Today was pretty relaxing. NEPA didn't take our electricity and I didn't get any more bug bites. I didn't have any clinical obligations in the morning which was a welcomed break. I woke up to chat with Eddy on Skype, napped a bit and heated up some leftover food on the stove. I even responded to my work and personal emails and even put my contact lenses in as I was going to give a presentation today at 1 PM. I even put on my nicest dress pants and a clean unwrinkled shirt I had brought with me and did my hair.Although my bug bites on my face weren't extremely red or swollen, every person (literally) I spoke to yesterday made mention of them as they stated the bumps were super obvious with my fair skin. In fact, I had to preface my presentation today so that everyone would just stop asking me about it! The head of the family medicine department even suggested that I get some steroid cream for them so they would fade away. Ayo suggested that I wear my glasses so that it wouldn't be as obvious. Dayo was convinced I got them in the "village" (= Igbo Ora) (no, got them in my room in the guesthouse!). No one really thought it was a mosquito bite because it wasn't itchy and no one really thought they were ant bites (apparently ant bites hurt a lot). In any case, I was relieved it didn't get any worse and was fading. Plus, I didn't wake up with any new insect bites in the meantime.The presentations were scheduled to start a 1 PM, first Dr. Sanwo and her thesis proposal, then Dr. Fasasi and his thesis proposal and then me. We were told to start when a critical mass (= 2-3 attendings) appeared. I think we started at about 1:45 pM and to give the family medicine residents a chance to get as much feedback as possible from as many attendings as possible who still were trickling in, I started off first. My presentation was brief and via Powerpoint. I shared a bit about my background and medical training including a couple of pictures of Match Day and my med school graduation with Eddy and my family which they liked (one of the questions in the end was what Eddy did for a living).I discussed my impressions from my clinical experiences (sorting hall, clinics, PEPFAR/HIV/AIDS and Igbo Ora including the rural surgery exposure). My goal was to keep things both positive and constructive as possible I have been truly impressed how they are able to provide the type of health care they are able to despite working under such suboptimal conditions and restrictions. I even got some laughs when I talked about my thoughts on goats in Igbo Ora (they are everywhere!). When I talked about my rural surgery exposure, I could tell that the attendings were a bit alarmed by the poor form demonstrated by the attending surgeon. In fact, at the end, I overheard the head of the department stating that they will be reexamining whether their residents will need to participate in the rural surgery experience as they weren't sure they wanted to expose their residents to that type of mentality and attitude. I was happy that I could have potentially helped the residents with this part of their training as overwhelmingly, in private, the residents voiced little joy and benefit from this component (and had diplomatically voiced these concerns to the higher ups) but little improvement or change had yet to happen.The last part of my presentation was my observations regarding their clinical practice, medical education and resident culture. I've been fortunate to be part of a residency program that enjoys eating and fosters an environment where I am able to eat lunch during the work day. As I had mentioned before, I rarely saw any resident eat anything during the work day and even later found out from a visiting medical student that some of the residents would be on a verge of passing out from hunger. While here, when I knew that if I didn't eat, I would keel over, I would say I needed to go to the bathroom or even needed to take a medication (i.e. anti-histamine) so that I could sneak away to get a snack. I also mentioned how the residents seemed to lack opportunities to interact on a social level and get to know each other as human beings (as opposed to doctors). The head of the department seemed receptive to this suggestion. With regards to medical education, I spoke about supervision and mentorship which in private some of the residents hoped that change (i.e. increased supervision and mentorship) would become a greater priority, particularly for those earlier in their training.All in all, I got a lot of good feedback and sentiment from the attendings and residents, some even requesting my Powerpoint presentation to save on their laptop. Ayo made mention how my presentation was different from the ones he had seen before as I didn't include much text, had pictures and didn't read my slides verbatim. This made sense to me after observing the next two presentations which mostly each presenter read from each