House: The One Year We Lived at Work 11.

 

Unprofessional hoodlums in uniforms

I am not sorry to say but that ward had the worst combination of nurses. They were not ready to do anything but they were ready to do everything to frustrate you. In fact, one of them once told me, “We know what to do if we want to frustrate a houseofficer on call on our ward”. Oh, there is one of them who I personally like and who ensures I do not have issues while on call but you see the others? I do not understand whether they all signed some sort of agreement to just be thorns in the flesh of houseofficers. My God! While some of my colleagues like the tall, dark and tom-boyish, often in earpiece female and the other tall, bespectacled and recently engaged female were able to ‘change it for these nurses’, some of us are just not cut out for such confrontation and because of this, need to deal with them in wisdom, else, not only would they frustrate you, they would ensure you got into trouble with your ogas.

 

Female Medical Ward calls

I remember being woken up in the middle of the night to come re-site an IV line for a patient…which I did, only to be on the ward round the next morning and I was seeing ‘IV line out of vein’ in the patient’s chart normally filled by the nurses. I was amazed.

“Was I sleepwalking when I re-sited this line? Was I dreaming when I flushed it and met no resistance? Or did I site the IV line for the wrong patient?“

Of course, the consultant was furious and was asking for those on call. I quickly explained to him and thankfully, he believed in my person enough for me to explain myself and also demonstrate that the cannula on my patient’s arm was indeed functional. This is just one of the mildest of things that could happen to a houseofficer on call on that ward. I have never caught them red-handed, but I do not put it past them to deliberately remove cannulas just to make the life of the houseofficer on call miserable. For real, people did not look forward to Female Medical Ward calls.

In all thine doings, be at peace with these nurses. They, weirdly enough, have enough power to actually deal with you. Even as a consultant.

I started praying that more of my calls would be on the other wards or at least if they had to be on the female medical ward, let the nurses on duty be reasonable. I am not one to neglect my duties but I know when people are being deliberately difficult. Another reason why being on call on the female medical ward was not palatable was because most of the diabetic patients were on that ward. Again, at this point, I would talk about shifting responsibilities.

 

About managing diabetics…

The random blood sugar of diabetic patients is an important indicator of their improvement and response to whatever anti-diabetic medication they are on at that time. This value is affected by their compliance to medications and diet modifications. Also, there are some phenomenon that occur at night and in the early hours of the day in which they can experience very low blood sugar levels and compensating/rebound high sugar levels. Point is, these things need to be monitored and taken note of in view of possible patterns significant per individual and per subsequent course of action. To the best of my knowledge, each ward is given a glucometer which is a small portable device that is used to measure blood sugar levels with just a drop of blood on the strip and is kept by the nurses.

There are times of the day  when diabetic patients need to have their sugar checked; before they have breakfast, two hours after breakfast, two hours after lunch and two hours after dinner. This means four definite times, when the blood sugar had to be checked, daily!

This is something that the nurses on the ward can conveniently do with the ward glucometer. They are on the ward when these patients wake up and can easily check the blood sugars before they eat. They know when the hospital food arrives for breakfast, lunch and dinner and when these patients eat, so, it is just a matter of noting this and checking the blood sugar two hours after. So, why were they not the ones doing this?

 

Frustrating weekend schedule

Why was the work shifted to the houseofficers with the threat of being punished if the measurements were not taken? Take note that, during weekdays, this kind of work is practically impossible for houseofficers because we are all in different units with different activities and there is no way we can be going to monitor some patient’s eating habit just so we could rush in to get a drop of blood unto the glucometer. And those at the top were aware of this. So, what did they do? They ensured that this particular kind of sugar monitoring was only done during the weekends, yeap!

So, here you are, reporting for a 24hour call that could swing whichever way and having it at the back of your mind that you just had to be there for the post breakfast, lunch and dinner sugar checks for these patients. The nurses were gracious enough to check the pre breakfast sugar levels but you see these other three checks, they were ours to figure out.

There was a time we had close to seven patients on that female medical ward who were diabetic and had to have these four checks in a day. So, every 9/10 a.m., 2/3 p.m., 8/9 p.m., we were to be on the ward to get these sugar levels checked and if there were any abnormalities, viz-a-viz, low or high levels, we had to do something about it. Reminds me of the night I came back for the post dinner check and all six of the diabetic patients were hypoglycemic, they all had low blood sugar…all! Some of them bad enough, with symptoms and needing intravenous glucose correction and some of them with no ready snacks or fruits like garden egg around nor relatives to get for them. Then one of them was being difficult. she was very obese and getting an intravenous access for her was like world war 2. So, even her medications had been changed to oral. So, correcting her sugar level intravenously was going to be an issue and she was still vehemently refusing to eat.

