The President's son and management of severe injury

Prevention
The accident could have been much worse!
Yusuf was wearing full protective gear while riding his power bike. He had on a helmet which protected his head and the riding suit which protected his spine and prevented certain neck and back injuries that may have led to paralysis. The accident was also witnessed and help was immediately available to extricate him from the bush and transport him to the nearest hospital.
That Yusuf had some self-protection was vital to his survival. So, wearing a seat belt in cars and a helmet when out riding can save lives.

Emergency treatment
Maybe there would have been no beds!
The nearest hospital seems to have been NISA Premier Hospital. NISA Premier Hospital is renowned for pediatric and obstetric care and does not have capacity for trauma care. Therefore, early recognition of the dire needs of Yusuf was paramount in making the decision to refer him onward with the support required on the journey. From reports available, he had emergency treatment and early referral to another facility for expert care and attention.
It is a fact that many of our ‘other’ hospitals would have no qualms saying, ‘Go away, we have no beds’ and care less of how you actually, ‘go away’. No ambulance and certainly no assistance in safe transfer, onward to another facility.
Not even a telephone call to warn them of your imminent arrival!

Early resuscitation
The Golden hour rules!
The first hour in emergency care is called the ‘Golden Hour’. This is the most critical period in the management of a trauma patient. Manage this hour well and the patient is likely to survive. The management includes recognition of the immediate life-threatening issues and correct management of those issues. These are the airway, breathing, circulation and disability.
Is the airway clear and the person breathing? Are they bleeding, whether outwards or internally? Are they injured with a broken neck or a broken spine? The care during the Golden Hour therefore saves lives by controlling the airway, breathing for the patient (if necessary) and stop bleeding/ replace blood loss as necessary. Preventing further injuries to the brain and spine is vitally important in the first few hours.
In this regard, Cedarcrest Hospitals provided exemplary care in the management of Yusuf.

Expert Management
Call in the experts to provide definitive care!
Resuscitate, resuscitate and resuscitate. Problems identified in the primary and secondary survey (examination) of the injured person will highlight the experts required to provide definitive care. The anesthetist is vital in controlling the airway and breathing of the patient. They must be on hand immediately if death is to be avoided. In the case of Yusuf, he had also injured his head and broken a leg. So, a neurosurgeon (we have about 80 in Nigeria) and an orthopedic surgeon were required.
This led to early operations to fix the broken bones and an operation on his head!

Intensive care
What happens next is very expensive!
Intensive care is very expensive in Nigeria and only available in a few hospitals. Real intensive care that is, and not just a ramshackle room with an old, used ventilator. In fact, the equipment is actually not as important as the presence of skilled nurses and doctors: manpower! They make the intensive care and without the right people, people die! Yusuf was managed in a real intensive care ward with all the required gadgets and gizmos. He was reviewed on the hour, every hour and by the minute.
Suffice to say that we do not have many intensive care beds in Abuja. However, it is very important to know where the quality and well-staffed units are. It is also important for collaboration and cooperation to exist between hospitals with intensive care units: whether private or public.
The lives of all Nigerians depend on it!

Rehabilitation
Rehab, for short!
Yusuf has now been transferred to a rehabilitation centre outside the shores of Nigeria for continued management. This is really because we do not have a recognizable high-quality rehabilitation centre in Nigeria. Okay, we have the NKST hospital, Nka, Gboko, Benue State where many of my patients have been treated.
However, it is a closely guarded secret!

Back to the beginning
Going back to the future!
It is imperative that we restructure our health care system in Nigeria and spend real money in prevention, effective response, with an ambulance service (with trained paramedics), upgrade of secondary and tertiary centres and the training of truly committed, passionate healthcare practitioners.
Yusuf may have died if he was an ordinary citizen and many do die daily if they were unlucky going to the wrong place! The wrong hospital, the wrong personnel with an ‘I don’t care attitude’, the wrong time (anesthetist doing school run) and the wrong social status (no money available). Therefore, things need to change.