slide, in part due to nervousness I think.When I observed the two presentations on senior registrar thesis proposals (a research dissertation must be completed in order to complete their final residency examination requirements), I was struck by the complexity and considerations that need to be taken to complete even the most basic research project. The major problem - money of course. They both had described projects that could have been completed in the US with a little bit a funding but as I learned, there was little funding available to apply for and even basic lab tests needed for their studies posed a significant barrier as who was going to pay for it?Dr. Sanwo's project was looking at hearing loss in elderly patients. Who was going to pay for a otoscope to look in ears? Who was going to pay for the hearing tests? Dr. Fasasi's project involved looking at the immunization levels of children under the age of 5. This project's had logistical issues as to how to get documentation of vaccinations as there is no registry or uniform charting (shots aren't required to go to school), patients go to different hospitals for vaccinations at different times, caregivers lose or misplace the card with their vaccination history and there was no way blood levels of immunity could be done as someone had mentioned this is not regularly done in Nigeria. What I found out is that many a senior registrar personally fund their own research thesis in order to graduate. Ayo told me that one resident spent 800,000 Naira of his own money (= $5194) to finish his project and graduate. Our required scholarly activity in residency training in US certainly pales in comparison.While we waited to get started, I took a picture with Dr. Sanwo. After she reviewed the picture we had taken, she said she looked "black" in comparison to me and I looked at her funny and said, "well you are black!" We both bursted out laughing. :)
After the presentations (and after Dr. Sanwo and Dr. Fasasi got a lot of constructive (and some very blunt) feedback), Dr. Sanwo took me shopping to two pretty westernized grocery stores. Now that I knew I liked the Indomie Instant Noodles, I brought a whole bunch to eat while I'm here and to bring back home. I got some Nigerian candies and a couple of Nigerian made bags to bring back to Chicago. Plus, I found oatmeal and Nutella which I had been eating almost daily in Chicago before leaving - it's like I'm at home again! I also brought a can of Progressive soup and guava juice from Lebanon.I have to tell you, it was so nice to shop somewhere were I recognized some the brands. At the last supermarket we went to, I even saw 5 oyibos (yes, I counted) in the store! I almost thought I was back in the US. The owner of the supermarket was ethnically Indian, raised in England and currently living in Nigeria. At this supermarket, I saw plums, strawberries, frozen corn on the cobb, bell peppers and good ole mushrooms. It struck me how Dr. Sanwo said she had not seen bell peppers or mushrooms before visiting this supermarket in the past as these vegetables are not used in Nigerian cuisine. Since I barely cook in general and couldn't justify paying $5 USD for a pound of mushrooms or $8 USD for two bell peppers (all imported from Holland), I didn't buy the produce but it was just nice to see something familiar. On second thought, I should have brought at least the mushrooms so I could have shown Dr. Sanwo how to cook them and how they tasted since she has never had them before!Later at night, I went out with Tola and her friend who was in between his medical officer year and starting a surgical residency (debating on whether to stay or leave Nigeria) to eat at Soups and Sauces, a restaurant in the Bodija area of Ibadan. It was nice to get out. Dayo called me and was alarmed that I was still outside of UCH. He told me to eat as quickly as possible and to get home before the 10 PM curfew before elections (it was only 7:30 PM); I felt that I was in high school again!I've realized a few things about Nigerian food - it always involves a starch or two such as yam or cassava in different forms (i.e. eba, amala, iyan) and/or rice and/or plantains, a protein (i.e. beef, goat, chicken, fish, I rarely see pork), a soup made some local spices and vegetables which I've realized isn't a soup soup (it's more like masala in Indian food) that you dip the starch into, and a sauce which is like a tomato/red pepper based dressing.Here is a picture of the different soups and sauces.
Here is iyan (pounded yam) and the different proteins. I didn't take a picture of the yellow and white rice.
I got iyan (pounded yam) (I only got 1 portion, Tola got 2 portions and her friend got 3 portions; everyone else finished their iyan except me!), egusi (soup made of grounded plant seeds) with the red sauce and chicken plus a Fanta. Total cost = approx $5.50 USD!
Here's a picture of us before enjoying our food.