 

I had help!

But we did it. And in the process, I learnt the importance of well informed and capable patients and patient relatives. It was easy to educate some of them on the importance of checking their blood sugar levels with their personal glucometers two hours after their meals and asking them to record the values in their books. There was this patient relative, ‘Gg’, who was very enlightened on the care his mother was receiving. She had just had a below the knee amputation of her left leg. He was enthusiastic about ensuring his mum’s sugar levels were normal and that her mood was light. He was always around, getting medications, cracking jokes and making friends. Soon enough, the patients on the ward started referring to him as ‘our husband’. He was no more valued as just his mother’s son but as the son of the other women on the ward. He started encouraging them on taking their insulin shots, eating as at when due, checking their blood sugar for them or ensuring their relatives did and recording them. So, my job on such calls were smooth.

All I had to do was tell ‘Gg’, “I would be coming back to check these values at so-so time, thank you for your help.’ And he never disappointed.

Of course, he was catching feelings at some point and asking for my phone number but I was quick to point out that he was now the ward husband and I was not a fan of polygamy. Did I also shift my role as ‘food monitor’? Or did I ensure that those patients and their patient relatives knew how to take care of themselves outside the hospital and know when things were not right? Or did I by doing one, achieve the other? While all these were actually fun to me, some things were not.

 

A little about VHFs

Some of these patients had diseases that were not fun. Hepatitis B, HIV…and the suspected case of Viral Hemorrhagic Fever (VHF). By VHFs, we are talking about Yellow Fever, Lassa, Ebola, etc.

It was a cardio-renal ward call. This 15 year old girl had been on the ward for some days and was not getting better. As at when I resumed the call, she was being worked up for dialysis, her kidneys were failing terribly and if something was not done fast, they were going to shut down. She was bleeding into her right eye, bleeding under her skin, alternating between consciousness and otherwise. It was a terrible sight. Her parents had some link with a top consultant in charge, so, everyone was on her matter. They also had money, so, she was not lacking in anything…medications, consumables, procedures, investigations, name it. The working diagnosis at the time was severe sepsis with multiple organ damage syndrome.

All things were put in place and she went for her dialysis session. Of course, she was not looking better when she got back… dialysis is not some sort of magic. I was worried for the girl, and I was not comfortable with her diagnosis because earlier in the day when the consultant came in, he was beginning to query the likelihood of a VHF.

The problem with these VHFs is that, nobody wants to raise a false alarm about a patient. Once you mention VHF, that patient is meant to be isolated and treated with special caution. There would be a lot of barrier nursing, contamination and decontamination, restricted in flow and outflow of people into the patient’s location, quarantine of those who had recently come into contact with the individual and if it is a confirmed case of VHF, it has to be reported to the health ministry.

It is a big deal when you mention VHF. I think we all remember the Ebola episode. Unfortunately, the VHF diagnostic kits we have in most hospitals are limited. They are unable to pick all the possible VHFs. So, even if the screen comes back as negative, it only means negative for the VHFs covered under that kit. We kept watch on her vitals. Took blood samples to recheck her electrolyte, urea and creatinine levels to know if further dialysis would be needed and also to know what her clotting profile was like.

 

She stopped breathing…

It was around 12 am when the nurses called me to come transfuse a patient. Oh… there is this funny thing about how doctors write a transfusion order for a transfusion to be carried out by themselves. (Story for another day). I was still setting up the materials when one of the nurses noticed that the 15 year old had stopped breathing… barely a minute after the nurse had checked her vital signs. “Doctor, I think you need to call your reg and SR. Now.” I put through calls to my reg but he was not picking, maybe he was busy elsewhere.

I commenced cardiopulmonary resuscitation but it proved abortive. She was certified dead. Her father was the first to come inside and when he saw his daughter, I saw the way his face fell. This man was determined not to cry but his heart was heavy. He kept saying, “My daughter… I knew it… oh God… so, she is really dead.” Soon after, his wife came in and she was first speechless. She sat on a chair just beside her daughter and was looking at the still body, maybe looking out for any signs of life we had missed. Then the tears came, first silent sobs punctuated with. “why?” then, loud wailings and shaking of the dead daughter’s body, asking why the daughter decided to leave her alone, why she decided to die, why she had to go like that.

Then, I heard her say, “You still went to Benin Republic last month and you did not die there, it is this Nigeria that killed you.”

I was still trying to wipe the tears from my eyes because these parents were really grieving and I could not even console them as much as I desired for fear of losing all the control I was holding on to. This was months after the death of ‘C’ in pediatrics and even though I had promised myself not to cry in front of patients again, here I was battling to see clearly through my tears.