We owe it to all Nigerians to be our brother’s keepers.

PATIENTS BEHAVING BADLY

Bad

An orthopaedic doctor referred a patient to consult with us recently. The patient had significant neck pains and arm pains. He was weak and unable to hold objects, his walking was also unsteady. The MRI showed evidence of pressure on the nerves in his neck, a condition called cervical myelopathy. He needed the services of a neurosurgeon to decompress the spinal cord. So, our consultation is N30, 000. However, he refused to pay because it was a doctor who referred him!

Seriously! How does that compute? Just because you were referred does not mean we should provide a free service. I mean you can be asked to take a flight on ARIK from Lagos to Abuja, but you do not go to the airport and ask to be flown across free of charge! And of course, if you think that N30, 000 is expensive, try N100, 000 for a similar consultation on Harley Street in London. Same neurosurgeon, same Nigerian patients, every time you come to the clinic! Because, of course, someone has to pay for the electricity, the air-conditioning, the reception staff and all else in between!

So bad

A young woman with a brain tumour came for clinic consultation. She required an emergency operation to remove the tumour and protect her from injury. The operation was discussed and she went off to think about it. A month later she called from India to say that she has had three operations! She related her experiences and confirmed that the Indian doctors did exactly all we had promised to do for her here in Nigeria and more besides. Oh really!

So she now feels she could trust us and wondered if we would be so kind to see her on her return from India for follow up care; as she cannot afford to go back and forth to India! Moreover, she had spent much more than the Indian hospital said the operation would cost. Now, I don’t know about you but that left a sour taste in my mouth. Pretty disrespectful to ask a qualified and highly trained neurosurgeon to do your follow up clinic visits for an operation you did not trust him to carry out in the first instance.

The said operation is usually billed cheaply at N5, 000, 000 in Nigeria and as much as N40, 000, 000 in other countries. This is the real cost of brain and spine operations on the open market. For example, a man was billed N40, 000, 000 for a brain operation in the USA. Same operation is being done successfully here in Nigeria for N5, 000, 000.

Another, a patient of mine had successful spine surgery for N2, 500, 000 right at the same time as his brother paid N15, 000, 000 for the same surgery in Dubai. The sad fact of course is that the foreign neurosurgeon earns almost half of the money for doing the operation as we twiddle our thumbs here working for chickenfeed. So, just because we keep the costs to the barest minimum does not mean we are stupid. It does not mean we should be treated as fools.

Pretty bad

A patient with severe back pains and leg pains came to the clinic for surgical intervention. He required an operation to fix the back through removing pressure on his nerves and then insertion of pedicle screws to hold the spine together. The bill for the operation was N1, 500, 000. By the way, the same operation will likely cost N5, 000, 000 in India and up to N20, 000, 000 in America. He agreed to pay and deposited N600, 000 begging that the operation should commence as he was in severe pains.

A retired civil servant, 70 years of age with no current source of income, he said he was friendly with the Governor who had promised to help him. We agreed and operated on him successfully. In fact, he was so happy he spent an extra week in Abuja enjoying the creature comforts of the hospital, till we insisted on his discharge. It is now almost 6 months since discharge without any effort to redeem the balance of the money owed. Apparently, the Governor has not had time to listen to him!

Now, what are we to do with such people who come in distress to a private facility expecting succour and then fail to redeem their pledges once health has been restored? Many doctors continue to help and offer emergency services and in this case assistance to a crippled old man, day in day out, without any appreciation from the same patient. Perhaps we need lawyers, the courts and bailiffs to help chase these debtors all over town!

Conclusion

The private sector in Nigeria is improving at a remarkable rate to deliver quality health care hitherto unavailable in Nigeria. Many hospitals especially in Abuja and Lagos are capable of performing safe brain and spine surgery. Yet, the costs are a small fraction of the market price for the same outcomes. And YES, we are delivering better outcomes today!