Afterwards, we hung out a bit at the guesthouse. I could definitely sense their internal ambivalence and struggle with wanting a better life which was felt to be abroad and whether, should they leave, would they return to Nigeria to help affect change. We talked a bit about the suggestions I had presented earlier in the day and Tola was among the hopeful that small changes could happen perhaps as a result of a foreigner; I had suggested that perhaps the residents could rally together (sort of how residents in my program rallied together when budget cuts and philosophy changes were terrorizing our hospital) for a specific issue and try to affect change within their program. Tola had said that she wanted to feel "empowered" to make change as constantly in their lives, they feel, to date, that they have little power to do so esp with corrupt government and leadership and misspent oil money. I could tell that voting for tomorrow's election for the next president of Nigeria was a big deal and that they hope and pray that their votes will be counted fair and square.I've really enjoyed making new friends in the family medicine department. They are truly generous, thoughtful, intelligent and broad-minded individuals. I feel badly at times because I know the conditions where I live in Chicago are so much better. I have a ton a respect on how they live and succeed in overcoming daily obstacles that border on ridiculousness. Should they be successful in studying and working abroad, I assured them that there is tons of running water and electricity to go around. They already accomplish so much despite these challenges; imagine what they could do if there was water and electricity to go around?
Day 13 was the day we left Igbo Ora and returned to Ibadan. Returning to Ibadan was like paradise and plus, Dr. Fasasi (since he had to drive me) and Dr. Sanwo (who is presenting on Friday as well) got to leave early!Dr. Sanwo was particularly attentive to my eating habits as I had mentioned I enjoyed eating fruits but was concerned about eating fresh fruit in Nigeria after reading all the medical travel advice (boil it, peel it or don't eat it at all!). I tried a cashew fruit (that we had picked off of a tree the day before) which tasted sour and a bit bitter so I didn't eat that.
I then tried to eat another mango but this mango had gone a little bad. Ultimately, I ended up eating Indomie Instant Noodles for breakfast!
I have to admit the instant noodles tasted pretty much like some Asian form of instant noodles with a MSG packet to boot. It's advertised in Nigeria as Tasty Nutrition. Good for you. I think I'm going to pick up some the next time we go grocery shopping and if there is interest to try it in Chicago, I'll bring some home too.Before we started our drive back, we went into the downtown of Igbo Ora to pick up some local food that cost about $1 USD. I (of course) wasn't able to partake in this. This was the area surrounding the place we purchased food.
I wish I could have taken a picture of the numerous children, women and men surrounded by goats and chickens. (I was refused again). The residents liked to tease me about the goats because the whole time I was there, I could not get over how they roamed everywhere and anywhere including the clinic rooms and even our kitchen. The day before, Dr. Sanwo even had to yell at a goat attempting to enter our kitchen while we cooked.Our drive back was filled with potholes and we even got pulled over once at a "security checkpoint" that Dr. Fasasi met with exasperation. Still no bribes given. Dr. Sanwo gave me a running commentary of the different types of fruits and spices we saw along the drive. Did you know there was an almond fruit and we basically just eat the seeds in the US? I'll have to try that before leaving.When I returned to Ibadan, I was relieved and extremely happy as the electricity had been restored!!!! YAY!! When we learned that electricity had been restored the night before leaving (we all had been checking in with people at UCH), we all rejoiced with happiness! It was like being back in luxury. I took a nice long shower with a running tap and sat in my room enjoying the air conditioning.... until of course the electricity went for a bit at night. Of course.Igbo Ora was an adventure but I'm glad to be back at UCH even with the unreliability of modern conveniences. If I can make it in rural Nigeria, I'm sure you can too.When I arrived home, everyone that I had become friends with me re-greeted me and welcomed me back either in form of a phone call, text or flash. The oyibo made it out of the bush!
In the morning, I woke up in a sweat. I think I sweated all night. I woke up a couple of times that night thinking that the bed net was smothering me. At least I had the security of not getting mosquito bites and yes, I didn't get any!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.
I left for Igbo Ora a little before 8 AM which is a rural community about 2 hours outside of Ibadan. Nigerians call the rural communities “the bush”. Igbo Ora has the distinction of being the twin capital of the world! Dr. Fasasi who is a senior family resident was on his way to report for duty this week and was kind to give me a ride. We stopped by his home to pick up a plate, fork and knife and I got to meet his two boys who were very wide eye and sweet – they sang a song for me and told me that they had seen an oyibo once before at school. We enjoyed a relatively uneventful car ride over as he encouraged me to take pictures at the small towns that we passed (he said, don’t worry, no one will get mad – he was right!). We listened to Michael Jackson and R Kelly on the way there. The roads were awful with many large gaping potholes due to poor maintenance and lack of repairs. We also passed some security checkpoints where one security guard was blatantly asking Dr. Fasasi for a bribe (Dr. Fasasi didn’t relent and drove off). He said I should take a picture of the security guards – I laughed. I wasn’t going to do that – they carried machine guns!Here is what I saw on our drive there
We got to the rural hospital that is supported by UCH and the state and local government.
