By Haruna Solomon Binkam
UPDATE I – PATIENT’S FOLDER
Emergency Ward, May 2023
The girl on the hospital couch is unconscious. Her husband and the health worker who brought her from the referral hospital stand by the lobby’s door. Modupe, Gbenga, and I make up the obstetrics and gynecology team on call.
“She had uterine rupture and a burst bladder,” the health worker says, like something rehearsed. He isn’t a doctor or nurse. Why he was sent by the referral hospital is puzzling. The girl’s husband looks at us in the dim space, expecting magic. The Emergency is unlit, except for the flashlight from our phones. Modupe examines the girl’s abdomen, I check her vital signs, Gbenga seeks more context on the referral letter.
Her vital signs are unstable—her breathing is rapid, her pulse is weak.
“Bladder injury and uterine rupture, how?” Modupe asks the health worker. She sounds like she is interrogating him. He stutters.
The letter of referral is vague as to what exactly happened. The uterus and bladder are not self-expanding organs that can auto-inflate. Something must have been done to this girl that looks about 15 years old. And it is apparent that whoever did it was inexperienced or a quack, which explains why she was brought here.
—Was she pregnant?
—How many weeks?
—Labour?
—How long?
—Theatre? Operation?
—Caesarean Section?
After responses to these questions, we figure that she was having a difficult labour that led to a Caesarian Section. The surgeon had injured her bladder. Blood and urine were freely flowing inside her body, outside their normal channels. Her life was in danger.
“We need to act fast, this is a serious emergency,” Modupe says, looking at Gbenga and me. “We’re taking her in.”
It’s a premature decision. We would need our superiors’ approval before we can proceed to the theatre for any procedure.
Modupe dials our senior resident doctor and informs her about the situation. She sighs. The senior resident says she’ll call our consultant and get back to us in a moment. As usual, the information has been tossed up the chain.
Normally, we should begin documenting this patient’s history and offer some interventions to prevent the girl from deteriorating. But we don’t do anything, we can’t do anything. Not a single blood sample is taken. No drip is fixed, no oxygen is provided to support her. Nothing. Not because we don’t want to but we have instructions regarding the admission of critical patients. The hospital is dysfunctional at the moment and unable to offer optimal services.
At the moment? The dysfunction at the University of Ilorin Teaching Hospital was there when I resumed my housemanship on 6 June 2022. It has only worsened.
The girl in the lobby is slipping off the couch. I quickly re-position her. Our senior resident’s call comes in. We are told we can’t admit the girl. There’s no light in the hospital, especially in the laboratory and theatre. We can’t work her up for emergency surgery that night. Her husband needs to hurry and take her to another hospital. This news wreaks him. But, for us, it is not the first time unavailability of power would sabotage an emergency case.
The look of disbelief and fright in the husband’s eyes stabs something in me. This is the largest hospital in Kwara’s capital city, a supposedly standard University Teaching Hospital. People come from far-out towns and neighbouring states, they sleep in the courtyard waiting their chance. If his wife can’t be saved here, where else would she find affordable treatment? He stares at me like I am a villain denying his wife treatment. His lips quiver.
“Please, even if it’s just to admit her for the night,” he pleads.
We dare not. Admitting her without intervention will aid her death. We tell him the quicker he leaves for another hospital, the better his wife’s chances. But I understand his disappointment. A few weeks before, I was on the hospital couch, and the fact that I was a doctor working in the hospital didn’t make it any easier.
Acute Appendicitis. That was the diagnosis. I had developed a severe abdominal pain. Weakness, fever, diarrhoea, and headache followed. Before my admission in the emergency ward, I had been diagnosed in the General Outpatient Department with malaria. The required antimalarial meds, one of the commonest groups of drugs in Nigeria, was unavailable in the entire hospital. It had to be purchased at a drugstore outside the hospital.
At the time of my admission, I was dehydrated and needed an intravenous drip, which was unavailable in the hospital. Where in God’s dysfunctional hospital had I found myself working? A renowned hospital had so fallen out of standard that it was impossible to believe nobody had shut it down.
“Is that not Doctor Haruna?” the nurse in charge of emergencies asked, walking closer to observe me.
She quickly dashed to her office where she had a reserve of intravenous medications. This was two hours or more after I had been admitted. Thankfully, a senior doctor came and the diagnosis changed to severe food poisoning. The source? Unhygienic food provided to doctors on call.
