Hospital Wards

Hello! Another week is almost gone, and we have been busy as usual. I have been working at the hospital in the medicine ward. Some things about medicine are so different here, and some things are so similar. We start our mornings with rounds, like we do in the US, and what happens here is that the house officer (intern) and I trade off doing the scribe work and scut work. We write the note, write prescriptions, take blood pressures and pulses, and hunt down lab results, papers, etc. They don’t really do as much of a physical exam as I’m used to, but often there are interesting signs and then I just stop scribing and go examine the patient, and the doctors are very good about helping me with that. Americans are afraid to hurt others so we don’t press nearly as hard when palpating stomachs or moving aching limbs---Nigerians want to get to the root of the problem quickly, so they press hard and elicit the pain response quite quickly!

I’m learning that they don’t do as much here simply because they can’t. For instance, the shorter physical exam. They do a thorough exam when a patient is first admitted, but after that, your physical exam findings may not affect how you treat the patient so you do as much as might be helpful, and that’s it. They are better at working on intuition than we do in the USA. There are limited drugs, limited scans, limited lab tests we can do here. They don’t have the drugs or equipment or training, and even if they did, most patients don’t have the money to pay for these things. Patients usually don’t come in till they are on the verge of dying, so often you can’t do anything for them anyway. So for instance, a young lady came in with fever, bloody diarrhea, cough, and liver dysfunction. We don’t do cultures because they often don’t have the means to be sterile enough, we can’t do a CT because we don’t have the equipment, so we just treat the likeliest cause---an infection. We give her three different antibiotics to cover for malaria, meningitis, and a gastroenteritis, and oxygen through nasal prongs and hope for the best. Four days later, she is dead. We visited her every morning and she worsened everyday, but what could we do? We treated her for what we thought she had, and clearly it didn’t work but we have no way to figure out what was wrong with our treatment. I know that a lot of the times in the beginning, I thought there was gross negligence going on, but now I realize that it’s just that they don’t have the same resources we do. One of the residents told me he hated internal medicine because you had to watch all these people with problems who you couldn’t really help and just died on you, and I tried to explain that it was a little different in the US since people came for regular check ups and didn’t get so sick before coming to the doctor. Preventative care is such a beautiful thing!

Their matter-of-fact attitude towards death I think is one of the biggest differences. Not that it doesn’t affect them when patients die, they are compassionate people, but, they see it so much it doesn’t bother them quite the same way it bothers Americans. I think it keeps you humble, because it reminds us that we aren’t gods. We can’t do everything, we can’t save everyone. We are helpless, we are limited, and after you do your best, all you can do is leave it in God’s hands. I think many doctors in the US forget this, and think they can save anyone and beat themselves up when their patient dies.

After rounding, we go to clinic. So here’s big difference number two. Time is fluid in Nigeria, even in medicine. Clinic starts whenever rounds end, whether at 9:30 or noon. Patients just show up and get into some sort of line and wait. They can wait 2 minutes or 6 hours, depending on when they show up in relation to when we show up. There are no appointments, Nigerians don’t do appointments. And when you want to get a hold of them, it’s hard, because many don’t have phones, and their postal system isn’t as structured, so many people put their churches or schools as their address and you have no idea where they really live. Big difference number 3: Privacy doesn’t really exist here. We see them sometimes privately, sometimes not. Nurses, other patients, other doctors, and other random people are always coming into the room and conducting their business while the patient is still there. Patients will often try to cut the line and come in before you’re done with a patient and stand there waiting, or two of us are in one room, both seeing patients. Sometimes I see them myself and then talk to a doctor about them, sometimes I help the doctors write the prescriptions, do the exam, etc. There is no co-signing here. They watch me, but they trust me to make sure I am responsible and do the right thing! Scary, but good training for becoming an intern.

We do clinic until all the patients are seen, and then we have a variety of things occur: following up on patients in the wards, going to lecture, admitting new patients, or going home! On call, we sit in the emergency room and see patients. I usually see them myself and then discuss it with the resident briefly. We see a lot of fever (always treat for malaria!), diarrhea, headaches, body aches, but we do see some really bizarre things too. Very, very bad cellulitis from a corn stalk puncture, very nasty breast cancer, hemorrhagic fever, lots of weird eye problems, and various other weird things. We also see a lot of motor vehicle accidents. The bikes, the lack of traffic rules, the people racing across the street---it’s not surprising, and usually they’re bad accidents and people die. Even in these serious accidents, the doctors and nurses don’t hurry because there’s not much we can do. We can’t intubate, do CT’s, type and cross quickly and get the appropriate blood, do continuous EKG’s, etc, which are all things necessary to keep to a person alive after a serious accident. Plus, patients need to pay a 5000N deposit before they’ll get any treatment, and how many Nigerians have that on them at a moment’s notice? Not many considering that’s a pretty good months wages for most.

Lastly, the one thing I have enjoyed so much is that the hospital is a mission hospital. When I was at Spring of Life, my favorite thing to do was pray with the patients. It is the same at Evangel. It is such a privilege to be able to minister not just to the physical needs, but the spiritual and emotional needs as well. In the US, we forget that keeping a person healthy means looking at the whole person, and that sometimes until you fix the emotional and spiritual needs, you may not be able to help the physical needs. Here at Evangel, sometimes it is very hard in the busy-ness of things to make the time to talk with the patients, but many of the doctors do, and it’s amazing to see. Sometimes, as a Christian, I can be so critical, I can see all the things I’m supposed to do, all the people I’m supposed to help, and then I feel very down that I’m doing such a poor job. But then something happens to remind me that God doesn’t need big things to happen, he just wants something to happen. I had the joy of being able to pray with a patient and one of the house officers a few days ago, and I can’t tell you how much that moved me. The house officer can’t be much older than me, if at all, yet, his words were from a person 10 years wiser than me. I could tell that his words, and our prayer time with her, meant more to her than all the medical treatment we’d given her in the past 4 days, when she arrived in a critically ill state. It was the first patient I was able to pray with here at Evangel, and it wasn’t a big thing, nothing heroic. Yet, I know the Lord found that time we spent with her to be a precious, precious thing in His eyes. The Nigerians are teaching me, the Lord is teaching me, my patients are teaching me. It’s a great thing!