Travellers beware: Deep vein thrombosis

One of the saddest deaths I have witnessed was that of a young man who sustained a severe head injury. We admitted him to hospital and spent a long time and plenty of money looking after him. He survived and actually regained consciousness, He also became so much better that he was able to walk out of hospital. Well, nearly! You see, he died at the hospital gates. He simply collapsed and died from a blood clot that had dislodged from his veins into the heart.

A patient of mine travelled to Dubai for surgery and returned after a successful operation, only to die suddenly a few days later. This was from exactly the same condition, deep vein thrombosis and pulmonary embolism. Another patient suffered a neck injury and was in bed for only a few days before surgery to fix her broken neck. However, in this woman, a few days of being immobile were enough. She nearly died after complaining of severe leg pains, leg swelling and difficulty in breathing.

Deep vein thrombosis

This means blood clot in the veins of the legs. Often due to lack of movement and therefore stagnation of the blood in the veins leading them to clot up and clog the same veins. The legs swell and become very painful. Untreated, the clots extend up into the abdomen and could very easily float up to the heart where they block the major veins carrying blood from the lungs to the heart-the pulmonary veins. This blockage stops a huge amount of blood from returning to the heart and therefore the heart stops working, suddenly leading to immediate or imminent death.

Deep vein thrombosis is common in patients with severe head injuries, cancer, the obese and pregnant women. These people are often immobile and therefore doing little leg exercise. When we exercise the legs, the muscle action pumps the blood in the veins out towards the heart. This effectively prevents blood from stagnating and clotting up in the legs.

Travellers beware

Let’s review a few public cases that have occurred in Nigeria. Unconfirmed reports suggest that Susan Harvey ‘Goldie’ may have died from deep vein thrombosis after returning from a long trip to the USA. The late Professor Olikoye Ransome-Kuti may have also died from deep vein thrombosis. We lost a colossus in that man! Anyway, regardless, I wanted to ask those travelling long distance to places such as the USA, China, India and other faraway places to be aware and ensure they actively protect themselves against this killer.

How to prevent it?

We would probably never know how many people come back from a long trip, slump and die suddenly. Sadly, it seems to affect the affluent especially those who fly first class and business class with very comfortable and relaxed chairs. Many are so lazy they do not get up and walk about because they are in first class! Well, the risk is that you develop blood clots in the legs and increase your risk of sudden death. Some airlines encourage exercise and activity while seated. Take advantage and do not act like you are too big to take a walk. Do walk around on the plane: find someone to talk to and save your own life!

Depending upon the risk for deep vein thrombosis (DVT for short), different preventive measures are used. Walking and calf exercises reduce venous stasis because leg muscle contractions compress the veins and pump blood up towards the heart. In immobile individuals, physical compression methods can improve blood flow.

The use of graduated compression stockings that fit below the knee and give about 15–30 mm Hg of pressure to the ankle has been suggested. Compression stockings have sharply reduced the levels of DVT in airline passengers. I will also recommend the use of aspirin for some days before and certainly weeks after returning to reduce your risk.

Anticoagulation, which increases the risk of bleeding, might be used in high-risk situations. The risk of major bleeding with long-term anticoagulation is about 3% per year but anyone with a high risk of DVT should be considered for treatment. Speak to your doctor.

Proper treatment of DVT

You and your doctor should figure out what may have caused your DVT, so you can take steps to avoid getting more clots. Your doctor may give you a drug to dissolve the clot. These medicines can save your life, but they can also cause bleeding that is hard to stop. You'll have to be in the hospital, and the staff will watch you carefully. One of my patients on such medications developed severe bleeding during her menstrual periods.

If your symptoms aren't life-threatening, or if using a thrombolytic would be too dangerous, your doctor will give you medication that interrupts the clotting process or stops platelets in your blood from sticking together. They don't break down the clot, but they'll keep it from getting bigger while your body works on dissolving it. 

Afterward, you'll probably take a blood thinner pill for at least 3 months. If your doctor prescribes a drug called warfarin (Coumadin), you'll need to get your blood tested often to make sure you have the right amount of the drug in your system. You won't need blood tests if you take a newer blood thinner, such as apixaban (Eliquis), dabigatran (Pradaxa), edoxaban (Savaysa), or rivaroxaban (Xarelto). For some very serious cases, a specialist may need to do surgery to break up and remove the clot. 

Okay, what is the bottom line here? Please be aware and do all you can to help yourself prevent sudden death. This one is not in your hands, but in your legs! Get moving!

What fools are kidnapping doctors?

I was going to write about deep vein thrombosis today. This is blood clot in the veins especially in the leg which can then travel to the lungs and cause sudden death. The article last week touched on this a little bit. I wanted to ask those travelling long distance to places such as the USA, China, India and other faraway places to be aware and ensure they actively protect themselves against this killer.

