This Saturday, I have to admit, I was pretty lazy. I didn't do any of my dictations (which is on my agenda for tomorrow) and I only managed to handwash 4 pairs of socks. I think I probably spent more time thinking about how I was going to try to get by with the clothing I had brought with me than actually washing the 4 pairs of socks. Yes, I was incredibly unproductive.I wasn't going to blog tonight but since I have the gent (= generator) on and am among the privileged few that can enjoy both light, the internet and air conditioning right now, I really have no excuse (except perhaps laziness).Today, everyone was under curfew and was only suppose to leave their homes to validate their voting starting at 8 AM and then to return to vote at 12 PM. Unrestricted movement started at 4 PM. Since there isn't a TV in the guesthouse, I rely on the internet to get my latest news and of course, headlines pertaining to Nigerian elections would talk about the bombings that had occurred the eve and today while the elections were occurring. Reading the online articles about the elections to Nigeria just brought to light how little I knew about Nigeria (and Africa for that matter) before my stay here and just how fascinating on what and why Nigeria is the way it is.Three of the new friends I made this week visited me today at the guesthouse as they knew that I had no where to go and was living alone in the guesthouse. All three did not vote today but were planning on voting next week for the president. All voiced common themes of hope that the new government would foster effective change. All did not vote today for a variety of reasons including work (there is no absentee voting given the widespread ballot irregularities in the past), feeling unwell and safety (Muhammed's parents were concerned about his safety and didn't want him to travel to the voting poll). Apparently, the presidential and the national assembly elections are not the elections the country is most concerned about regarding violence. It is in fact the governors' election happening on April 23 where most of the concern about violence exists. Election leaders are hoping that once the president is selected, this will help guide voting for the governors of each state. This will be interesting to see how it unfolds.Invariably, my conversations with Nigerians also somehow loops back to this whole electricity thing. Ayo, a family medicine resident who is from Odun State and did some other work before ending up in medicine, had laughed at me earlier this week when I was gleeful when the electricity returned in the hospital while we were seeing patients in clinic. He had mentioned how as a child, he would yell NEPA Oooo! once the electricity had turned back on. (NEPA = National Electric Power Authority, now known as Power Holding Company of Nigeria). He said that my reaction to the return of electricity (and subsequent air conditioning as I was sweating through my layers of clothing including my white coat) reminded him of that. He also mentioned that given the power goes out at least once daily or indefinitely (up to a week or so in some areas), this joy to have the return of electricity soon abated and became a fact of life.For me not to have electricity is an inconvenience (i.e. I can't go online to surf the web) and completely temporary but for many others, it is something they have known all their life. It means studying with a flashlight or candles for those not fortunate enough to have a generator or living with dependence on light from generators that are shut off at midnight (as they are at the medical student dorms) to conserve electricity. Tola, another family medicine resident, described times in her childhood when her family would just turn on the gent for 4 hours a day (7 PM to 11 PM) as that was what they could afford (as the gents require gas or diesel to run) just so they could have some light during the night. This also means that many sleep without air conditioning (if they can afford one) let alone fans during hot and humid Nigerian nights. I read an article online about the current Nigerian president's plan to solve this electricity crisis with the goal to have one continuous day (and then one continuous wk, etc) of electricity by December 2012. I do hope this can be achieved sooner with the leadership being elected this month.In adaptation of the unreliability of electricity, I have learned several things:* When you have power, charge everything that has a battery because you never know when the power will go off or come back. I made this mistake last week and my cell phone went dead and people couldn't get a hold of me and had to send others (or will call others) to come make sure I was okay.* Bring a flashlight (or at least your cell phone) with you when you are roaming the guesthouse just in case the power goes out. I learned today that my Nokia cell phone has a built in flashlight component that is good to help one navigate in the dark and also a great substitute on the wards as a penlight.* Once the electricity turns back on, turn off the gent. This is to conserve the fuel for the gent. If the gent is on when I go to sleep, I have asked the night guard stationed at the guesthouse to turn off the gent and turn back the central power source.I also learned a bit about what Nigerians do when there isn't any running water as I've learned that some people, at baseline, don't have running water consistently. They might have running water from the tap once a week or so. They live on water from jugs that are filled from a reservoir and they pay $50 naira for day workers to fill and deliver these jugs of water. I also learned that when your toilet doesn't flush (because you don't have running water), there is a way to pour a bucket of water into the toilet to simulate a flush and push all the contents of the toilet down the drain. I was pretty impressed by this and will ask them to show me how this is done.After learning all this, essentially, the guesthouse I'm staying at is like a 5 star hotel. I have air conditioning, a substantial generator that can support air conditioning, light, internet and the fridge, and for the most part, running water. The new friends I have made have been so kind to offer to show me where they live so I can get a better sense of how Nigerians live.One common theme I noticed through these different conversations today was the strong faith that they all had, as a Christian or as a Muslim. In Yorubaland (Ibadan is part of Yorubaland where the Yoruba tribe primarily lives), most are either Christian or Muslim. All three of my friends today made reference to how they will pray for Nigeria to be stronger, to soon offer its citizens reliable modern life necessities like electricity and water and lastly, for a robust democracy.My pictures to share today is the flashlight component of my Nokia cell phone (very useful I have to say) and a small banana I enjoyed today (my first fresh fruit in Nigeria!).
