There have been stories of how the healthcare system
in Nigeria has been so decapitated that the need for
its urgent resuscitation is of immediate
implementation as an emergency.
I have heard of stories of patients going through hell
and being badly managed by healthcare systems and
practitioners alike that I never thought that one day
I will be an indirect victim of the degenerated
healthcare system prevailing in Nigeria.
As usual in the Nigeria society of my time, my
admission to medical school was a joy to the family
and on my graduation, there was a fanfare being the
first physician in my family. I do remember telling my
Dad that the gain to my family of my being a physician
will firstly be the fact that they will always get a
very quick and reliable advice on issues concerning
their health and not necessary financial gains. By
irony of faith, I found myself undergoing extensive
postgraduate training in Surgery in the UK and
Rehabilitation Medicine with rotations through
internal medicine for a year along with medical
subspecialties though equipping me with a deeper
knowledge of medicine in key areas of medical
practice.
Over the last seven years, I have been going to
Nigeria on an average of every three months with focus
on direct patient care, teaching and public forum
discussions. While I could not treat patients, these I
had hope will allow physicians who listen to me to
imbibe some etiquette and ethics in their dealings
with patients. My initial obstacles including
difficulty in getting registered/licensed with the
Medical and Dental Council of Nigeria (MDCN) which was
resolved due to the intervention of a young
administrator in the Council who was magnanimous in
ensuring that my registration went through without too
much hassle which even took a while. Then the
difficulty having a place to treat patients with its
associated rigmarole in finding an hospital to do the
procedures and management along with the slow pace of
things that have been very frustrating to say this
least.
On October 17, 2010, I arrived in Abuja with a
weeklong schedule for me to give lectures in Abuja and
Lagos on both current trends in stroke management and
current trends in interventional pain management. I
was also scheduled to appear on Classic FM program to
give a talk on Stroke prevention and management.
While in Abuja, I had paid a courtesy call on the
young physician administrator to express my sincere
thanks for a good job and efficiency on his part in
ensuring that my license and registration were
approved without the usual hindrance that others have
experienced and to also pay my condolence on the death
of his wife few weeks before then. In the process, I
asked him what happened. The story that came out was
mind-boggling and unexpected. His pregnant wife had
gone into a private hospital with low blood count and
otherwise hale and hearty and within 24 hours of
admission, he was called that the wife had passed
away. Apparently the story was that the wife was given
blood transfusion and immediately the transfusion was
started she experienced shortness of breath and
immediate massive failure of her organs leading to
immediate death. From the story, it is apparent that
she must have been given the wrong blood type. In
blood transfusion process all over the world, certain
steps are taken to ensure that the right blood type is
given to a woman especially one who is pregnant. The
first is to find the blood with the right group and
then to direct cross-match that blood with that of the
patient. Since this is not an emergency, this is done
meticulously and also because of the fact that she is
a pregnant woman, the blood type should also be Rhesus
negative to prevent development of Rhesus antibodies
that could attack the baby/fetus. After all these are
done, the final step before connecting the blood to
the patient is to ensure that the right cross-matched
blood is being given to the right patient after
ensuring that the blood has been appropriately labeled
for the right patient. These are all simple steps that
do not require high technology. From what has
happened, it is obvious that someone cut corners and
did not fully implement the steps leading to the wrong
blood being given to the wrong patient and leading to
an unnecessary death. While expressing my condolence
to this young man on October 18, 2010, I did not know
nor had any premonition (unusual) that another
physician and hospital inefficiency in Lagos will lead
to the death of a very close cousin.