This is the clinic.
Yes, there are random goats wandering around (they are like dogs around here except people eat them at some point).This was my quarters for the next two nights – considered one of the best available in the area.
Here’s the living area.
Here’s the shower where you shower with bucket. No water from the tap here… in a very long time.
There is a separate room for the toilet too. No flushing – you need to pour a big bucket of water to flush it. Apparently, this community does not habit using toilets – they void near trees and in the trenches. I am now pretty good at flushing with a bucket and grateful to have a toilet.The gent is only on for 4 hrs a day 7 pm to 11 pm. They rarely have any electricity in general at baseline. Otherwise, we rely on battery power or kerosene to cook. Fans only between 7 pm to 11 pm otherwise, we are all just sweating, seeking shade and enjoying ever slightest breeze (thus sometimes showering multiple times a day). Once the gent turned on, we all promptly started charging our battery operated devices.I stayed with Dr. Sanwo who is also a senior family resident. She was very generous to have me sleep in the bed (she slept on a mattress in the living room) and helped me rig up the bednet. We weren’t sure if mosquitoes would make it into the quarters (thus placing me at risk of malaria as the mosquitoes that transmit malaria bite at night between dusk and dawn) so I had brought a bednet for safety. Dr. Sanwo had mentioned that at the quarters she stayed at for the first 6 wks, she just had a mattress on the floor and roaches would crawl on her at night. Eeek!
Dr. Sanwo is such a kind soul who, to my delight, enjoys cooking! The head of family medicine wanted to make sure that I was well fed (and not with locally made food in the above pictured facilities) and not subsisting on just snacks during my time here. Dr. Sanwo took this to heart and prepared a lovely meal of eba (starchy, thicker than mash potatoes, made out of cassava) and stew with goat, chicken and snails called ila alasepo. It was so good to have a home cooked meal! I even had a mango (after it was washed in drinking water and salt)! She made a point to make me as comfortable as possible (the residents weren’t all that comfortable as well with the facilities and being away from loved ones). I was so thankful.
At night, we all joined together with 4 other residents including Dr. Sanwo and Dr. Fasasi and a training physician doing her year of service in Igo Bora (she was feeling unwell and being treated for malaria) and we ate together. One thing I noticed again was that they all refer to each other by their last names or doctor so and so – they don’t know each other’s first names! Having light and a fan seemed to bring up everyone’s spirits and we enjoyed a vibrant conversation, spending a good deal of time talking about the surgery we had observed (see below).Earlier in the day, I participated in a walk-in clinic staffed by three senior family medicine residents and one medical officer doing her year of service to Nigeria. The consultant physicians that had staffed this hospital had been on strike for over 4 months now. Thus, this clinic wouldn’t have really continued without the support and staffing from the family medicine residents. We saw children and adults and even the elderly – we saw a pt in a 70s. I make mention of this because the life expectancy in Nigeria hovers around 50 years old plus or minus a few years (life expectancy in the US is about 78 years old). I had noticed that they would refer to pts in their 60s as elderly and I just had to share how elderly some of the pts we would take care of on the wards in US. Clinic only lasted a few hours and I of course saw a good deal of presumptive malaria – some confirmed with blood smears but most just a clinical diagnosis. One was even admitted for concern of severe malaria for parenteral antimalarial agents. They treat malaria with artemisinin-combination therapy to combat resistance.What I noticed again was the lack of immediate attending supervision but it was available is some form as they could have called an attending surgeon who runs a surgical ward 10 minutes down the street. This wasn’t pursued as would you want to ask a surgeon a primary care question? (Loaded question yes from an internal medicine resident.) Patients waited patiently and those that would be sent for tests or medications would return in a bit with their results slips or medications to be reviewed with the physician. Exams were limited but mostly would include looking at conjunctiva and checking BP. Noticably, less patients spoke English to a basic proficiency in this community (thus making me reliant on the resident’s translations) and we even saw a patient from Benin republic where I were able to exchange some few phrases in French. The little bit of French that I knew (that Eddy had taught me for our trip to Paris a few years back) certainly brought a smile to both of us. As he left, he said “Merci, au revoir!”Later in the day, we observed rural surgery – an exploratory abdominal surgery (= laparotomy) in a 10 year old girl with abdominal pain. Here is where the surgery took place… the hospital.
