Square One

I was invited – quite soon after the then new ER in OAU Teaching Hospital, Ile-Ife was completed about five years ago – by Chibuzo Odigwe to co-write a short article on commission for the studentBMJ about ‘the Nigerian Emergency Department’, which was to go alongside an article on a newly refurbished ER in the US. I remember in our discussions we had to work out a middle ground between ‘telling it like it is’ and being ‘economical with the truth’, and also having quite similar train of thoughts as Damilola Onikepe Owolabi expresses here in this guest blog post on a new ER in the Lagos hospital where she is presently working as pre-registration house officer, written exclusively for Square One:

The New ER in Lagos

Emergency room medicine is the highlight of movie medicine. Glamorous, fast paced, it displays the skills of medicine, its infrastructure and puts its personnel in hero light. Your heart beat doubles in rhythm as you watch every move to save that patient, and as the balance of the scales tilt back towards life, your radial pulse slowly normalizes and with it a compensatory increase in your mind for the value of medicine.

Yes! ER medicine is “it” only it literally doesn’t exist in this country. Internship has been traumatic as I watch countless lives slip out of a world with technology so advanced it lies on the brink of cloning human organs.

For lack of a simple nebulizer a 37 year old asthmatic is no more. And I really have never and probably will not soon see a defibrillator, an integral part of TV ER. Adrenaline to kick a heart back to normal takes at least 15 minutes to procure, and for want of funds to buy a grey cannula, easily correctable shock lingers till the damage cannot be undone.

It hurts so much to know how much you could achieve with simple basic things: drugs, equipment, extra personnel. How does one nurse man a surgery ER with more than 20 patients. And the classic trademark scrubs, forget it! Part of the ghastly experience of watching people barely survive is having relics of bloody stains on any part of you.

The most amazing thing, the federal government-run government hospital where I’m presently interning completed a new ER two months ago. Slowly but gradually it rose and when the commisioning date was set, in typical Nigerian style, work tempo took on a whole new pitch. Painters scrambling about, technicians banging on new split units, it was to be the ultimate A&E. The ceremony ended, the building looked good, painted. The standard marble nameplate was unveiled, and since then all activity has ceased.

Its doors are not yet open and numerous questions abound, like who will staff the new building? There is literally not much more equipment inside to get better work done anyway. This monster shell of a building doesn’t improve our blood bank services. It will not hasten the tardy laboratory technicians to do tests; neither will it fill up syringes with much need resuscitants and antibiotics. It will not defibrillate failing hearts or provide the required number of trained personnel to improve survival. And unfortunately it will not make more affordable to its usual customers what they need to keep on living.

Quite frequently our national policies on diverse things are reviewed. Budgets are re-written for health, and our verbose bureaucrats make numerous promises and pledges. It is quite irksome to see year in and out our problems have not changed: “We need more funding from developed countries, and better means to implement policies.” “We need the statistics of infectious diseases.” We need to train and retrain our personnel please.” These are the lines towed by content of reports from WHO, African Development Bank and other proposals from diverse health organizations.

We have prioritized and re-prioritized amongst re-doing many things, but every time I look around me, I see a system falling to pieces. So as not to be cynical I admit we do indeed have rebel fighters in our midst, people who will improvise, substitute, work until they die, but how much do they really achieve with an almost abject dearth of everything.

My new ER is but a facade of what it should really be because within itself, its architects and managers, it lacks the substance to achieve the reason why it was built which is exactly my problem with reviewing policies in Nigeria. They have become routine, empty words, quixotic promises, sometimes derived from well analyzed data, but unadapted to our local needs.

And even when great minds have worked to customize the solution to our peculiar realities, it seems like what we do is document, give speeches and set up committees. Many defunct committees exist, many noble ideas have never been translated into deeds. We do not need words of change, we need people to get their hands grimy, their thoughts realistic, not to fear the world of politics, and to make decisions and take actions to start off the slow process of change.

I often found myself thinking of my own mortality when I was working as a pre-registration house officer. Too many patients died that shouldn’t have, and one often felt helpless in the face of death with too little to give, either because the patient was too poor to afford the best care, or the right facilities were not in place to offer it.

Whenever those thoughts came intruding, and that was often, I would reprimand myself, and struggle to shift my mind to something else, succeeding only rarely. I’d tell myself, re-echoing Shakespeare, that death, a necessary end, will come when it will come, making the case to myself on behalf of the newly deceased patient, assuaging the emotional burden, and trying to get on with my life.

Then it strikes me again that death is what we are as a profession called upon to avert, to postpone, and to fight, a battle in which we oftentimes fail. At those times, my only succor would be to think the good that could come out of death. The consciousness of the dynamic spectrum that spans life and death renders one more sensitive to life, the same way darkness increases the perception of light and bondage the appreciation of freedom.

This seems to me to be the geography of the common ground that health care professionals share with practitioners of the literary arts. The affirmation of life in spite of besetting evidence otherwise. Not many people experience death in its many varied forms, at such close range, and frequent intervals. Caring for the persistently moribund, tending the dying, and some times having to keep the dying aware of the imminent potentiality of death when it exists could be incredibly daunting.

This is a job that has to be done, in the hope that they might be able to savour all the beauty and the ugliness of their world that is fast rounding off before the final knell sounds and the bell tolls and death finally strikes. These are difficult roles, throwing up turbulent emotions, particularly for those that release themselves to the numinous effect of such experiences. I have found myself weeping only once, and in this case the dying patient had been unconscious for days, so it wasn’t the effect of sharing any words with the patient. It was something else. I could identify with the patient on several levels.

The patient was about my age, sustained a puncture injury while playing football, then tetanus, generalised tetanus, with all the spasms, and respiratory failure that put a lot of stress on our lean resuscitative facilities. He was going to die, and there was little more we could do than to keep struggling to bag him to life, and to keep the spasms at bay. That evening, all the efforts were not going to bring him back. I kept bagging though, even after I knew he was long gone.

His mother would frequently ask me how he was doing, and I would try to convey hope, and act like I was doing something important, something that would keep him alive, something, hopefully. When the time came, I couldn’t admit to myself that he was dead, and I found it even more difficult to tell the mother. He was the hope of the family. He had been sponsored through university with the family’s meagre earnings, mostly from farming and petty trading, and he was in his final year, hoping he’d soon start working and earning and giving back to his family, paying his younger ones’ way through school.

Then an elderly nurse came in to join me. She asked me if it was over, not in words but in gestures. I couldn’t respond. She knew it was. She saw it in my eyes. She saw the tears. She waited awhile. When she saw the futlity of my efforts, she called the time of death, and I agreed, reluctantly. I walked out of the room to let off some more tears and dry my eyes. The nurse had broken the news to the patient’s mother before I was back. I heard the greatest wail of my life. It rang as high as it bore deep into my bones. I was re-induced to tears, and all I could do was go back outside to do it.

I relived part of this story to a friend recently, and she told me of a similar experience. In her own case her patient’s parents saw her weep. She felt it might not be a very good thing to have been seen with the tears and all. She had invested a lot of time and emotion in the patient, and thought that she would never allow herself to be so taken again.

The exchange raised a series of questions though. My friend asked me how I would have felt if I allowed the patient’s mother too see me weep? She wondered if it would have left my patient’s mother more consoled, or made her feel better in some way. Or would it have worsened things? We concluded the conversation, dwelling on how it was such a good idea to conduct a qualitative study, investigating what would be patients’, their parents’ and other proxies’ preferences about seeing their carer cry.