 

I concerned with what I heard

But my ears caught what the mother said and it registered in my brain that in all the history and documentations of these patient I read, never was it written that she had had any recent travel out of the country. That could mean three things; either the mother withheld that information or she was never asked or she was asked but it was not seen as consequential. The last two options were almost not possible because when some diagnosis are being suspected, history of travel is very important. No one would have heard that she traveled to Benin Republic and just discard such an information and to not even ask at all? Nah. So, we are left with the first option which is that the mother deliberately kept that information from the managing team.

The mother was a nurse. She should have know the implications of such. She should have told the truth from the start. But, she did not. She did not want us to consider VHFs, which we finally did. She did not want her daughter to be labelled, which eventually happened even though the VHF was not confirmed. She did not want her daughter to die, which sadly, was still the outcome.

The one thing she did not think of was the possible implications on the managing team, on other patients and on the visitors that kept trooping in to see the patient before she died. What would have become of us all if a VHF was eventually confirmed but was confirmed late just because someone held back some information?

This is a note to my readers out there.

When you go to the hospital to see a doctor, you are not going to see a magician or a prophet or prophetess. You are going to see a human being who with the help of the knowledge he has would tie up the information you give and the signs and symptoms he sees to arrive at a diagnosis and would then go further to carry out investigations to confirm or rule out possibilities and then commence treatment.

 

Don’t lie to doctors!

Tell the truth… all of the truth. And do so right from the start. We are not out to judge or condemn anybody. We are not going to laugh at you or ridicule you. We are only going to use what you give us to help you. In fact, if you think you have important information that no one has asked you, volunteer it. That may be the one thing that marks you out either to live or not.

Many times, we have to coerce or threaten the truth out of patients and it gets frustrating. I mean, you give us false information or half-truths and send us on a wild goose chase, endangering your life and the lives of others. It is not fair and it is not right. If you are not ready to be sincere, then, stay away from the hospital.

This is Nigeria. We have not yet reached that point where we can strap you in and get all the investigations we need at the snap of our fingers and then sit down to analyze each one and conclude on how to treat you. We need to hear from the horse’ mouth. And if the horse is unable to speak, we need the horses’ relatives to tell all they can as accurately as possible.

 

Shoutouts

I went on to rotate through all the units in internal medicine except dermatology and GIT (both of which I rotated through in medical school anyway). I was able to pick a lot of things really. Special shout outs to Dr. Ajani and Dr. Oladeji… Yeap, you read that right. These two SRs are hardworking and diligent and very accommodating. They know their stuff and take good care of their patients. They can be quite demanding but I quickly realized that they had/have our best interests at heart. Dr. Oladeji would be like, “Oya, let’s make them wonder with our names.” Hehehe, it was fun. Thank you, Uncle.

And Dr. Ajani… I did many of my calls with him as the SR and we always had it smooth, no matter how many patients we had. And when the consultants came around, they usually did not have much to add or remove because, he would have done a thorough job. I won’t forget the days of, “Eunice, so, you mean you can actually add color color to your hair? Wow.” “Eunice, how much is this your wristwatch?”” Eunice, this your brother that is always buying you stuff…okay oh.” Hehehe. Thank you, Chief SR, sir. Both of them continued to look out for me even after I left internal medicine. They wanted the best for me at work and in all that pertained to me.

Dr. Ikuseedun and Dr. Uche… let’s do neurology again together. Thank you for doing good as much as you could.

Now, special special shout outs to my UCH guys… Ore, Vaughan, Tomiwa. Mariam, Lawal, Omole…you guys really really made me proud. Not once did I hear any negative report about you. Not once did anyone beat UCH down on your account. All I kept hearing were accolades for your stuff base, your hard work, your resilience, your leadership skills, your team spirit and your ability to get results. I know we are not all the same but you guys kept the standard and I am forever grateful for you. I don’t know why it means so much to me that my colleagues are outstanding anywhere they are. But it does mean a lot to me. Thank you.

 

My internal medicine rating:

1. Percussion: 8
2. Hands-on-skills: 8
3. Patient satisfaction: 5.5
4. Morbidity and mortality: 4
5. (Non) Toxicity of learning environment: 7

Total: 65%

Truth is, internal medicine won my heart not just because of what I saw but also because of what I could envision. If we take preventive medicine and primary health care serious, if we carry it on our heads the same way we carry money matters on our head, we would see a drastic reduction in mortalities and people with chronic diseases would live better and longer lives with less hospital admissions. We lose a lot of lives because people are not intentional about their health, they are scared of hospitals and hospitals are adding to that fear by being understaffed, underpaid and overburdened.

But, the narrative MUST CHANGE.

And on this note, we close the talk on Internal Medicine and open up the chapter to Obstetrics and Gynecology. God safe us!