Here is a snapshot of the surgery.
Yes, these were the conditions. The surgical equipment was sterilized they told me. The patient was sedated with just ketamine without a protected airway. A local anesthetic was used during the incision. The young girl moaned, a lot. The person assisting with the surgery and the other person assisting with the IVs seemed to have little medical knowledge and experience. The family sat in the operating room. As like the A & E at UCH, no monitors anywhere (UCH only had 1 or 2 functioning monitors in the A & E).Me and three residents all walked in with our street clothes with cell phones. No scrubs. No masks. We didn’t even wash their hands. I had a bottle of water in the operating room. The waste basket was a box that I later discovered was reused. People of whom I was unclear of their role leaned over the surgical field which is suppose to be sterile.The room smelled of bowel contents, there was only a fan for ventilation and I started to feel nauseous and weak in my knees. I had to leave.I didn’t see the remainder of the surgery but the young patient made it though as I saw the next day. She had typhoid intestinal perforation. To be honest, this was one of the most uncomfortable, frankly horrifying experiences I’ve seen as a US trained physician. I could clearly tell that the surgeon was well trained and qualified (he had operated in the UK and Saudi Arabia) but the degree of sterility as well as professionalism was well below what I have become accustomed to in medical practice. A number of unnecessary unclean individuals were in the operating theatre (= operating room) leaning over the surgical field. The patient was poorly draped. The family saw their daughter’s intestines. The abdomen remained open longer for the surgeon to “teach” and show us and other non medical staff this young patient’s organs. The surgeon even said that if he did this in America, he would be arrested. That’s for damn sure. In fact, he told me to take pictures to show everyone in America. Operating in a rural, resource limited environment certainly will have its drawbacks and limitations but I feel like in part, the conditions could have been improved. The family could sit outside. We could wear masks and limit the number of non-scrubbed and nonessential individuals in the operating room. In part, the surgeon is able to conduct things in such way as the community does not know of any other way. To give the surgeon credit, his surgery was likely life saving and prevented a catastrophe but it certainly could have been done with better even despite economic constraints.My first day in Igbo Ora left me to see and reflect on the intense poverty. A man sitting next to me outside the hospital while I waited for the others to be dismissed asked me if I could take him with me when I went home. The day before, the guard sitting in front of the guest house asked me what I what food I was going to give to him. As I sat outside the hospital, waiting, I sat on a bench with other Yoruba women and a child that couldn’t have been older than about 1-1.5 years old. Her mother was in the operating room with her sister who was the patient on the table. She had on a diaper and underwear but was otherwise naked and without footwear. It was evident that she was learning how to walk as she could prop herself up onto her feet and then fall back on her bottom. She crawled throughout the dirt, staring at me with her big eyes. She reached for my feet a few times only to be redirected by the aunties that sat around. She put quite a bunch of dirt in her mouth a few times. We tried to give her a snack (looked like a Cheetos) but she seemed to prefer the rocks. The Yoruba woman started to sing a rhythmic song and we started to clap; the toddler started to imitate us and clap her hands. Her smile was darling. I wish I could have taken a picture. (I asked but wasn’t given permission).My first day in Igbo Ora was a bit frustrating as it was intensely hot and there was no electricity anywhere and we weren’t going to get any relief until the gent was on from 7 to 11. I was sweating through all layers of my clothing and the coolest place was in the car when the AC was on. Plus, given how I am such a clean freak, the accommodations, despite them being the most comfortable available, were simply put, dirty. But what made this day so much better was the company and generosity of the family medicine residents. So many thanks to them, esp Dr. Sanwo.
