Rounds was very teaching oriented at bedside with a large team composed of senior and junior residents, house officers (= interns) and medical students. The most senior resident would lead rounds, hear an abbreviated presentation by the junior resident/house officer and proceed to interview, examine, review any radiology films (actual ones) at the bedside and dictate his note for the junior resident/house officer to write down in the patient chart. Patient charts are on paper (on paper of different sizes and colors) and the residents write down any orders/recommendations they have in the notes. For the most part, the notes looked pretty legible as this was the only way to communicate with other health professionals. In fact, Dr. Amby was trying to institute a new system where residents would log in their patients in a logbook that would eventually be entered into a MS Excel spreadsheet so that they could search a database of patients that had been seen. Generally, physicians rely on family members and the patient to provide history as there is no way to access prior notes from prior hospitalizations. Even labs and radiology reports are handwritten onto different colors of paper.
A few first striking impressions:
1. The senior resident led rounds with no consultant (attending) in sight for the neurosurgery team. Junior residents/house officers and students were all very engaged in learning anything and everything the senior resident shared on rounds. The senior resident had two years of post-graduate experience. The way I understand it - physicians in Nigeria have a combined 6 year medical school and undergraduate experience; do 1 year of house officer (internship), one year of being a general practitioner as part of a national service program under little or no supervision, take a test, and then move on to a specific specialty like Medicine, Pediatrics, Surgery for 2-3 years followed by another 2-3 years for a subspecialty.
2. Physician presentations of patients were somewhat structured but very abbreviated in part due to whether recommended studies were completed. Whereas on rounds at the UofC, medical students will chime in and residents and interns may disagree/banter on the plans during rounds, it was extremely hierarchical with the senior resident's plan being THE plan.
3. Recommended studies for patients were not always completed because the Nigerian health care system is based on pay for care. There is no insurance. You need to pay for every Xray, CBC, basic metabolic panel, blood transfusions, antibiotics, beta blockers, aspirin, bandages, surgery, and even Tylenol. If you can't pay for it, you can't get it unless it's an extreme life threatening emergency in which case the patient gets a waiver to pay upfront and can have the service/procedure immediately but must pay the fee at some point. In order to be even be seen, there is a fee to pay as well. Thus, I've seen young men and women who have been involved in motor vehicle accidents presenting with altered mental status waiting to head CTs (with their clinical status declining in the process but not yet guarded) waiting for family to bring enough money to get the head CT. If you need an amputation - you need to pay upfront. If you have appendicitis, they may waive it at first but you are still on the hook to pay for it afterwards. I was assured that whoever collects the money will find you. No one uses credit cards in Nigeria so everything is paid up front in cash.
4. Where I work in Chicago, we have lots of issues about admitted patients (patients staying in a hospital ward for acute/complex medical issues) staying in the emergency room because of the lack of beds available on the hospital wards. The same problem exists here. Some patients need to be admitted to a specific service but that service no longer has any beds in the wards. Some patients who were found and brought to the A & E have no family at bedside (and therefore no money) and only very basic medical care is provided (cot, fan, IV with a bag of IV fluids). The social worker's job is to locate family so that fees can be paid to expedite care. Otherwise, the patient just stays there as the natural course of whatever disease process continues without significant intervention. Here are some examples:
* There was one such gentleman with otitis media/external (ear infection) with pus coming out of his ear, who was also altered, who had been in the A & E for 10 days now with no family found yet. He had not yet received antibiotics.
* There was also a 1 year old boy that had suffered a fall and had a head trauma that needed surgery. He had been waiting for 2 days already for OR time to have the surgery. In the meantime, he had a new fever and was started on empiric treatment for malaria.
* There was another case where a patient presented with suspected acute myocardial infarction (heart attack) (MIs rarely present to the ED in Ibadan, they see more strokes) and the patient's therapy and transfer to the cardiac intensive care unit was delayed; this patient sadly expired.
5. Family members at the bedside in the A & E are the patient's nurse. They bring food for the pts and feed the patient. They clean the patients. They help the patients go to the bathroom. They bring sheets and pillows and blankets for the patients. They keep track of the Xray and CT films at the bedside to give to the doctors when they round. They are extremely respectful and cooperative to all physicians. Imagine if family members were like this in your hospital?
6. These hospitals can function on a power generator and without running water. I live within the hospital complex and on Day 2, I woke up with no electricity and no running water (again). When I got to the hospital after brushing my teeth with bottled water (which everyone should do in Africa) and washing my face with a moist towelette (what a smart thing to bring), I noticed that the hospital too had no running water and was functioning on a power generator. The power came back on while I was there but the A & E only had fans with poor ventilation in hot and humid weather with extremely noticeable smell of urine, sweat and blood. The neurosurgery resident that lead rounds examined 10 patients and never washed his hands. There were some sinks available with a bar of soap to wash hands but since there was no running water, there were several very large buckets with lids filled with water. People would use a smaller bucket to scoop up some water, wet their hands, use soap if any was available, and then rinse with the water in the smaller bucket. As you probably know, I'm a germaphobe and I Purell at work like a bazillion times a day and I constantly wash my hands at home after doing whatever task. I was so happy to have Purell in my pocket to clean my hands as we went from one patient to another. Also, from what I noticed, there was no air conditioning in any of the patient quarters in the A & E and the wards. The only time I experienced air conditioning in the hospital was in a physician's private office.
In this first day, I was so struck by how if the family couldn't afford certain care, certain care could not be received. Here in the US, anyone and everyone that walks into an emergency room can get an extensive work up; in fact, many feel entitled to this care. If they don't have insurance or have limited insurance, they all get the same immediate emergency room care; how it's paid comes later. This socioeconomic divide leading to health outcomes was especially heart wrenching as many of the motor vehicle accident patients we saw were very young if not infants waiting for definitive therapies for medical issues that were preventable.
Despite all these challenges and non-ideal conditions and situations, I could tell that Nigerian physicians cared deeply for their patients and did as much as they could do within the expectations and culture of health care in Nigeria. This is to be applauded. They are definitely doing the best that they can and they acknowledge that improvement needs to and hopefully can be made, esp with upcoming state and national elections this month.
On a lighter note, I had some included pictures about how I bathed last night - water in a bucket, as yes, I still have no running water. I even learned how to pump the water into the house but I can only pump water into the house only if the city refills our water reservoir. I also learned how to use the power generator for our house for when (not just in case) the electricity goes out again.
I'll have to take some pictures of the A & E later on when it is not as busy as there were a couple of very clearly written signs stating pictures of patients were strictly prohibited.
Also, Nigerians are very welcoming and accommodating and want to make sure an oyibo (white man, yes they consider me white here) is well cared for. In fact, my contact at the UofC, Sope, calls or texts me daily to make sure I'm doing okay and helping me to troubleshoot. I appreciate it.
I'll have to blog about being an oyibo sometime soon.
On the left, the small bucket of water with water I took from the really big bucket of water on the right.
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