Large brain tumour: Meningioma

This pleasant 67 year old man was seen with a large right temporal brain tumour. The tumour had caused weakness of the left side of the body and he had also gradually become unconscious. He had been in another hospital for a month while awaiting transfer to India for treatment. The scan showed severe intracranial pressure and I felt that he would not survive the flight abroad. Clinically, he was neurologically debilitated and moribund. We admitted him and treated for a week on steroid therapy to reduce the intracranial pressure. We subsequently proceeded with surgery.   

The operation: Right temporal craniotomy and COMPLETE excision of the tumour. We also excised the involved dura mater and replaced with artificial dura. A post operation CT brain scan confirms complete excision. He has improved significantly since the operation and was discharged home in good condition.
 

Points to note: He was being managed in a hospital for weeks with a large brain tumour and significant raised intracranial pressure. The hospital had no neurosurgeon available and never bothered to refer him locally. They were keen to plan transfer to India. He would not have survived the flight.

The unknown fact is that many Nigerian patients with tumours and cancer are best treated here especially if the condition is severe. Many die on the way or soon thereafter. Of course, many are packaged and returned back home if no treatment can be offered.

Advice: It is always best to get an opinion from a specialist here first before traveling abroad. Use the ABUJA HEALTH CARE DIRECTORY to find a suitable and qualified specialist.
 

 Can you spot the tumour?

  

It is about half the size of the brain on the right side (on your left). The brain on that side has been compressed and its function impaired by the weight of the tumour.

.

Following the operation, the tumour is gone and the brain is re expanding.

Anterior decompression, fusion and plating in cervical spine injury: Early experience in Abuja, Nigeria

SUBMITTED FOR PUBLICATION
ABSTRACT

Aims and Objectives

We present a review of the results of the current surgical management of acute cervical spine injuries in the Federal Capital Territory, Abuja, Nigeria. This is the first detailed retrospective study on the surgical management of patients with cervical spine injuries from Nigeria.

Method

The medical reports of patients with traumatic cervical spine and spinal cord injuries undergoing surgery from 1st August 2009 till 30th August 2010 were reviewed. Management and early results of outcome were ascertained and detailed consecutively in a prospective Microsoft Office Access® database (Microsoft Group of Companies). Frankel grading was used for pre and immediate post operative evaluation (within 48 hours). The Barthel Index (BI) was used to classify patients as dependent or independent at follow-up.

Results

Twenty consecutive patients presented with acute cervical spine and spinal cord injuries since August 2009. 20 anterior cervical spine decompression and fixation with an iliac graft and an anterior cervical plate (ACDF) were performed in 18 patients. All operations were performed with general anaesthesia using standard techniques but without a microscope or a high speed drill. Of the 18 patients who were operated, 4 patients died within a short period following surgical intervention. 7 patients have made a full recovery and 7 remain fully dependent. Only two of the dependent quadriplegic patients have become reintegrated back into the society.

Conclusion

The management of spinal cord injuries in Abuja is evolving. The operations were performed adequately with much limited complement of equipment. The morbidity and mortality in this series is acceptable. Poor intensive care therapy is a major challenge and improvements in this area of care will likely lead to better patient outcomes.

Keywords

Trauma, Cervical Spine traumatic instability, Surgical fixation, Anterior cervical discectomy, Outcome, Nigeria

Comments:

The points to note is that these emergency operations can be performed in Nigeria to a satisfactory standard and achieving good results. Five of the patients went abroad (UK, SA and Beirut) for rehabilitation and none had to be re-operated by the reviewing neurosurgeons.

Patients with acute cervical spine injuries can be operated as soon as possible to decompress the spinal cord, re align the fractured bones and therefore ease them into rehabilitation early. Information is important and so YOU need to know that we have the facility to offer early intervention for your patients.

The days of bed rest for months while the doctor thinks about what to do are over, at least in Abuja. These operations reported here were performed safely with a minimum complement of equipments. We now of course, have additional equipments and have operated on many more patients who would be reported in the near future. 

Example below showing before and after surgery MRI scan images. The spinal canal has been opened up and the pressure off the spinal cord.

Another case: The chap had a complex fracture at C2/C3 and spinal cord contusion at C5/C6. He was operated at both levels with spinal screw fixation, anteriorly. Post operative image a few days later. On the right, in a wheel chair and active rehabilitation has commenced. He improved to walking and independent function within a few months after discharge to rehab in Gboko, Benue State. He is back to his previous employment.