The sad fact is that some patients do not value what they have. Some will complain about the environment even though it is better than home! Some will complain about the service though they have not pressurized the government to provide quality services in public hospitals. They then appear in a private facility expecting free or cheap treatment for the same quality of service they might hope to enjoy at huge costs in India or Germany. And after a good outcome and recovery, refuse to pay!

The travesty!

NB: Please feel free to discuss and share your experiences.

How to sleep well?

Sleep comes natural to many and difficult for some others. Most people sleep and wake up without a care in the world. Some people wake up with aches, pains and problems related to sleep. If you have trouble sleeping - or know someone who has – this article may be helpful. It explains some ideas that may be useful.

The unusual

A man came to see me recently complaining of severe back and neck pains when he woke up in the morning. Another woke up and was unable to move due to severe leg pains and weakness. He had to actually crawl out of bed on all fours. These are the extreme situations though and require proper investigations and management.

In the mind

Ordinarily, a disturbed night and difficulty sleeping can be due to a troubled mind. Some people carry the struggles of the day into bed which makes it difficult for them to rest and so they toss and turn all night long. Counting sheep does not help these people as their thoughts are interrupted regularly by their problems. However, a few tricks and decisions can make the difference for you.

Before you sleep

Before you actually decide to go to sleep, you need to clear your mind. The best way to do this is to review your day noting what you achieved and the things that remain undone. Focus on the positives and relegate the negatives to the past. Then, plan your next day, by listing the stuff you need to do and the order of priority. List only three!

Ditch the phone

Reading emails and messages in bed is not really ideal. It perpetuates your wakefulness and keep you worrying about things when you actually want to sleep. You should make it a habit to stop reading and responding to stuff long before you get into bed. Deal with stuff and close the chapter on your day to day activities to free your mind of clutter. No reading SMS messages once you have decided to go to sleep.

Stop eating late

Eating late at night or after 8 pm at the latest is bad for you. It does not allow the body systems to rest as the gut remains active trying to digest the food. Studies tend to show that when food is consumed late at night — anywhere from after dinner to outside a person's typical sleep/wake cycle — the body is more likely to store those calories as fat and gain weight rather than burn it as energy. Well, the body cannot convert it to energy since the body is actually shutting down in sleep mode for the day!

In bed

We think that sleeping on your bed with a small soft pillow under the neck and under the knees offer the best position for your neck and back. It seems to ease off the pressure on the spine and realigns you. Sleeping on the stomach is comfortable for some but is something we frown on. Especially after spine surgery, sleeping on the stomach puts much stress on the spine. Multiple pillows that kink the neck are also not good for you unless you have a heart condition and need to be elevated. Otherwise, try a small soft, flat pillow behind the neck for a restful spine.

How you sleep

Do you sleep curled up? Like a baby? It shows a lack of confidence as you make yourself small and insignificant. It portrays a lack of self-worth and insecurity. Some think it is better to sleep with reckless abandon, filling up the bed in a show of confidence and a sense of being. Take deep breaths and feel happy with yourself as you sleep. Women have also been advised to sleep in pyjamas or completely naked for health reasons!

Insomnia

You don't usually need to think very much about sleep. It's an ordinary part of life, but sometimes you just can't sleep properly (we call it insomnia). It's usually just for a short time, perhaps when you're worried or excited about something. When things settle down, you start to sleep properly again. If you truly can't sleep properly, it can be a real problem and you might need to see a doctor for some assistance with medical treatment.

Wake up

On waking up, stretch out in bed making yourself as tall as possible. This increases your confidence and ensures you fill your mind and spirit with a can-do attitude as you go out to conquer the world. Minimise your trips to the bathroom by planning your activities better. Go to the bathroom once and do all you need to do which saves you time and energy, as you get ready for the day.

This means, use the toilet, brush your teeth, shave, have a bath or shower, etc, etc, in a nice smooth sequence: not going in and out as you remember what next to do. Focus, plan, execute and then carry this efficiency into your day for maximum impact.

Now, please wash your hands!

