to observe another surgery. This time the surgery was for cholecystitis (inflammation/infection of the gallbladder) to remove the gallbladder; she also got an exploration of her belly because the surgeon said "it'll be a long time before anyone looks in there again." Typically, in the US, this procedure can be done minimally invasively (laparoscopic) or at least with a smallish incision in the right upper quadrant of the belly. However, this surgery was again done with a large midline incision.
To my relief, we walked in as the surgery was about 2/3s done. Of course the patient moaned. I was still a bit horrified by the conditions (Dr. Fasasi kept on telling me not to forget this sight... I'm sure I won't!). We got pimped with random questions (Describe acalculous cholecystitis; what is Courvoisier's law?; how many segments of the liver are there? (answer= 8)). We listened to the surgeon's oration regarding evidence based medicine and medicine in the US. He (of course) asked me where I was really from because I didn't look like an American.
At the very end, we rounded on the three surgical patients he had at the hospital. The young child that had the typhoid perforation was looking better. There was also another patient that had fetal demise that had a C section; she looked the healthiest. The last patient was the one that her gallbladder removed that day. She had been transported from the operating room to a bed by 6 individuals that held the sheet of which she lied on. Since there were no hospital beds that could prop her head up (as she was still unconscious), the surgeon placed a pillow before her neck that that her neck would fall over the pillow as a way to prevent her from swallowing her stomach secretions (= aspirate). An unconventional solution in a resource limited environment I thought.
That night, Dr. Sanwo and I just chatted like girlfriends. She had mentioned that should she get married, she would be interested in a non-African husband to avoid having a husband expecting traditional gender roles. We also talked about how the majority of her family is abroad (US, UK, Australia) and how she is among the last to remain in Nigeria. As it seems, many Nigerians leave (and don't return) and I could sense that she was struggling with this decision and the potential challenges should she try to leave. Plus, from what I hear, the US embassy in Nigeria doesn't have a great reputation in terms of giving visas. We also talked about buying cars as she was looking to buy a car. Did you know that many Nigerians purchase used cars from the US online and have them shipped to Nigeria? Apparently, it's cheaper than buying a used car here. Dayo had purchased his car this way as well.
The night was quiet and went by quickly. It was still very hot. I still felt smothered by the bed net. Dr. Sanwo had recommended that I sleep naked under the bednet (as it was protecting me from bug bites) to potentially feel cooler but I just couldn't do it in part because I had seen lizards climb on the walls of the room the day before. All nights at the guesthouse, I'm alone. It was nice to know someone else was in the same living quarters as I was.
I'm going to sleep now so I can Skype with Eddy in the morning before work. Plus, I need to work on my presentation to the entire family medicine department on Friday which I heard was announced to everyone today. Ahhhh! I'll post about Day 13 tomorrow.
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