This is what we are hoping to achieve in a consistent manner. Operating early allows the patient to go for rehab early and prevents bed sores, urinary/ chest infections, deep vein thrombosis, depression and early death.

‘Let’s diagnose accurately and restore confidence of Nigerians in their doctors’

Published.

September 15, 2011 By nigerianhealthjournal 1 Comment

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Austin Obichere,MD

“I was diagnosed with pneumonia and being treated for pneumonia until I got to London where I was told I had cancer of the lungs”. That was the story of Late Chief Gani Fawehinmi and indeed the story of many patients in this part of the world; and Austin Obichere, a Consultant Colorectal Surgeon at the University College London Hospital (UCLH) is concerned. He shared this concern with NIGERIAN HEALTH JOURNAL which led him to set up D&TEC (Diagnostic &Therapeutic Endoscopy Centre, Ikoyi, Lagos) which is the first purpose designed endoscopy suite in Nigeria offering world class endoscopy services. In 2003, Austin was appointed Hon. Senior Lecturer, University College London (UCL) in having completed specialist training in coloproctology at St. Mark Hospital London and Mount Sinai Hospital in Toronto.  He is a Joint Advisory Board (JAG) accredited bowel cancer screening colonoscopist and currently the Director Bowel Cancer Screening Programme at UCLH. He had also held the post of Chairman Colorectal Cancer Tumour Board HCA Hospitals, U.K. His area of specialist interest include laparoscopic colorectal cancer surgery, screening and surgical management of colorectal cancer along with other benign disorders of the gastrointestinal tract and pelvic floor.
What’s the attraction for you in medical diagnostics?
Accurate medical diagnosis with an emphasis on the word ‘accurate’ is critical before any doctor can begin to formulate a plan to successfully treat their patient. A good doctor given the tools at our disposal in modern medical practice should strive to make an accurate diagnosis in more than 90 percent of all cases.
What is wrong with our approach to diagnosing diseases in Nigeria?
It’s basically inability to make accurate diagnosis more frequently than not! I believe competent doctors are in abundance in Nigeria but they carry an “Achilles Heel” in that the necessary infrastructure / support services required are either none existent or at best rudimentary.  By these services one is referring to a triad of; a) Laboratory Services (inclusive of pathology services; b). Imaging services (Ultrasound scan, ct-scan, mri-scan, mammograms etc; c) Endoscopic services (ability to visualise any luminal structure or organs using flexible fibre-optic cameras).With these triad of services provided that they are quality assured, the clinician is empowered to make an accurate diagnosis in more than 90% of cases.
Can there ever be an acceptable justification for the high cost of medical diagnosis especially CD4 Count, Viral load tests, ECG and the likes?
The answer is a categorical NO! Because, you end up denying the vast majority of our population access to basic health services that should not be a privilege but the right of every Nigerian. The simple problem is that the expertise is lacking therefore demand exceeds supply-meaning that the few providers have a monopoly and thereby escalate prices. The fact is that the cost of these equipments/agents used worldwide for medical diagnosis is relatively cheap so what we need is training enough personnel with the expertise to provide these tests effectively and thereby bring down costs. In the case of cancer; for instance, cancer of the bowel, it is known that this is on the increase or has always been there, but we did not have the equipments or expertise required to diagnose it.  Furthermore, endoscopy services are critical to allow the doctor to directly visualise any part of the body not only to see the problem but also to take tissue samples to confirm diagnosis. This is standard practise all over the world but sadly is lacking in Nigeria in terms of availability of these service and paucity of the necessary expertise to deliver this essential arm required for accurate diagnosis.
Chief Gani Fawehinmi was wrongly diagnosed with pneumonia until he got to the UK where he was diagnosed with Cancer. Where does this place our healthcare system?
It places us at the very bottom on the League of Nations providing quality health care for their population. This in my view is the single most degrading aspect of modern day Nigeria given that many of our citizens have no other choice but to join the band-wagon of health migrants with significant contribution to foreign economies like India.
Is there anything synonymous with what you are doing and the clamour for evidenced-based care?
What we are doing is merely trying to address one aspect of the triad (Endoscopy) of services alluded to above. There is no greater evidence than to directly visualise a diseased organ at endoscopy, obtain appropriate tissue samples for confirmatory histology of the disease. In other words we are providing the evidence in the area of diagnostic endoscopy that will arm clinicians to deliver the right treatment based on “accurate diagnosis”. This is one small contribution D&TEC is making towards a quality service and hopefully, the eventual eradication of the TMD (Typhoid, Malaria Doctors) syndrome from our society.
Iam sure some would be interested in what the TMD Syndrome is all about?
The TMD syndrome refers to the fact that these are the only two diagnoses (typhoiod and malaria) that many doctors in Nigeria make when patients come to see them with an illness without thinking of other causes.
So what then is the contribution of improper diagnosis to the growing cases of medical accidents especially in Nigeria?