It was easy to know the source because it was common knowledge that doctors’ welfare was of little interest to the hospital’s management. At some point, the food was served in torn styrofoam packs with no spoons. Are we supposed to use our hands to eat? Hands used for rectal examinations, pus draining, skin disease examinations, and other unclean procedures.
A subsequent dose of medications wasn’t guaranteed. Mosquitoes feasted on my blood. I felt sicker. My only relief was that the final diagnosis was not acute appendicitis, which was a surgical emergency. We once had a patient who was admitted for acute appendicitis, a condition that demands urgent surgery but the patient didn’t get surgery on the day, the next day, or even two days after admission. Complications, like peritonitis, set in.
But there was only one functional theatre room at the University of Ilorin Teaching Hospital; a small generator was assigned specifically to it. The situation led to surgical teams almost fighting each other just to take patients in for surgery.
The ruptured appendicitis patient stayed at the hospital for about four days. We had expected his caregivers to demand that we discharge him so they’ll seek care elsewhere. But his people didn’t make that request. In a bid to cover the dysfunctionality of the hospital, referring patients to smaller ones for basic cases was frowned upon by the hospital’s management. So, time passed slowly for this man without definitive treatment.
Fortunately, days after his admission, we were able to use the lone theatre room and its generator for his surgery.
In my case, the sicker I felt on the couch, the more determined I was to avoid getting admitted. At some point, I heard a thud rise over the groans, wheezing, and cries of patients in the ward. Someone had passed out. It was a doctor. He was on call and had been denied rest and food. More than a handful of my colleagues had collapsed over a stretch of four months.
I saw that the doctor who had fainted declined admission. He left—and that gave me the confidence I needed. Like an aquarium without water, the laboratory in the hospital couldn’t get my PCV or full blood tests done. These are basic investigations.
After visiting a private laboratory, I treated myself outside the hospital I was working for.
UPDATE II – PATIENT’S FOLDER
Operating Theatre, April 2023
The theatre is an inferno, the AC is off, and the available power from a small generator can only power monitors.
“Dr. Haruna, I’m literally burning. I’m sure if I check my temperature it would be like 39 degrees,” Abiola says.
I lift my eyes from the open womb of the woman who had just delivered a baby. The headlamp Abiola is wearing to illuminate the new mother’s abdomen and uterus is a little askew. His surgical gown is wet at the neck and chest. Mine is just as wet. It is so hot that our sweat has soaked through our scrubs, our aprons, and has reached our gowns.
“É pelé, Dr. Abiola. Well done, Dr. Haruna,” Sule, the anaesthetist, says. He begins to hand-fan us.
It is time to suture the patient’s womb close but we can barely breathe because of poor ventilation. The theatre is designed to be as closed as possible: Nothing and no one should enter the operating room except for the operation team, the patient, and the surgical items needed. There are no windows, only the entrance/exit door. But with the suffocating heat in the theatre, it is a matter of time before Abiola, the surgeon, or I, the assistant—or both of us—collapse, leaving a bleeding patient on the operation table.
“Let’s open the door, please,” Abiola says.
The door is flung wide open, which is bad practice, but we need to survive.
Weeks later, we have three surgeries lined up and wait for the theatre to be illuminated.
“No light yet o. The generator that was used yesterday was the small one and it has spoilt,” the theatre nurse informs me when I complain about the delay.
Eventually, the small generator is fixed and we rush into the theatre. As usual, the AC is off and the overhead surgical light isn’t bright enough for an operation to be done. The surgeon wears a headlamp to illuminate his surgical field.
Soon, I am asked to bring two standing fans into the theatre. Abiola and I, junior doctors, had flung open the doors when we were suffocating. Now our consultants are bringing foreign objects inside—an utter neglect of standard protocols, just to mitigate the patient’s suffering. The situation is not ideal for surgery but the surgeons proceed out of pity.
Perhaps because these are private actions, none of these acts of mercy saved doctors from the anger of the public. Doctors have been beaten by patients’ relatives for the failures of the management and the government. During my time at the University of Ilorin Teaching Hospital, doctors were physically assaulted in the Medical Emergency in December 2022 and again in the Paediatrics department in March the following year.
At one point, doctors embarked on a 5-day strike against such attacks in the hospital. We couldn’t risk our lives for patients and still be attacked by their caregivers. To take another example, a friend of mine taking a blood sample in the dark had been pricked by a needle. He was attending to a known Hepatitis B patient.
We reached out to the hospital management for assistance in procuring the immunoglobulin he needed to take within 24 hours but administrative protocol made it impossible. In the end, other doctors had to contribute money for the purchase.