Bad practices

Way back during my training, we were sent to the Island Maternity hospital in Lagos for a labour ward posting. This was sometime in the late 80’s before we left medical school. I swear we were sewing women up with used needles from a big bowl in the labour ward. The bowl was filled with blood and Dettol antiseptic solution. You need to imagine this and visualise the dirty concoction in which the needles were kept.

Okay, if this was way back then, can you believe it is still happening now? In public and private hospitals! In 2016 and in Abuja, FCT! Let me explain this properly.

Episiotomy

Sometimes when women are delivering babies, there may be a tear of the vagina or sometimes doctors and midwives deliberately cut the wall of the vagina to ease the passage of the head of the baby. A deliberate cut by the doctors is called an episiotomy. So an episiotomy is a surgical incision made in the area between the vagina and anus (perineum). This is done during the last stages of labour and delivery to expand the opening of the vagina to prevent tearing during the delivery of the baby. The area we cut then needs to be sewn up again. Did you get that?

The sewing is done by midwives in some places and by doctors in other places. It is often done by junior doctors in many situations as it is considered beneath the consultant. I was taught how to do it by a midwife and then you are told to get on with it. There are usually a few women waiting for this procedure after the delivery of their baby! It is often done late and done in a hurry to get through the waiting list of screaming women!

Big bad job

Therefore, it is often a job not done properly! It is also one area where hygiene is thrown to the winds. Not done in an aseptic manner means we can cause minor or even serious infections for the mother. It is likely we were ‘inadvertently’ infecting women with hepatitis and HIV that many years ago at the Island Maternity Hospital! If you can see through the mirror, you can therefore imagine that with the mother infected, the baby can get infected through the milk and the father, of course, through sex later on.

Of course, if it not sewn properly and the tissue of the vagina lined up edge to edge, it can lead to a lax vagina or perhaps even a vagina that is too tight causing problems later. Some cuts can be so bad that it leads to a weak anus and inability to control the passage of stool. This can become a serious and permanent problem for the woman.

Poor sterilisation techniques

Another major area of concern is also the actual sterilization of equipment used in our hospitals. Many hospitals do not have a working sterilization unit. In fact, a hospital in Enugu uses a cooking pot and a stove to boil equipments used in theatre. Unbelievable! This is why many patients develop broken, gaping and infected wounds in many of our public hospitals.

Some hospitals and doctors even reuse gloves and other materials especially plastic that costs so little and should be discarded after each patient. Many hospitals and most especially government hospitals reuse items expressly SPECIFIED as single use only. These are cleaned, washed under the tap and dumped into antiseptic solution for use later, on as many patients as they can, before the equipment gives up the ghost.

Don’t reuse needles

Are you using unsterile needles and syringes on your patients? What does a new needle cost that you have to reuse them? This practice must be investigated by the regulatory bodies and stopped. It is likely to be increasing the incidence of HIV and hepatitis in the community apart from the obvious high risk to life and limb for all concerned. All doctors and nurses need to take stock today and review their practices and actively prevent infections.

Blow the whistle

If you are going to a crummy hospital and you close your eyes to the dirty environment, well, it might end up in your wound. If you are not aware, you may end up paying for much more than you bargained for! The fact is that often the environment of the hospital, the level of cleanliness on the wards and its surrounding areas are a very good clue to the level of hygiene in theatre and the care in general.

Nurses, midwives, doctors and even cleaners in hospitals need to review these types of bad practises and blow the whistle on the hospitals. The first thing to do is to point out the issue to your line manager and the hospital management. If they fail to act, then please call attention to the problem in any way you can, till a solution is found.

Hospitals should review their own surgeons for rate of infection, morbidity and mortality. Hospitals should also be rated on the number of hospital acquired infections and wound infections in particular. Bad performing surgeons should be retrained and bad hospitals should be sanctioned.

Now, please wash your hands and do all you can to prevent infections!

NB: Patients must also insist that nurses and doctors wash their hands before touching you. See them do it!