Gani:a victim of wrong diagnoses;a diagnostics centre has been dedicated in his honour by the Ondo State govt to avert wrong diagnosis ta least in the state.

The contribution is immeasurable! I am too embarrassed to even consider mentioning numerous personal experiences in my practice here in Lagos and the U.K. I have seen many Nigerians in my private practise in Harley Street who presented with bowel symptoms that were investigated in Nigeria and found to be normal. However, on repeating a colonoscopy I was surprised to find the presence of bowel cancer- indicating that the previous examination in Nigeria was either not complete or that the doctor did not have the necessary skills to complete the examination. There are also cases where patients have been told they have cancer only to discover after a repeat colonoscopy that there was no evidence of cancer. Sadly, I am not alone in these experiences and quality of Diagnosis was the subject of ridicule amongst my English colleagues. This was the catalyst that led to my setting up D&TEC.

Is there any close correlation between the problem of fake drugs and the quality of diagnosis?
I think we are dealing with two separate issues here in that fake drugs relate to attempts to treat what is often a flawed diagnosis resulting in “double jeopardy”. Firstly, the diagnosis is wrong more often than not, and secondly, you are receiving fake drugs that can lead to the demise of the patient concerned as we have seen from various cases in Nigeria.
Have you been able to evaluate your organisation’s contribution towards improving the quality of healthcare in Nigeria?
Yes; and one has to be careful not to appear boastful. However, at this point in time we have performed over 250 endoscopic procedures and 11 colon cancers diagnosed from nearly 150 colonoscopies, equating to 7 per cent


incidence within this small group that were screened at D&TEC. Many did not have a diagnosis until they arrived at D&TEC and more than half had advanced cancers that were not surgically treatable because they had either ignored the symptoms for too long or were treated for the wrong condition. On the other hand, 5 patients in the group with cancer have been successfully treated by surgery with excellent prognosis. I believe we have succeeded in not only raising awareness in the need to embark on preventive screening strategies but also demonstrated that D&TEC can provide that very same world class endoscopic service seen abroad right here on our doorstep in Lagos.
Recently, Dr. Okonjo-Iweala was quoted as saying that Nigerians spent about N300 Billion seeking for healthcare overseas. Does this give an indication of a business prospects for anybody like you interested in diagnosis…since it is a search for the best quality of care?
It certainly does! And just imagine how much the Nigerian economy would benefit if the very same amount of money is left within these shores rather than diverted to build up the economy of others. This is where I believe our government has an essential role to play using whatever resources are at its disposal to reverse this trend. They can start by changing the attitude of some state and Federal governments who think it is cool to send employees abroad for medical treatment. Imagine the uproar in the USA if Barack Obama had to travel to India to be treated for an ailment. The message is clear; our government has to assist/partner those who have a genuine desire from their actions to raise the standard of healthcare in Nigeria so that we can reverse health tourism.
And can you articulate the role quality diagnosis can play in turning the tide of medical tourism in our favour?
Accurate high quality diagnosis should be our “holy grail” as it is the single most important step in transforming the health care service in Nigeria from dependency on health tourism to independence. It is the critical building block in ensuring that our country can provide a health service comparable to the best in the world because we are already blessed with Nigerians who have expertise in all aspects of any comprehensive health care system. D&TEC, I would hope, is one’s small contribution towards the Holy Grail that hopefully will trigger many other similar ventures and restore the confidence of Nigerians in their doctors.
Interview  by Kingsley Obom-Egbulem
©NIGERIAN HEALTH JOURNAL

Comments

 

 

Biodun Ogungbo says:

September 16, 2011 at 1:00 pm

This article raises very important issues and I could not help but comment on it.
One of the reasons that Nigerians fail to trust doctors is in the area of misdiagnosis and the reasons are legion. Diagnosing pneumonia for cancer and calling cancer, TB, is all too common. I blame the radiologists. They blame the referring physician! The patient blames the doctor. We all blame each other till the pathologists arrive.
The key focus must be that we practice medicine to the very best of our abilities. Recognition of the limits of those abilities and limits/ extent of training is sometimes the key problem. There are elderly doctors who think they know best and continue to give outdated information and advice. There are young doctors who think they know best and perform beyond their level of experience.
This has been best summarised as below, in the levels of skill and consciousness: Where do you fit in on a daily basis? In respect of particular care, procedures and skill when treating patients.