However, you have to wait till next week for the article. There is something very important to talk about this week. Yes, even more important than blood clots in the legs of travellers!

Strike Action

I heard that doctors in Portharcourt, Rivers State went on strike to protect the continued kidnapping of doctors in the state. This was a very timely and a decisive tactic seeking to draw the attention of the public and the government to this growing menace.

A female medical doctor, Dr. I. B. Apriokor, who works with the Braithwaite Memorial Specialist Hospital, in Port Harcourt, Rivers, was kidnapped by gunmen in the state capital. She was on her way to church.

The only neurologist at the Delta State University Teaching Hospital, Dr. Obiabo Yahaya was also abducted by gunmen who trailed him to his house. He was said to have been kidnapped at about 8:30 pm while trying to enter his compound.

Further, three doctors who came to conduct medical missions were kidnapped in Imo State. It was reported that the three medical doctors had hardly arrived at their operational base at Isu local council area, when they were forcefully stopped by suspected kidnappers and taken away at gunpoint.

What planet are we on?

For God’s sake, how stupid can it get? What is going on in God’s own country? What fools see doctors, humanitarians, as targets for kidnapping? Doctors have been kidnapped in almost all states of the federation and very little has been done by the government. Do we know the numbers? Is someone keeping count? What is going on here? Sorry, but this is actually not normal!

Doctors heal

Doctors do not question who you are: rich, poor, male or female, God fearing or a criminal. We are sworn to treat everyone and give the best care regardless of your ethnic origin or religious affiliation. Doctors swear an oath that affirms that they are a valuable member of the society. That they are blessed with special obligations to all fellow human beings, those of sound mind and body as well as the infirm. Doctors are to preserve life and heal the sick so they can experience the joy of healing those who sought their help. Doctors are asked not to violate the oath so they can be respected while alive and remembered with affection thereafter. Not sent to the thereafter by kidnappers!

Biting the hand that feeds

You cannot then traumatise those same doctors, making them wary of all who come before them and therefore distracted from providing the care required. Doctors are slowly becoming endangered species and difficult to find on the streets of Portharcourt, Owerri and Akure. Perhaps we now need armed rangers and a fenced enclosure to keep the numbers of doctors from dwindling to zero!

The dangers 

Doctors are now difficult to identify as they strip their cars off all stickers saying, ‘DOCTOR’ or even any reference to the Nigeria Medical Association. It seems like this is akin to putting a target on your forehead saying, ‘here, come get me’. Many are now wary of going out late in the evening or once it is dark, for fear of being targeted. So, if you are going to be sick please ensure it is between the hours of 9 am and 6 pm in the evening.

Of course, doctors also have to protect themselves from attacks in the clinic and hospital. So, perhaps it is time to have massive gates and security in the hospital. Before anyone is admitted, they have to show their wounds, pregnancy with the baby’s head about to drop or even evidence of loose stool at the gates. We could have a closed circuit camera at the gates for history taking and even teach the security man how to take blood pressure and temperature. Only those with deranged blood tests to be allowed into the hospital and even then, the doctor will only appear after more verification of a real life situation...like imminent death of the patient!

Action stations please

Why is there no task force of crack detectives and smart policemen doing something about this? The Police in Imo State asked all public spirited individuals, community leaders, and other friends of the police, to come up with useful information that would burst this and other criminal activities in the state. 

While this is important, the Police authorities must actively cultivate and develop an intelligence gathering system and share information with other units throughout the country. Use technology and the teeming population of unemployed youths currently roaming the streets as informants and pay them for services rendered. There should be no hiding place for kidnappers in Nigeria.

Doctors need protection from kidnappers in Nigeria and the government must wake up to its responsibility of protecting all citizens. We cannot start telling you to do your job!

Lonely deaths in Indian hospitals

Recently, we read about the shocking and sudden death of Chinenye. Chinenye apparently succumbed during a simple elective procedure on her leg at Fortis Hospital, India. The mother and a host of sympathisers had besieged the Indian High Commission crying for justice. The mother alleges negligence on behalf of the hospital. A charge the hospital denies. However, ours is not to judge but to state a few facts.

Our shame

Newspapers have been full of stories of Nigerians dying in Indian hospitals and the latest is just one more in a procession of coffins returning following medical tourism abroad. Nigerian Senators, wives of former Nigerian Presidents, former ministers, Nigerian Supreme Court Judges and ordinary Nigerians have all died lonely deaths in a foreign hospital bed. It has got to the stage that bereaved families advertise the death of a loved one in newspapers: proud that the body was flying in, from a hospital abroad.

Yet, this is what we are reduced to: an assembly of shameless people without national pride. Our communal irresponsible behaviour has led to the collapse of our industries, educational and health care systems. We have systematically run down and bastardized our hospitals and fail to support our health care system with responsible people and significant investments. We are where we are because of the insatiable greed of our people and our past leaders. Leaders? What’s that then?

