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The need for improved medical services in Nigeria

By Mr. Debe Nwanze, On Wednesday 21st April, 2022 a female airline passenger on her way to Lagos slumped and died at the NnamdiAzikiwe International…

By Mr. Debe Nwanze,

On Wednesday 21st April, 2022 a female airline passenger on her way to Lagos slumped and died at the NnamdiAzikiwe International Airport, in Abuja (Vanguard, 2022)[1]. It was noted that the passenger had a health challenge prior to this incident, however passengers lamented the delay by the Federal Airports Authority of Nigeria (FAAN) in sending doctors quickly to attend to her when it was most needed. A social media post from an eye-witness account read, “For 13 minutes, no FAAN medical personnel. She died in my hands and a few others. A medical doctor on his way to Kano tried but as he finally said, ‘we lost her’. But she would have been saved had FAAN provided basic insulin…FAAN and the entire airline staff on the ground were stupidly acting as if e no concern them.” Basically, the eye-witness lamented the delays in providing the much needed medical attention. He went further to note that over the public address system, announcements for flights carried on in the usual manner, and no request was made for a health professional. Unfortunately, the woman died in the ordeal.

On the 7th of November, 2018 another passenger with Etihad Airways, Mr. AdemolaAdeleke slumped and died at the Murtala Muhammed International Airport, MMIA, Lagos (Mikairu, 2018)[2]. It was reported that the passenger had suddenly slumped, gasping for breath. An unnamed passenger tried to revive him by administering cardiopulmonary resuscitation (CPR), before the arrival of Port Health officials who applied oxygen on him, but he wasn’t responding to treatment.

The internet is replete with these kind of stories. Only a few month ago, the back page of BusinessDay[3] contained an account by a general surgeon, Dr. Damian C. Onyeaguocha who works with the Federal Medical Center (FMC), Owerri and suffered a heart attack, but survived. The surgeon had suffered a myocardial infarction, a massive heart attack, at his home around 5:00 a.m. after experiencing sudden chest pain, difficulty breathing and inability walking. His family immediately rushed him to FMC Owerri, where it was discovered that he had suffered a heart attack, and he was subsequently transferred to Savealife Hospital in Port-Harcourt, which contained a fully equipped Cath Lab facility for immediate cardiac intervention. At Savealife, a Coronary artery angiography and angioplasty to quickly open and restore blood flow in his heart was conducted. Dr. Damian by his own account is very lucky, many others are not so lucky.

On October 16, 2022 a former public official took to his social media handle to describe a hospital process and cultural failure where his brother-in-law who had visited the hospital with complaints of chest pain earlier was given pain-killers and asked to do an Echo Cardiogram (ECG) test. At the lab he was told the day was far spent and he was asked to return the next day. He told how his brother-in-law suffered what the family suspects to be a cardiac arrest at home, and he was immediately rushed to the hospital by his wife. On getting to the hospital a doctor came out to examine him in the car and pronounced him dead. They gave her a form to fill out and asked her to take the body to the morgue. That was it. He told how his sister remained in the car with the corpse until he got to the hospital, as the hospital did not attempt to remove the body from the vehicle, nor separate the wife from the corpse. This, he considered a failing in process and culture.

A similar scenario had hit closer to home when a friend and colleague had slumped in the shower while we were on an out-of-station trip to Onitsha, Anambra state. He was immediately rushed to the hospital but met with a delayed response from the health workers at the first hospital visited, despite cries for emergency medical attention, not to mention hesitancy from the security guards at the gate (keep in mind this was Onitsha in the evening). They rejected him upon looking at him, without a close examination. It felt as though they would be taking on a liability if they were simply to come close to him or examine him. In retrospect, some doctors regal how there is a tacit culture of ‘owning’ a patient once you have touched or examined them. Such a mindset can serve as a deterrent to accepting critical patients because of the risk of losing them to death.

Phillip (real name withheld) was taken to three other hospitals after this, and suffered a similar fate at each health facility. At each instance a doctor would examine him, while he was still in the commercial tricycle (‘Bless that rider for standing by us through all those visits to the various hospitals)but refused to attend to him subsequently saying there’s nothing that could be done. I joined my colleagues at the third hospital where I was shocked to meet them outside the hospital facility without any medical attention being paid to Phillip who at this time was lying lifeless. My colleague later told how his body twitched when they raced between the second and third hospitals visited. I rushed into the hospital calling for a doctor, and was told by a staff that the doctor was behind a locked door and would not come out despite my calls. The nurse explained that the doctor had examined Phillip before my arrival, and I learnt from my colleagues that they refused to treat him. We were advised by well-wishers, as a small crowd had gathered by this time, to take him to St. Charles Borromeo Hospital which was the closest specialist hospital in the area.

At St. Charles, we arrived calling for emergency care. A doctor met us outside in our tricycle, examined Phillip, and said there is nothing that could be done, as he was dead. We resisted, arguing that his pulse could be weak, that they should hook him up to a machine, and take his vitals. Ascertaining him dead based on feeling his pulse and dilated pupils seemed uncertain in our opinion. They could have missed his pulse. The attending doctor attached an oximeter to Phillip’s finger. We all looked, but our untrained eyes didn’t make sense of the readings that appeared on the screen immediately. The doctor also struggled to explain the displayed reading by attaching it to his finger and indicating the difference. He muttered something which I couldn’t make out, but when he unplugged the oximeter and put it aside, I understood it had malfunctioned or at best wasn’t useful.