Level 1: ground level: Unconsciously Unskilled
Level 2: next level up: Consciously Unskilled
Level 3: next level up: Consciously Skilled
Level 4: Highest level: Unconsciously Skilled

The unconsciously unskilled are the total novice and charlatans who do not know that they do not know anything. The unconsciously skilled are the experts who can operate without even thinking about it. It is the highest skill level. This does not necessarily equate to the consultant!!!!!

Recently, I attended a radiology conference and presented patients with CT and MRI scans misdiagnosed by radiologists. Most of the radiologists agree and one hopes that many would refrain from reporting on areas where they have little or limited knowledge. But, they did say that many referral letters fail to provide adequate information. Return them, I say, but its not that simple.

Again, only last week, I also attended a conference of the Ophthalmology Society of Nigeria to talk about patients with visual loss due to brain tumors, who have been misdiagnosed. Many of the patients were treated for refractory errors and given glasses for progressive blindness. They finally had huge brain tumors such as pituitary macroadenoma diagnosed. They should have been offered early neurological evaluations and CT or MRI scans. The optometrists and ophthalmologists were only interested in selling spectacles to theses patients and watch them go blind. The cost, morbidity and mortality related to treating these huge tumors is very high.

Is it the training that is deficient or the level of communication? Lack of communication? Is it mistrust? Is it greed?

But, what about patients who default and go off to traditional healers and faith healers in churches and mosques? What about those who present daily at the chemists and pharmacies asking to be treated by untrained people simply because it is cheaper. The treatment may then complicate the diagnosis and affect recovery.

So many issues and so many reasons.

Steroids have no place in the management of cervical myelopathy

PERSPECTIVE

Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in adults in Western society. Very little has been written about it in Nigeria. This would give the impression that it is rare in Nigeria. Unfortunately, this is not the case and having seen a few patients now in Abuja, we can appreciate some of the real issues.

Patients with cervical spondylotic myelopathy are not being properly diagnosed and managed. It is often thought to be a disease of old age and part of life. Others feel that old age and infirmity precludes management and so patients are not referred to hospital. Families also at times prefer local management with traditional healers.  Finally, patients are often treated only by general practitioners, general medicine physicians and neurologists. We have now seen a few patients who have been treated long term for CSM by neurologists without referral for surgical intervention. Patients having been seen are placed on long term steroid therapy, vitamin C and analgesics and neuropathic pain medicines such as Carbamazepine, Gabapentin and Pregabalin. Our perspective is that such treatment especially for moderate or severe CSM is of little benefit to address the fundamental and underlying problem in CSM. In our opinion, steroid use is not necessary and predisposes patients to diabetes, osteoporosis and avascular necrosis of the head of femur. The other two key problems in the past were poor availability of MRI scans and spine trained neurosurgeons.

 Cervical Spondylotic Myelopathy

Cervical spondylotic myelopathy is a serious consequence of cervical intervertebral disc degeneration and ligamentous hypertrophy. In these patients, the diagnosis should be established on the basis of both neurological examination and Magnetic Resonance Imaging (MRI). Symptoms range from chronic neck pain, headache, radicular pain down the arms or down the spine, to myelopathy leading to weakness, numbness, impaired fine motor coordination, mono/ quadriparesis and/or sphincter dysfunction. MRI findings that should show spinal cord compression and myelomalacia (see figure 1, 2 and 3).

The management of cervical myelopathy is informed by an MRI scan or CT myelography. Even ordinary contrast enhanced CT scan can be of benefit. Plain x-ray is not diagnostic and cannot be used as a standalone investigation. It is however important to show spinal alignment, bone quality and other diagnosis such as cancer or infections, for example, tuberculosis. An MRI scan is the gold standard investigative modality. It shows the cause of the myelopathy whether due to anterior disc prolapse, osterophytes or posteriorly based compression from ligamentous hypertrophy. MRI also shows up evidence of damage to the spinal cord (myelomalacia). In this regard, the presence of myelomalacia (hyper intensity) of the cord is an important radiological sign.