I was hoping to write daily posts every night but however... can you guess? There was no electricity again! Our generator ran out of fuel (I think one of the guards turned the generator on earlier in the day and we didn't realize it b/c the generator needs to be turned off once the central electricity is on to conserve fuel but there is no way to know except to look at the generator). So last night, I had running water and was able to bathe with a shower.... to the illumination of a flashlight. Good times!
I was ready to eat some Nigerian food and we ended getting some amala with obe (soup) with efo (vegetables) and chicken. Very traditional West African food. The amala had a nice texture which is kind of pasty/starchy which I enjoyed and I thought the soup was nicely spiced. You are suppose to take a piece of the amala with your hands and dip it in the soup. Dayo ate with hands and I ate with a fork. This was in part because we brought the food to the guesthouse to enjoy and discovered more cockroaches (one of them crawling next to my laptop in the dining room... you better know that I disinfected my laptop!) in the dining room. Bunmi was pretty adept at killing them with her shoe. I of course was useless and squealing and therefore ate food with a fork. This is when we also realized that the generator was out of fuel and we ate using light from the flashlights. 
While we waited for the food to be the ready, Dayo, Bunmi and I talked about life in Nigeria. I expressed my stress and discomfort with the unpredictability of having electricity and running water. We discussed the sad cases of patients who could not receive care because of intense poverty as Bunmi is an ENT ward nurse at University College Hospital (UCH) Ibadan. She talked about how she would use a manual suction in the dark to suction out her patients during power outages. We also discussed how Nigeria was so rich in oil (resulting in much of the fighting and violence again foreigners related to the oil trade in the Niger-Delta region up north) and yet most of its people up to 60-75% live in poverty and where I've seen quoted, on less than $1 USD a day.
Having electricity and running water is something that I've taken for granted every day and if there was no electricity or running water, there was a clear reason and I would wait knowing that something was happening to get it resolved as soon as possible. However, there just seems to be no rhyme or no reason why the electricity goes out or why we don't have any water. If you are living already in poverty and now you need to worry about how to cook food for your family or how to have water to bathe and drink as well that is already a lot of spent energy and thought.
This now brings me to the all important Nigerian elections for state assembly, governor and president that will be happening 3 consecutive Saturdays in April. Each Saturday, starting this coming Saturday, April 9, there will be a curfew that is imposed between 8 am to 4 pm. People are only allowed out of their home to vote during that period and otherwise should be at home. This is because of the election related violence that has been happening, has happened in the past and is anticipated to occur. It seems like the violence is related between members of different parties killing each and assassinating politicians. Being an elected official is quite a coveted job as it pays extremely well including perks valued at up to $1 million a year. Crazy.
In part, because of this, Nigerian government has been viewed to be corrupted, self-oriented and ineffectual in implementing nation wide changes to improve health, clean drinkable water and electricity among other things. In fact, I was told that the Chinese mafia in Nigeria (who are quite the entrepreneurs) run an very lucrative business of importing and selling generators that almost every household has with such spotty electricity. Perhaps the power outages are in part driven by this profit margin?
In any case, these upcoming elections are very important in electing officials that will advocate and work for positive change. The elections were to start this last Saturday but had to be delayed because ballots were not received in time to be distributed throughout Nigeria before the voting was to start. Then, it was suppose to happen on the Monday but ultimately rescheduled to start this Saturday. From all the locals I've spoken too about this, they hope for a clean and fair election as prior ones had been marred by tainted votes, ballot stuffing and the like. From what I've told, the violence is very directed to specific people and specific locations that does not reach the UCH complex (thank goodness!). You can be sure I'm staying indoors!
This now brings me to discussing being an oyibo. Literally, in Yoruba, oyibo means white man but over the years has evolved to mean foriegner with any skin color other than black. Of course, I find lots of humor in this because well I have never considered myself white! Growing up, I was always 1 of a handful of minorities in the schools I attended in the suburbs of Chicago. In fact, I knew I wasn't white esp when my white classmates and strangers would make a point to say things about my squinty, slanty eyes. Thus, to be considered white and what that means historically in Africa and the US, is kind of amusing. Everywhere I go, everyone looks at me as it appears I'm the only oyibo that is around the hospital complex. Children look at me with wonder as previously the only oyibos they have seen might be on TV. Men and women squeal "oyibo!" when they see me. I've been told to take this as a term of endearment. Quite frankly, it just makes me feel much more self conscious. Where I work in Chicago, most of my patients are African American and while I know that I'm Asian and they are African American, it's not something I think about. Here, being pointed out, albeit in mostly a friendly manner, draws some unwanted attention. I suppose I'll get use to it.
Here's Dayo and Bunmi
I suppose relatively speaking... I look white....
Saturday was my first day in the hospital. I rotated in the Accident and Emergency room with Dr. Amby who is the head and consultant (= attending) in the A & E. Dr. Amby is also an anesthetist (anesthesiologist) that happens to practice Emergency Medicine as there are no dedicated trained physicians for EM. I participate in morning rounds with the Neurosurgery team who were seeing their 10+ pts in the A & E with head trauma secondary to motor vehicle accidents, falls, pedestrians getting hit by cars/motorbikes, etc.
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.
