House: The One Year We Lived at Work 10.

 

A girl at the emergency

There was a 16 year old girl brought into the Emergency Treatment Room with altered consciousness and running a terrible fever. She was having seizures, talking irrationally and crying, asking her mother to help her. Her mother in turn was crying to us to help her daughter. It was a terrible scene of tears and confusion which was threatening to drag all of us in. She was given diazepam to calm her and work on the seizures. This young girl was terribly restless. Obviously, this was a brain thing.

Was she a previous seizure patient? No. was she involved in an accident? Did she use some illegal drugs? Maybe at a party? But, no, she was a good Christian girl, a fellowship pastor. Okay. Is she hypertensive? Nope. Alright, what’s her retroviral status? That is, does she have HIV? Yes.
Ha. Bingo. NeuroAIDS!!!

Lol, I want to at this point, give a special, special, shout out to my consultant, Dr. Wahab. In my time in neurology, we had about three cases (all female by the way) of HIV positive patients with neurological symptoms and he took those three opportunities to teach us that saying a patient has ‘NeuroAIDS’ is so… useless. Apologies. But, that is the truth.

 

NeuroAIDS

NeuroAIDS is a word that is used to classify a conglomerate of possible complications that can occur in the nervous system due to the virus itself, from infections (viral, bacterial, fungi), from malignancies, from the drugs used in treating, from other affectations and that, my dear reader, is a wide spectrum. It is not a diagnosis. Rather, it is a lot of diagnosis in one word. And God forbid that one patient has all of those things at the same time and in that same one body. Who did he/she offend?

Another thing Dr. Wahab disabused our minds from was quickly labeling any HIV patient with neurological symptoms as a NeuroAIDS (whichever of the many diagnoses you have in mind). What if this person hit her head some days back? What if she is a hypertensive with stroke? What if she has always been a seizure patient? I mean, it could be the HIV, but did you try to exclude other things? It is as if, once a diagnosis of HIV is made, all reasoning is focused on how HIV affects the brain and the patient must not be suffering from any other disease entity.

 

More about the girl (my patient)

Back to our 16 year old patient; she needed an imaging of her brain ASAP. This is also one place where the Nigerian health system troubles me. The hospital’s CT machine had just been repaired recently, probably some days or weeks before this lady came in. Prior to that, patients in need of a Computed Tomography scan had to go to either Ibadan or Lagos or Babcock to get it done. It was just rubbish.

How do you transport a sick patient across our terrible roads, at the risk of different accidents, to still pass through ‘friendly extorting’ policemen who after collecting money from the driver would pray for speedy recovery and then expect the patient’s recovery not to be set back a little?

By the way, a nurse has to accompany the ambulance on these trips, which means, fewer hands left at work. And from what I’ve seen, it seems there is just one functional ambulance. I have heard of times a patient needs to be moved, just within the hospital, and the relatives would be told the only ambulance working has gone to Lagos or something.

Fortunately for us, the CT machine was working when ‘B’ came in (let me call her B so I don’t keep saying 16 year old patient). All of us were bothered about this lady. What could be wrong? She was stabilized and stopped having seizures by the next day which is when she could eventually have the CT done even though we kept insisting she was an emergency (terrible tertiary delays). She was recommenced on her antiretroviral drugs and continued on other medications. Her presenting symptoms looked like she had an abscess in the brain (a collection of pus), likely located in her frontal lobe and extending enough to compress on the sixth nerve because of some of her eye symptoms.

 

Thank you Dr. Wahab

Now, the way my consultant, Dr. Wahab, helped me see the possibilities of her case, I do not think anyone has ever ever explained neurology to me like that before. Calm down, this does not mean I suddenly understand everything about this complex organ called the brain and all its accessories, but, I am no more scared to approach it anymore. Several times, he would ask questions about images we were looking at and while my initial response was always something in the lines of, “I do not know’, “I am not sure’, he was not quick to let me off the hook. He would ask me to look at it again, think about it again, analyze it with the patient’s symptoms or with the scenario he had just painted and be confident about my answer. Funny enough, times without number, I would come forth with the right answer or at least, something more acceptable than what I first said… which was nothing. And those times when I was not able to figure it out, he would explain, starting from the basics and going on to, well, the non-basics. Which is why Dr. Wahab’s rounds were rarely short.

I recall one particular ward round which had been going on for hours. It was already 4 pm, the closing time for those of us not on call. We left the last ward and were already thinking of finding our ways to our homes and just falling on our beds, not only from physical exhaustion but also from the mental overload. Next thing, Conso said,

“Why don’t we all go to my office so I can properly explain something about why the categorization of the brain circulation into posterior circulation and anterior circulation is not the best and …” some other long thing like that.