Cervical spondylotic myelopathy is one of the most common disorders treated by spine surgeons who could be orthopaedic or neurosurgical trained experts. Patients can be treated from an anterior or posterior approach. With the pressure from anterior, we adopt an anterior approach on principle. While for patients with the pressure of spinal cord from posterior elements such as ligamentous hypertrophy, the best approach may be from the back. The anterior operation is often an anterior cervical discectomy and fusion. The posterior approach is often a laminectomy or modifications thereof.

Surgical decompression remains the mainstay of management of CSM once myelopathy develops. Both anterior and posterior approaches have fine effect to the treatment of CSM. Patients treated with surgery have better neurological recovery, less axial neck pain, and lower incidences of loss of sagittal plane alignment. But the selection of the patient and a clear definition of the indication for surgery are very important. Assessment of the patient, determination of the surgical approach and a realistic objective is also crucial. It is treatable and the condition is reversible in some cases, if caught before permanent cord damage had occurred.   

Despite continued increases in patient medical co-morbidities, overall complication rates are around 10.3% and mortality rates are less than 1%. Treatment of mild CSM may involve surgical decompression or nonoperative therapy for the first 3 years after diagnosis. More severe CSM should be considered for surgery depending upon the individual case.

 Conclusion

It is not a disease of old age and should not be ignored. It is treatable and the condition may be significantly improved. Please note that MRI scans are now fairly available and should be insisted upon in patients with the symptomatology and signs suggestive of CSM. Likewise, it is imperative that a team based approach to management is instituted for the patient. The team must include a neurosurgeon and a physiotherapist. General practitioners and neurologists who suspect CSM should obtain an MRI scan and identify a local neurosurgeon who should be asked for an opinion on the case. Insist on early consideration for surgical intervention. Patients should then be counselled on the short term expectations and long term outcome. Steroid use is of no real benefit in management of patients with moderate or severe Cervical Spondylotic Myelopathy.

 Watch our new video on cervical spondylotic myelopathy operated at cedarcrest hospital, abuja. We used a cage and an anterior cervical plate. Video by health tv africa.

Cervical Spondylotic Myelopathy in Africa 2.wmv

www.youtube.com

Links to recent publications and advocacy on neurosciences

1. Neurosurgeons hold seminar October 10
(News/Healthy Living)

... Dr Biodun Ogungbo, said the seminar, which has been scheduled to hold in Abuja from October 10 to 15, 2011, would gather neurosurgeons from America, Europe and Africa. He said the seminar has an “ultimate ...

2. Why neck and spinal cord injury patients die in Nigeria
(News/Healthy Living)

... in our hospitals in Nigeria. According to Dr. Biodun Ogungbo, a consultant neurologist with Cedarcrest Hospital, Abuja, at least one person sustains neck and spine cord injury in every road accident. ...

3. Group decries marginalisation of South-West at federal level
(News/National News)

... of the nation is under threat. Speaking through its Coordinator and the former Chairman of Nigeria Union of Journalists (NUJ), Ogun state Council, Comrade Niyi Ogungbola, regretted that the Yoruba ...

4. Hospital to hold lecture on brain injuries management
(News/Healthy Living)

... A statement by the Consultant Neorosurgeon in the hospital, Dr. Biodun Ogungbo, said the hospital would also conduct free CT brain scan during the week. “Our activities will also include talking to children ...

5. Nigeria has high rate of arthritis patients, say surgeons
(News/National News)

... added that, such facilities are available in the Federal Capital Territory (FCT). Earlier, a consultant neurosurgeon at Cedarcrest Hospitals, Abuja, Dr. Biodun Ogungbo, said, there was an urgent need, ...

6. Council chair charges residents on refuse dumping
(Life Style/Mother Earth)

Residents of Mowe and Ibafo in Obafemi/Owode local government area of Ogun state have been urged to desist from indiscriminate dumping of refuse. The Acting Chairman of the council, Mr Morenikeji Ogungbona, ...

7. Enact law on medical tourism, medical practitioners urge FG
(News/Healthy Living)

... specialist in the hospital, Dr Biodun Ogungbo, revealed that some doctors in Nigeria connive with hospitals abroad to refer patients to them in exchange, for a percentage of their treatment funds. “We ...

How To ‘Arrest’ Cardiac Arrest

.“Heart attacks occur when the heart muscle tissue is ... transfer to a hospital as soon as possible. Dr Ogungbo , consultant neurosurgeon and Dr Sunny Ekwunife , consultant family ...