On October 19, I was in Lagos and picked up by my
cousin Deborah and we did the usual which is her
preparing my favorite Amala and then spending time
discussing issues pertaining to events around us and
giving advice. In the process, I asked her about the
status of her treatment for her hyperthyroid goiter
and if she had followed up with her doctors in London,
UK. She then told me that she was following up with a
surgeon in Nigeria with plan to do the surgery a week
or two later. I asked her which hospital and she had
mention Eko Hospital in Lagos. I did not ask questions
about the surgeon mainly because I had no much idea
about physicians generally in Lagos and believed that
my cousin must have made the necessary inquiries. I
felt comfortable with the hospital knowing that there
is a chain of command/hierarchy along with training of
junior doctors that allows a constant presence of
physicians and experienced after-care nurses. I had in
passing asked her why she did not follow up with her
doctor in UK but her answer was that she has been
assured that the doctor is experienced and that she is
actually paying him about N750,000 for the
thyroidectomy. I believed that her answer was to calm
my fear and to assure me that the surgeon has been
checked out and that she was paying premium money for
the surgery(by Nigeria and even UK standard). On
October 20, I gave the classic FM interview in Lagos
and then flew to Abuja immediately and later that day
gave the lectures. I returned to Lagos the following
day and spoke to her briefly and also on October 23
after the lectures in Lagos.
Classical Thyroidectomy surgery by itself is an old
surgical procedure that is apt with my dangers due to
the surrounding structures that are vulnerable to
damage. Historically, the way to avoid damaging those
organs involved carefully looking out for them and
separating them before cutting. The young
trainee-surgeon is always asked to describe the
anatomy of that area and recant all possible
complications before he or she is given the knife at
the beginning of the training to do such surgeries.
The thick tissue surrounding the thyroid gland in that
part of the neck can also be suffocating if blood is
formed(from post-operative bleeding) after surgery. It
is in lieu of this bleeding that thyroid surgery
closure of the skin was done with clips and not suture
to enable anyone one around the patient without
surgical skill to take out the clips and let out the
blood and preventing its collection from suffocating
the patient to death. There is an historical
perspective to this that was taught to all medical
students in Nigeria during my days and this was of a
VIP patient in the 1960s who had the surgery and
developed the bleeding complication and before the
surgeon could drive to the hospital to remove the
stitches, that VIP was dead. A clip removal which
could have been done by anyone could have saved that
patient’s life. The essence of using clips for such
surgery has since become the gold standard of care for
such surgery. The main nerves that supply the vocal
cords and major arteries going to the brain and coming
from the heart are also very near the area of surgery
for thyroidectomy. Damage to the nerve that supplies
the vocal cord could lead to partial paralysis of the
vocal cords that can then lead to hoarse voice and a
full paralysis could lead to the vocal cords closing
and therefore difficulty in breathing in and out since
the vocal cords are at the entrance to the airway into
the lungs. There are newer techniques for modern
thyroid surgery that use modern technologies to
monitor the nerves, blood vessels, etc with very
minimal approach that allows the patient to even be
discharged much early from hospital.
On October 26 flying out of Abuja(a BA flight that
departs circa 8.45 am) and back to the states, I had
called my cousin to let her know that I was leaving
Nigeria and back to the US. She did not pick up her
phone but she later called back and then informed me
that she had the surgery the day before(her voice
sounded a little hoarse but I attributed that to being
early morning and the fact that she just woke up).
This was shocking because I had thought that she was
going to wait and also shocking was the fact that the
surgery was done in a hospital on Olowu Street, Ikeja
and not Eko Hospital as I had thought. Knowing this, I
was happy and congratulated her for a successful
surgery but because my flight was about to depart, I
did not have much time to ask further questions. On
paper, I had a 2-hour transit time in London which
with delay turned to less than an hour and therefore I
did not have time to call her and hoped to call her on
my arrival in Washington DC. On my final arrival, the
shock was a voice message from another cousin in Los
Angeles(the older of the two cousins of same parents)
who left a message sobbing that things went wrong with
Deborah and that I should call her. I had a sudden
fear that made me to turn my phone off and afraid to
listen to the rest of the message. I called my wife
who confirmed my fear that my cousin had died that
evening.
I am yet to get the full story of what could have
occurred as I was told that the surgeon went
incommunicado immediately after the death. But the few
information I gathered was that she complained of
sever onset of pain around her neck and the nurses
took ages to eventually come to her by which time she
became short of breath. All attempts to resuscitate
failed.