We also complained that they had not even attempted cardiopulmonary resuscitation (CPR). We put a call to a doctor who was familiar to us on the phone with the attending doctor at the hospital. Our doctor friend reverted confirming our fears. We asked if we could do the CPR ourselves and he said we could try. We administered CPR until we observed foam gathering in Phillip’s mouth. Only then had it occurred to us that Phillip, who we had worked together with just a few hours ago, was dead. We were now left with the question of what to do with the body, all this while being outside at the entrance to the building, as we were not let in. We kept wondering why we were rejected at all four hospitals to the point of not even being allowed to carry Phillip into the hospital facility. This would have only helped for a proper examination, and comforted us a little that at least he was being properly attended to. Why did the health workers at the first hospital fail to examine Phillip within his ‘golden hour’? They didn’t listen to his breathing, nor get close enough to medically examine him. Several trauma care studies show that trauma patients’ chances of survival increase if they receive medical care within the first one hour of the traumatic incident, the golden hour. Why wasn’t such priority attention given to Phillip? Are hospitals dis-incentivized for the death of patients? If yes, do they stand to be less optimistic about accepting critical-care emergency patients?

Over the years, several hospitals imbibed the practice of turning down victims of emergencies on account of failure to produce a police report or other supporting documents from law enforcement authorities (Ochojila, 2022)[4]. The justification for this is the fear of being harassed by law enforcement agencies for aiding and abetting criminals or offenders. Other reasons include inability of patients to foot their bills, which becomes a liability to the hospital. A recent story which developed on 31st December, 2022 of a medical doctor, Dr. UyiIluobe, who was gunned down at his privately-owned hospital purportedly for the death of a gun-shot wound (GSW) patient who passed away at his hospital[5]. Some reports claimed that the assailants were relatives or affiliates of the patient, although some sources refuted this. Such incidencies that exposes medical workers to such vulnerabilities may to some justify the decision to reject critically-ill patients.

The Compulsory Treatment and Care for Victims of Gunshot Act 2017 caters to the provision of services to emergency patients with penalties to persons who deny care and contravene the law with as much as N100,000 and/or imprisonment for as much as six months or imprisonment of not more than 15 years without an option of a fine. The Act provides that every hospital, whether public or private, shall offer treatment, with or without police clearance, with or without monetary deposit of persons with gunshot wounds (Ochojila, 2022). Phillip had not suffered a gun-shot wound (GSW), but at the very least he deserved care, he deserved to be examined and treated. This type of care should not be reserved for medical professionals alone who are connected.

I felt some empathy for the doctor at St. Charles who attended to us because, although he seemed unemotional while attending to Phillip and our barrage of criticisms, it seemed that he didn’t have the adequate tools he needed to do his job; like that faulty oximeter. He was also the only doctor, or probably the doctor responsible for the Emergency Unit at the time of our visit, and he appeared young, in his late thirties. We witnessed him move from one patient’s bed-side to the other, attending to each of them. We learned this because while we took Phillip’s body to the morgue which was within the premises, one among us fainted, and it was that same doctor who resuscitated her.

An aspect of the Hippocratic oath that medical doctors take requires them, ‘first, to do no harm’. Some would argue that accepting a critical patient that you cannot treat, not because you lack the training and skills to do so, but because you lack the much needed equipment and facilities, that accepting a critical patient under such conditions would be ‘doing harm’ to such a patient because it is inevitable how such a situation will end up.

But Phillip deserved the dignity of care at the very least. If he had been attended to at the first hospitalvisited (as he was rushed immediately after he collapsed), maybe the outcome would have been different. May be we would be singing the same song as Dr. Damian. Do you need to know someone in the hospital system to receive priority medical attention? Isn’t that the point of formulating laws and policies, to provide a level playing ground to cater to everyone?

In early 2022, the Federal Ministry of Health signed a multi-sectoral Memorandum of Understanding (MOU) and launched the Implementation Manual for operationalizing the National Emergency Medical Service and Ambulance System (NEMSAS) (Biriowo, 2022)[6]. The Federal Ministry of Health, had earlier in 2020, set-up a committee to implement the NEMSAS, sequel to approval of the National Council of Health[7]. The aim was for the committee, which comprised members of the Guild of Medical Directors (GMD) and the Association of General and Private Medical Practitioners (AGPMN), to pool both public and private assets in setting up and implementing this all important service. Some persons would argue that the reason why some critical patients are denied care at hospitals is based on ignorance, particularly on the patient and care-giver’s side. If the NEMSAS is fully established and implemented, it would go a long way to reducing the number of rejected critical cases, as there would be a strong policy on ground supporting emergency care for; 1. Road accident victims, 2. Coverage of emergencies within states and the FCT such as workplace related accidents, assault, etc. and 3. Rural ambulance service which in collaboration with the local government, ward, and primary health care centers will meet rural health needs such as access to maternal and child health particularly at odd hours[8].

As beautiful as this sounds on paper, government seems to be dragging its feet to implement as it has taken over two years at the least with series of meetings to take off, while hapless Nigerians continue to lose their lives in circumstances that this very policy is meant to protect against. It is also a call to the IT savvy in our society to develop Applications (Apps) that would help better our lives. For example, if online taxi services like Uber and Taxify (Bolt) can connect passengers who request a ride with available drivers in their area, then why can’t we have Apps that can indicate which hospital in our vicinity has oxygen available, or available beds in the labor and delivery ward, etc.? So it would take a multi-sectoral, all hands on deck approach to help improve on the current situation. I can only plead and hope that in honor of my friend, and all those who have lost their lives on account of the inefficiencies in our system, that effort is expedited to fully implement the NEMSAS, as it may save the life of the next emergency care patient, who could be anyone of us. In addition, the Legal and Justice system should be willing to take up health facilities that default against this policy. When a few of such have been made an example of, it would hopefully improve performance and the culture of the healthcare system on the whole.

A friend and colleague of the deceased and a concerned Nigerian. He writes from Abuja, Nigeria.