Articles - Isah Ramat - 12/09/2011 - 10:55am - 0 comments - 0 attachments

 

Silent Killer Diseases

A neurosurgeon, Dr Biodun Ogungbo , categorically stated that hypertension or high blood pressure is a ... at Cedarcrest hospital, Abuja , Biodun Ogungbo , causes significant disability and death in many countries and places ...

Articles - Isah Ramat - 06/09/2011 - 11:27am - 0 comments - 0 attachments

 

Who Can Afford A Stroke?

Biodun Ogungbo , disclosed that the incident of stroke causes significant disability ... wondered at the cost implication of treating a stroke, Ogungbo observed that the impact on the local economy and the financial ...

Articles - Isah Ramat - 26/08/2011 - 11:32am - 0 comments - 0 attachments

 

Hypertension, The Silent Killer

A neuro-surgeon , Dr. Biodun Ogungbo , categorically stated that hypertension or high blood pressure is a ... unexpected natural death.” Ekwunife and Ogungbo both shared their views on the different aspects of hypertension, ...

Articles - Austin Atibile - 14/08/2011 - 8:46am - 0 comments - 0 attachments

 

Epilepsy: What You Need To Know

Epilepsy does not respect level of education, social status and class. Dr Biodun Ogungbo , a consultant neurosurgeon at Cedarcrest Hospitals, Abuja and ...

Articles - Isah Ramat - 25/07/2011 - 1:00am - 0 comments - 0 attachments

 

Learning Mode That Sticks To Memory

According to an Abuja-based neurosurgeon, Dr. Biodun Ogungbo, cramming is not the best way to study. “The best way to study is ... over time, because it eventually becomes indelible,” Ogungbo explains. Educationists in Nigeria have also confirmed the study. .... 

Crying out for Nigeria’s ignored trauma patients

Published

September 15, 2011 By nigerianhealthjournal 1 Comment

 

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Like voices crying in the wilderness, three Nigerian surgeons are worried about the country’s growing albeit ignored victims of trauma; a medical condition ranked as the 5th leading cause of death in all ages and the leading cause of death in people under the age of 30. In the face of several bomb explosions and unending cases of violent crimes in Nigeria, BIODUN OGUNGBO, ELIJAH MINER and FELIX OGEDEGBE provide a blueprint for the country as a step to prioritising trauma care and hopefully nip an impending crisis in the bud.

On the 27th of August, a huge bomb ripped through part of the United Nations (UN) building in Abuja causing significant injury and multiple deaths. The UN building is home to more than 400 employees. The total number of injured or dead has not been officially confirmed. In July, at least two people were killed after a powerful blast triggered by a suicide bomber struck the headquarters of the Nigerian Police in Abuja. Many policemen were injured in the stampede that followed the blast. The injured were taken to various hospitals. Apart from these recent events, road traffic accidents cause multiple car pile ups and significant injuries and deaths on our roads. Nigeria is ranked 191 out of 192 countries in the world with un-safe roads and she records 162 deaths per 100,000 population from road traffic accident.
The World Health Organisation (WHO) estimates that over 1.3 million people are killed annually in road accidents while over 50 million people sustain different degrees of injuries from such crashes. Mr. Osita Chidoka, Corps Marshal and Chief Executive of the Federal Road Safety Commission (FRSC), said in Benin recently at the national launch of the United Nations Decade of Action on Road Safety, that “WHO had predicted that if nothing was done by countries to stem the tide, death by Road Traffic Accidents (RTA) would overtake deaths from malaria and tuberculosis”. Moreover, we also have injuries and deaths resulting from ethnic and religious clashes, oil blasts, fires, domestic violence and from buildings collapsing in different parts of the country. Nigeria is under siege from trauma to limbs, head and neck and abdominal injuries.



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.

Rescue workers assisting victims after a bomb blast at the UN House in Abuja on August 26.

Trauma Centre
 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.

Below some UN Staff grieving over the incident many of them yet to recover from the trauma.Who is providing trauma care for them??

Pix:Femi Ipaye,PM News

Trauma Centre
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.

About the authors
Dr. Biodun Ogungbo, is a Consultant Neurosurgeon and a member of Editorial Board, Nigerian Health Journal; Dr. Elijah Miner is a Consultant General Surgeon and Dr. Felix Ogedegbe is a Consultant Orthopedic Surgeon. They are all practicing in Abuja and can be reached through this journal.
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