I met in the resident work room a little before 9 AM and the consultant arrived at about 9:15 AM. Not bad. We started rounds relatively promptly considering African time. I was a little confused at first because the "consultant" that had arrived was introduced to me as a senior registrar the day before. As it turns out, he just became a consultant (having passed his exams) in Cardiology.
We rounded on about 16 patients scattered throughout the hospital. We first went to the emergency room wards for both men and women. Unfortunately, while we were seeing two of the male patients, one of the neighboring patients was noticed to be expired (= dead). There were flies landing on the man's body but his body never moved. It looked like he had been dead for a while. I was slightly alarmed given if this had happened in the hospital where I work in Chicago, the nurses/staff would have likely called a code blue/Dr. CART for a cardiac arrest. Here, we just went on with things. The nurse put up a removable room divider to give the patient more privacy (there are no curtains or separate rooms - just one large room filled with 12-15 patients). One of the house officers stepped out of rounds to complete the death examination.
One thing I've noticed both here and in Ibadan is that despite having a Cardiology or Pulmonary or Endocrinology service, by and large, these services are just General Medicine services. They admit any and all medical patients via the ED and occasionally get consulted by other services for specialty specific consultations. I was participating on Cardiology service ward rounds and only maybe about a quarter of the patients had an active cardiology issue. Among those with cardiology issues (this is going to get very medical now) included dilated cardiomyopathy (presumably non-ischemic but none of them had any type of cardiac catherization (it's too expensive and there are no facilities for it available on site), decompensated heart failure, and endomyocardial fibrosis which is a type of restrictive cardiomyopathy common in tropical areas with eosinophilla. Didn't seem like the endomyocardial fibrosis was confirmed with biopsy of heart tissue (as this is commonly done in an interventional manner) but rather diagnosed in a clinical manner. The other types of patients we saw included a man that had not walked in 3 wks (presumably had a neurological lesion but had not had any imaging yet), a man with likely terminal cancer in the abdomen with a large swollen belly of fluid and significant cachexia and a young boy with some type acute leukemia that was languishing. It was not an uplifting morning.
It was still very evident that patients that had little or no money did not get the standards of care though it may be possible that these patients got more care on admission than patients in Ibadan. Not sure about that. It became apparent that patients at least 60 years or older when admitted did not have any costs. Their families had to pay for emergency care if they went through the ED but by and large, the rest of their medical care once they were admitted was free. Glad the Lagos state government it taking care of the seniors. I also learned that one session of hemodialysis costs 40,000 Naira each and every time. They place temporary catheters to do dialysis in the groin and remove them every week. They don't have problems with catheter associated line infections.
Remember how I showed you pictures of the newer hospital ward? Apparently, that is the only hospital ward that appears that way. While seeing the 16 patients, we went into a variety of different hospital wards that were all in different states of cleanliness and modernization. The newer ones were large rooms with 16-20 patients without any curtains. There were fans and screens in the windows. The more run down hospital wards were dingy (and smelly) with some fans and often times, compromised window screens. Unlike Ibadan where all patients had bed nets, virtually all of the patients did not have bednets, definitely placing them at risk of malaria.
The consultant leading rounds, despite his junior status, I could tell had subscribed to the culture of the consultants I've seen in Nigeria thus far. He dictated his notes to the house officers/resident and never washed his hands between the 16 patients. He taught a little bit and even pimped me (not nice to pimp the guest!). I thought he did a nice job telling a gentleman that he likely had incurable cancer and that he should go home (as opposed to stay in the hospital). However, given that his area of specialty is in Cardiology, I thought that he would spend more time teaching cardiology when we came across the more cardiology focused patients. Unfortunately, this was not the case. In some situations, I felt that perhaps the patients were missing out on potential benefits of therapy (i.e. getting a ACE in heart failure as opposed to digoxin). For the residents, I felt bad because they were barely learning anything beyond transcribing the attending's note and his plan. There wasn't much teaching outside of this. We even saw a patient that had a pacemaker for a second degree heart block complicated by the pacemaker pocket infection (I've seen a gazillion of these cases in Chicago) and then had a new one placed and found to have ventricular tachycardia. When I heard about this case, I instantly thought that there was so much to learn and to teach! Sadly, the consultant dictated his plan of getting a EKG, reviewing the EKG and checking a basic metabolic panel. No discussion of what is ventricular tachycardia, who gets it, how to work it up, what to do let alone learning about pacemakers, indications for pacemakers and second degree heart blocks. We never reviewed any EKGs (because the patients with exception to 2 did not have one done) and of course never looked at telemetry because there was none except for one patient that had a transport monitor at his bedside. I was totally unimpressed. When rounds ended, the consultant didn't even address us and walked away. As I said, totally unimpressed.
Though it was nice to finally experience a hospital that had running water and electricity, I could still see that the dysfunctions and lapses in professionalism that was seen in Ibadan still persisted despite the existence of water and power. Whereas in Ibadan I had started to blend in and become part of their community, I was just the visitor that was in Lagos for a brief time asking questions here and there so who knows if my observations are clearly representative of what is actually going on. I also missed out on chart review (= morning report) as it was canceled due to resident meetings. I heard that they used NEJM cases instead of actual cases for these chart reviews.
Later in the day, I finally ate the highly recommended live catfish! Dr. Adekunle took me on a 7 minute walk to a side street near the hospital to pick out a live catfish. You don't actually eat the live catfish but you pick a live catfish, they kill the fish right there and then and then cook it really nice and hot and spicy.
On our way there, I thought I was going to die crossing the street. Literally. Remember those pictures from Day 27 where I was sitting in traffic trying to get to the post office? Well, that was the traffic I encountered while walking to get live catfish. Dr. Adekunle laughed at me and held my hand when we crossed the street on the way back. Yes, I know. I'm a scared oyibo.
Here is the selection of live catfish. They barely moved until of course the owner lady poked at them and then I jumped and yelped (still probably skittish from walking in that traffic).
Here are the two we purchased. One for Dr. Adekunle and one for me. I wasn't sure I could finish one but Dr. Adekunle assured me it wouldn't be a problem. It was 700 Naira per fish. Good deal!
Here is the piping hot and spicy and peppery catfish. The spiciness reminded me of Korean spices. My nose starting running when I was eating the fish. I think Nigerians would like Korean food which I heard isn't really available in Lagos. (If it's not available in Lagos, it's not available in Nigeria.)
I did have a small stomachache the next day (probably because of the spiciness) but it was totally worth it! This was probably my most favorite Nigerian food. I want to have it again in Chicago.
Dayo dropped by from Ibadan and picked up my cell phone and plug adapters. He also dropped off our matching clothes made for Eddy and I. They look very cool! Maybe Eddy will let me post a picture of us wearing them. Now that we have matching clothes, I hope we will get invited to a Nigerian party in Chicago!
It's happening! I'm going home soon!
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