In my opinion, the blame for these lonely deaths lies squarely on our collective tables of misery. Each individual running to other climes does not solve the problem at home!

Back to Chinenye

Dr Felix Ogedegbe, a practising orthopaedic surgeon in Abuja was distraught to learn about the case of Chineye. He has seen countless numbers of patients trooping to India and a few other countries looking for care that is available in their backyard. Dr Ogedegbe runs Cedarcrest Hospitals and the operation that she went to India for could have been performed easily in Abuja. What a shame!!

Sadly, many patients have very little clue as regards what we are capable of and many do not know where serious help and expertise is available locally. In many situations, this is because of the restrictive laws of the medical establishment on advertising. Yet, many foreign hospitals especially the likes of Fortis regularly flout those same laws by advertising and recruiting patients from Nigeria.

In other situations, our medical practitioners willfully refer patients abroad because of financial gains, kickbacks from Indian hospitals and diagnostic centres. This is where the love for each other and the nation fail us! So much for Nigeria being a religious country!

Misinformed

Patients and relatives, seeking to make an informed choice, are inundated with misinformation by Indian hospitals and their local paid collaborators who give absolutely no risk information. Many are full of praises for their treatment results, marketing aggressively in blatant disregard for our local laws. In their books, there are no risks involved in travelling for surgery. Yet, there are real risks. Please listen and learn!

Real risks

We will attempt to enumerate some of the risks you face when you chose to travel so people are better informed of the choices they have to make. 

1. Blood clots. This is called deep vein thrombosis and pulmonary embolism. Once you have recently done a long distance travel by air in a pressurized aircraft and shortly after that, you have a surgical operation, you are at a very high risk of massive blood clots which can detach and block the lungs, leading to sudden death. Chineye may have suffered this complication, sadly.
2. Infection. Everyone’s body is wired to fight germs that are in one’s usual environment. Therefore, when you arrive in a new city, your body defences are attacked by new bugs that you are not ordinarily used to. Your infection risk may be higher than normal.
3. Inadequately trained doctors. This does not mean the doctors are not well trained but they may not be well versed in the types of diseases suffered where you are coming from. A case in point is the kind of treatment Chineye travelled for and complications following sickle cell disease.
4. Inadequate assessment. Most people just go abroad and the doctors there have to figure out what is wrong. In many situations, you end up spending all your money on investigations you did not plan for but are essential for safe surgery and treatment. 
5. Language difficulties. Effective communication is an integral part of proper medical practice and important things can get missing in communication. Even a heavy accent can be a barrier to vital medical communication. At least, here in Nigeria, someone can speak your language and translate if necessary.
6. Poor follow up. This is one major concern with foreign medical treatment. The Japanese medical association was said to have resisted opening up her healthcare to medical tourism for years because it was worried about what it considered unethical practice. The main concern was about treating a patient living thousands of miles away and therefore not being able to follow them up effectively. Many times, people cannot go back for follow up treatment. So if there are unanticipated complications such as with drugs, wounds, implants, many run into difficulties.

The way forward

We need to develop our own local health care system designed to treat everyone equitably. Governments at all level should see their responsibility to develop home grown healthcare as sacrosanct, not optional. Doctors and governments must all work to transfer the skills available in other climes home to treat our people. Anyone choosing to go abroad for surgical treatment must plainly understand the risks of death and severe disability that come with such a venture. Nigerians should be sure before travelling abroad.

People die but let us at least die with dignity and pride as Nigerians, not with ignorance.

Trauma Care in Nigeria

Trauma

Trauma is a strong word, used by doctors to describe a catastrophic event that has had an adverse effect on either the physical, physiological or mental makeup of the human body. In the context of this article, trauma causes physical damage to the body with significant wounds, shock, pain, disability and a high potential for death to occur.  This definition is often associated with trauma medicine practiced in emergency rooms. And traumatology is the branch of surgery dealing with trauma patients and their injuries. Trauma is now recognised as a disease entity; the 5th leading cause of death in all ages and, the leading cause of death in those less than 30 years of age. Therefore, it is decimating the young; society’s potentially most productive people. We need to gear up, ready to confront this endemic menace. Trauma is predictable. It happened yesterday, it is happening today, and it will happen tomorrow. The time to act is now.

The Golden Hour

In emergency medicine, the golden hour is the first 60 minutes after the occurrence of a major multisystem trauma. It is known that the victim’s chances of survival are greatest if he or she receives definitive care within the first hour. The first aid can be provided at the site of the injury by members of the emergency medical services, the police and other trained personnel. The golden hour can be summarized by the 3R rule of Dr. Donald Trunkey, an academic trauma surgeon, “Getting the right patient to the right place at the right time.” For this, you need the emergency medical services.