There is no doubt that negligence in care is the main
contributory factor to the death a bubbling and
energetic 40 year old who walked into the hospital for
what was supposed to be an easy elective surgery but
ended up dead about 36 hours later. In the legal
field, the prove of Negligence does not always require
all the elements of Duty of care, breach of that duty
of care, causation and injury which are all present in
this instance anyway but also by the principle of Res
ipso Loquitor which basically means that “ The Thing
speaks for itself” and refers to a situation when it
can be assumed that a person’s injury can only be
caused by the negligent action of another party
because the accident was the type that could not have
happened unless someone was negligent.
The issue here is the deplorable state of Nigeria’s
healthcare system where internationally acceptable
standard of care is not followed, where regulation of
the practice of medicine is by itself neglected in a
situation where the physicians themselves are being
allowed to police themselves, where there is no
financial or legal repercussions for such negligent
acts on the part of a physician who has knowingly and
purposely decided to cut corners in order to increase
his profit margin and in the process put the life of a
young woman in fatal jeopardy. I do believe that part
of cutting corners may include going to this cheaper
hospital in Ikeja as against the Eko Hospital and also
not doing all the necessary post-operative care and
managing all expected complications within the realm
of such type of surgery.
The need for the Medical and Dental Council of Nigeria
to regulate the activities and performance of doctors
is hereby demanded. The need to also enforce
continuous medical education for physicians cannot be
over emphasized. The era of a specialist qualification
not expiring and lasting ad infinitum should also be
abandoned because in the UK and the US, specialist
qualifications only last 7-10 years after which one
has to sit for the specialist examinations all over
again. Also most states require evidence of continuous
medical education of at least 50 hours in 2 years to
enable a license to be renewed. As someone one who has
specialist qualification in 6 different areas of
medicine, maintaining these hours of continuous
medication education has been followed to the letter
and sitting for the specialist examination early to
prevent their expiring has also been followed. It is
inevitable that as I get older, I may opt to remain
focused on 1 or 2 of the specialist practice and may
then let the other 4 expire and not practicing such
specialties.
In Nigeria, this is not the case as the older
physicians while going around touting experience have
actually lost currency in ideas and skills that some
of them should be out rightly banned from ever
practicing medicine, definitely not as specialist.
There is also need for the state to look at the
criminality in the actions of doctors who negligently
or recklessly perform surgeries or actions that lead
to the death of their patients and the need for such
physicians to be prosecuted and let them face the
consequences of their actions.
Developed societies have also in the past gone through
what Nigeria is currently going through and made
changes including what I mentioned above and also
allowing more lay persons to form majority in the
medical boards that look into licensing physicians to
practice medicine. Members of the public are allowed
to contact the medical boards and file complaints
against physicians. This allows non-members of the
profession in the board to protect the interest of the
public as against members of the profession in the
board protecting their profession. In most of my round
of lectures in Nigeria, I have always warned from my
experience as a physician and a lawyer that if Nigeria
based physicians do not start taking steps to regulate
themselves and exposing the charlatans among them,
other extraneous sources in the society will be forced
to take steps to regulate the medical profession.
I am not wasting time talking about what government
can do or not do because the current political climate
in Nigeria is messed up, headless and without
direction and asking a government that cannot even
provide basic security for its citizens or portable
water for them to provide more for health will be like
asking God to send manna from heaven. I focused on the
need of the medical profession in Nigeria to buckle-up
and meet a certain acceptable basic standard of care
that does not require any high technology. As a
licensed Nigeria physician, I know this is doable. As
a foreign-based Nigeria, I know that the standard of
care current prevailing in Nigeria is not acceptable
and the reason why I still go there and teach hoping
that someone out there will see the light.
I will definitely miss my cousin who left a 7 year old
daughter behind. I was in shock for the first few
hours and then wept which I had not done for years for
a very promising life that was cut down by the greed
and incompetence of another in a system reminiscent of
the jungle where everyone for himself and God for us
all.
Adieu Deborah as she is buried tomorrow. Adieu to all
those who lives have been cut short due to an
incompetent and bastardized healthcare. God who gives
is also the one that takes as he is the one that knows
best.
Dr.
Dawodu, MD, JD, MBA is a physician and lawyer based
in the USA
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