I will confess to you, I grumbled.

Haba, I am barely still standing on my feet at this point, yet, you want me to WHAT?!?!? Did I tell you I want to be a neurologist? What is all this by fire by force recruitment?

This teaching in his office continued till all of us had dozed at one point or the other, of course except him, and until some individuals actually started sleeping. We were tired and no one was going to give us the next day off because. ‘They were being taught till late’. And at that time, I could not be sure anything I was being taught was actually being learnt… or even heard. Little wonder we all looked blank some weeks after when a question came up during a ward round related to what he taught us that evening. there was nothing left of our attention span. I was awake till the end, minus some instances of dozing, and while I did not catch everything he taught, I was amazed at how passionate one man could be to impart knowledge. But, a big shout out to Dr. Wahab. Really, he never gave up on us, even when he threatened to out of frustration at our inability to grasp the wonders of the nervous system.

 

Alarming death rates

So, about the high rate of mortality in internal medicine, I cannot dispute it. People were and are still dying anyhow. My God!

Just imagine your first day in the posting and you are already filling out death certificates for two patients.

Going through any call in internal medicine without certifying a patient dead is deemed a miracle. You can almost not avoid it… whether from the emergency cases rushed in at the odd hour of the night, or those admitted earlier in the day who were already looking poorly or those who had been on the ward for days or weeks and were sadly not responding well to treatment. The way your phone would ring and you would hear the ward nurse calling you to come ‘satisfy’ the patient. And these deaths were not limited to call hours. Definitely not. I remember how I resumed on Monday to a lot of patients because our unit was the one that admitted over the weekend. I had just been handed the list/consults for the patients and by the time we started the ward rounds, one patient was already dead.

 

 

One time, I was on a ward round with my regs and I was to count the pulse rate of this patient. I initially felt it but it was faint. I lifted my fingers off her wrist for a microsecond to replace them and… I was getting no pulse rate again. 

I thought it was a mind trick. I took a look at her chest and it was not moving. I looked over at my regs, made eye contact with one of them to let him know something was terribly wrong. This woman was gone. Just like that. Of course, I knew it was not… Just like that. She had been on the ward for a while but it still felt surreal. I thought I was the one who did not know the signs of death anymore. Sigh… the signs of death. The things/places we just have to check to be able to declare a person dead. It never gets easy doing this. Many times, I have to still my breathing and heart rate so I do not mistake my physiology for the dead patient.

 

 

Sniper poisoning…

There were many cases of hearts giving out, stroke patients with repeat strokes who unfortunately did not survive this repeat, HIV positive patients and then the ones that worried me… Sniper poisoning cases. There was the young man who had been loaned some huge amount of money which he intended to use in some business he thought was sure to bring in quick profit. Unknown to him, the supposed business partner was also looking for quick cash and his own business venture was to scam gullible people like this patient. Long story short, patient realized he had just lost millions to a scam artist and he decided to down the poison. He did not make it.

Another patient who died of similar causes was a young lady, barely 20 years of age who took the insecticide for reasons best known to her. Nobody could explain her actions, definitely not her boyfriend whose house she was at when she took the poison. Of course, the guy was arrested as a suspect in her death even though he kept claiming innocence. He was the one who found her when he got back from church and brought her to the hospital, was what he kept insisting on.

So, boys and girls, if you have any friend coming over, in a relationship with you or not, be sure of their mental health. If they seem unstable mentally, please do not take your eyes off them at any point. Nothing like, you are going to church and they are staying back. Drag them with you everywhere till they are done staying at your place or whatever. May we not be giving stories that touch.

The cases were coming in too frequently and I was wondering if there was some kind of promo on Sniper we were not aware of. Those incidents made me wonder about how much information was just enough for the public and when information could be qualified as being too much? It seemed the awareness of the insecticide as a suicide agent was rising more than the awareness that its indiscriminate use was fatal.

 

Internal medicine calls

I think I had two or three calls in my three months of internal medicine during which apart from serving drugs and setting intravenous lines, I had nothing else doing other than to sleep. We call those kind of calls, ‘calm calls’. One of such calls was done on the cardiorenal ward during which the total number of patients was five and only three had intravenous drugs to be administered. The other two were definitely NOT ON THE FEMALE MEDICAL WARD.

 

A little note

1. I need PAID writing jobs. If you have any such links, this is my number: 07064900756.
2. Target readership is still 250. Till it is attained…