Emergency Medical Services

All trauma care is emergent but not all emergency care is trauma. Emergency rooms and departments treat ill and injured people, while dedicated hospitals handle the most severe, life-threatening blunt force and penetrating injuries. Emergency medical technicians and specially trained paramedics transport complex injury victims to centres where a sophisticated and highly trained interdisciplinary team of health care professionals provides the services needed to save that person’s life and prevent further disability or physical deterioration. The Federal Road Safety Corps (FRSC), the Civil Defence Corps, the Police and other members of the armed forces have been doing a great job in the absence of real paramedics in Nigeria. They need to be commended and now trained further, so they can respond even better.

Ambulances

The average hospital ambulance in Nigeria is used to carry corpses rather than the sick. They also ferry nurses and doctors and run errands. Most of our ambulances are not equipped to save lives during transportation of the sick or severely injured. Proper ambulances must be equipped to provide intensive care support to the patient. Air ambulances are also only available to some private organisation in Nigeria. We should introduce this service once trauma centres are available.

Trauma Centre

Rescue workers assisting victims after a bomb blast at the UN House in Abuja on August 26.Below some UN Staff grieving over the incident many of them yet to recover from the trauma.Who is providing trauma care for them??

We do not have one designated trauma centre in Nigeria. Our suggestion for Nigeria to mitigate major trauma due to natural or manmade disasters include the setting up of trauma centres.

Trauma centres were outcomes of the emergency medical service system (EMS) built by the United States (US) military in Vietnam in 1970. Trauma centres play a critical role in saving the lives of those seriously injured in everyday accidents and assaults. Further, trauma centres are uniquely positioned to respond to emergencies of mass scale, such as another terrorist attack, when compared to general hospitals based on their resources, constant state of readiness, extra capacity, and strong healthcare facility connections with the local and regional emergency care community.

Trauma centres are specialised medical facilities that are specially equipped and staffed by suitably trained personnel to manage all forms of trauma. They reduce death rate and so many countries are increasing their number of trauma centres. Trauma centres dedicate extensive staff, physician and faculty resources 24/7, sothat seriously injured patients have the best possible chance of survival and least residual disability. They provide support to other health care providers in their region to optimize the initial care of the injured patient prior to transfer. So, there must be prompt action by government and the private sector to set up regional trauma centres to cover the whole country, especially the ‘hot spots’ such as Abuja, Maiduguri, Jos and Bauchi.

Categories of trauma centres : There are different types of trauma centres designated as Levels I, II, III to level V. The different levels indicate the specific needs of the local area and trauma centres can even be in a local government level. A level I category is the highest and most sophisticated trauma centre and can be located to cover a whole geopolitical zone.

Trauma Team

The Federal Minister of Health, Professor Onyebuchi Chukwu is a professor of Orthopedics and a trauma surgeon. He would be one of the key people responsible for managing trauma cases coming to his hospital. Other surgeons such as neurosurgeons, general surgeons, plastic surgeons and other doctors including anaesthetists are part of the trauma team. This team also includes nurses and other paramedical staff to ensure a good outcome for the patient. They should all interact seamlessly and effectively in the hospital setting of a dedicated trauma centre or facility. There are specialised services critical for managing the trauma patient.

National Blood Transfusion Service

This service is in existence in Nigeria but not widely known. The organisation must create wide awareness and links with public and private hospitals so that it can be called upon in a simple and effective way. A concerted effort must be made to attract donors to ensure a robust service delivery. They also need a special reserve of personnel, funds and resources (blood and blood materials) in a major emergency.

Trauma Training and Simulations

There cannot be a trauma centre and excellence in trauma care without the training of staff. These people including the first responders to the scene of a disaster, the emergency services and the trauma centre staff need training appropriate to their levels. The type of training includes the following: first aid, basic life support, advanced trauma life support, definitive surgical trauma course and specialist training for particular conditions such as brain and spine injuries.

Trauma Incident Plan

Every hospital or medical facility treating trauma patients must have a Major Incident or Trauma Incident Plan. This is also called a Disaster Plan. It helps with protocols and guidelines in management so that they are not caught unawares when a sudden disaster occurs and patients start piling up. Major disaster plans such as these are multifaceted but include the following: triage, management and command structure, information systems, list of emergency personnel to call, access to extra equipment and specialist materials, extra funding, etc. The command structure is vital for effective coordination. Also individuals have ‘action cards’ to assist them in carrying out their specific roles during the disaster management. Simulations and dry runs are carried out regularly to test the readiness and understanding of staff of their specific activities and responses during an accident. The Federal Government must create a PRESIDENTIAL TASK FORCE that will design a blue print, break through bureaucratic red tapes and make trauma centres available and operational in the country as a matter of urgency.