UPDATE III – PATIENT’S FOLDER
Labour Ward, April 2023
A man plunges into the Labour Ward screaming, “Where’s doctor so-so-so, where’s he? How can you keep somebody who was supposed to have surgery since yesterday and hasn’t had it till now?”
The man has come with fury but can’t find his target. The patient he is talking about is his wife; our consultant had planned to perform the surgery but she had been booked for surgery for months before now. She is pregnant and has had two previous abdominal surgeries. She is already 9 months into the pregnancy and is HIV positive. She could go into labour any moment and the outcome for her and the baby could be fatal. But she meets this disappointment after months of preparation because of “logistics”. There’s no light.
The woman is discharged and asked to go to Emergency if she falls into labour—or to return to the hospital the following week for her surgery to be rescheduled. It is absurd. Why risk a stable case becoming an emergency? Her husband is powerless. He knows that even if they returned as an emergency case, the theatre situation is likely to be the same. Or they could even be denied admission at the Emergency because the hospital is in utter darkness and high risk cases are not admitted.
He is, however, in luck because our consultant “lobbied” for a space in the theatre the following week. It was on a day our team wasn’t supposed to perform surgeries.
UPDATE IV – PATIENT’S FOLDER
Obstetrics and Gynaecology Staff Meeting, May 2023
The recurring power outages in the hospital have not deterred us from working. It is unsafe practice but what can we do? We do consultations in the dark. We examine in the dark. We take blood samples in the dark. We carry out deliveries of babies in the dark.
Our perseverance and dedication, in spite of the challenges, do the good it can, although in some instances, the outcomes are otherwise. How can a surgery be ongoing and there’d be a power outage?
Once, I was in the theatre corridor when a surgeon walked out of the operating room and threw up his bloodstained, gloved hands in frustration. A blackout had interrupted the surgery.
In one meeting, the HOD of obstetrics and gynaecology, too worried about the rates of pregnancy and childbirth-related deaths, spoke about the mortalities that had occurred the previous month.
“They should not be heard of anywhere. Anywhere!” she said.
Few weeks after that meeting, a pregnant woman was carried on a stretcher, dead with her foetus still in her, dead because of delayed intervention.
I wondered why patients still come to a hospital with a very heavy patient load and limited staff. The dreadfulness of the hospital is such that to achieve a result, one would have to try over and over. To do a blood test, for instance, one might have to take samples for the same test more than once because the blood might be unattended to in the lab because there’s no power or because of a lack of reagents.
The day I did my blood test in the private laboratory outside the hospital, I realised that the bulk of referrals the laboratory received was from the teaching hospital where I worked.
UPDATE V – PERSONAL FOLDER
General Hospital, April 2024
I no longer work at the University of Ilorin Teaching Hospital. Now I work at a private hospital and at a General Hospital in another state. The private hospitals are so expensive. (It is the reason why citizens rely on the federal hospitals.)
But the situation at the General Hospital is worse. I thought Nigeria’s healthcare was rotting, and then I took up a job at a General Hospital, where there are hardly two doctors in each department.
On my first night duty, I was the only doctor in the entire General Hospital attending to patients in the Emergency unit and to those in the wards, male and female (medical and surgical), paediatrics, and maternity. On so many occasions, before my attention is gotten from a case I’m attending to, nurses in the various wards have needed to use their initiative in offering interventions. Very experienced nurses have been helpful; the inexperienced ones have committed grave errors.
During morning duty at the general hospital, I cover the Out Patient Department, where a market square of patients awaits my arrival. The rowdiness, the agitation, the sometimes physical altercations between patients or their caregivers recur because everyone wants to be attended to. The shortage of doctors has led people to seek out quacks, even if for temporary relief. And it hardly ends well.
The pregnant woman with high blood pressure who sought an “auxiliary nurse”? Mother and baby died. The girl who was injected by someone who-is-like-a-nurse? The many drugs she was administered turned her into a vegetable.
“What’s your plan?” a senior consultant asked me one day.
I knew what he was talking about: Doctors are leaving the country. I told him I’d work for a few years here before I know what to do next.
“It’s not worth it,” he said, lamenting the outrageous work load, the difficult working conditions, the meagre salary.
I’m only a few years in but I understand all of it. Soon, the few doctors left in the country might no longer save lives. They’ll just write updates of patients’ deaths. E
*The names of doctors mentioned in this essay have been changed.