That the standard in the Nigerian Health Care Sector has declined to an all-time low, is no longer news. Onikepo Braithwaite examines some of the major reasons for its descent into the abyss, including medical negligence, lack of equipment and inadequate manpower. She also spoke to patients and doctors

 

Recently, Nigerians were proud to celebrate Dr Olutoye, who trained at Obafemi Awolowo University (formerly University of Ife), Ile-Ife, Nigeria. He is a specialist with expertise in fetal and neonatal surgery with specific interest in congenital diaphragmatichernia and complex wounds. A Nigerian trained Dr working in Texas, USA, along with his partner, performed an incredible feat of delivering the same baby twice, thirteen weeks apart. He removed the baby from the mother’s womb at 23 weeks, performed surgery on her to remove a tumour, then replaced her in her mother’s womb and delivered her again, healthy at 36 weeks.

 

Most foreign countries one goes to, whether, UK, USA, UAE, to name a few, one finds that several top medical consultants in their hospitals are Nigerian. Same with nurses. A lot of them trained here. In Nigeria, lets begin with the death of a child at a Lagos Hospital:

 

The Child

Last week, the tragic death of a six year old child at a Victoria Island hospital, finally necessitated the writing of this piece. I have however, decided to omit the names of the parties involved in this sad case for reasons best known to me. There have been allegations of medical negligence against the hospital by the Parents of the child, while the hospital maintains that they did all that was required of them in the treatment of the child.

 

I interviewed both the Parents of the child and doctors from the hospital. The Parents of the child (the Parents, the mother or the father) and the hospital confirmed to me that the child suffered from sickle cell anaemia. The hospital also went further to say that the child also suffered from asthma, as they put it, suffering from ‘two chronic illnesses’.

 

Here is a brief overview of what happened. I will try to be as accurate as possible. Kindly, forgive me if I have left out any pertinent details.

 

Day 1

The child did not eat breakfast in the morning. His father offered to feed him, but he refused. The child was obviously having some of his asthma issues. The child was insisting on going to school. The father refused, saying he could not go to school on an empty stomach. He decided there and then that instead of going to school, the child should see the family doctor. The family doctor happened to be away, abroad, but another doctor on duty at the clinic nebulised the child and administered an antibiotic injection, Rocephin.

 

Nebulisation is the treatment of asthma and other respiratory related diseases by the administration of medication in form of a mist inhaled into the lungs through a machine. It is not clear whether the doctor on duty informed the father that the child should be admitted to a hospital, but the doctor put a call through to the family doctor abroad, informing her that the child should be admitted to hospital, so as to be able to take the antibiotics intravenously.

 

The child went home, felt better, and even ate a hearty meal of rice and stew.

 

Day 2

It was not clear what happened to the child that day, but the father took him to the hospital late that night and into the next morning. The child was complaining of stomach ache.

 

Day 3

The father and child were in the hospital into the very early hours of the morning, say about 1 am. The child still had the stomach ache and the doctor on night duty (Young doctor) asked that the child should be admitted, but gave no viable reason why, according to the father. The father asked Young doctor if there was an immediate treatment plan, necessitating the child’s admission to the hospital at that time. The Young doctor offered him no viable explanation or treatment plan, so he left with his son, saying that they would return later that morning (I guess when the Consultants would have resumed duty).

 

Later that morning, as early as 7am, the father and child were back at the hospital, with the child still complaining of a stomach ache. On their return they still met Young Dr, who was getting ready to go off duty. Not too long after, two Consultants of the hospital, resumed. They took charge of the child’s case (Consultants 1 & 2). The child was placed on admission that morning.

 

In the meantime, the mother’s sister, a paediatrician practising in USA (Aunty Dr), had been contacted by the mother. The chats that were made available to me, that is, between Aunty Dr and the mother, were from very early in the morning of Day 3. Aunty Dr suspected that the child may have pneumonia, and acute chest syndrome, which was not unusual in a child with sickle cell. Aunty Dr felt that the pneumonia should have been evident from a physical examination. She also recommended that an ultrasound of the child and respiratory etiology should be carried out.

 

The Parents claimed that Aunty Dr’s suggestions did not go down well with Consultant 2, who seemed to feel offended about being told what to do by another doctor. The father informed me that it was several hours after Aunty Dr’s suggestion, which in tears, he passed on to Consultant 1, that the child was finally given a chest x-ray which confirmed Aunty Dr’s fears, that indeed, he had pneumonia, with the left lung being in a worse condition than the other.

 

Consultant 1 directed that the child should be nebulised every four hours. Aunty Dr told the mother that she was unclear as to the reason for nebulisation. She was more concerned about the pneumonia being treated.The child was still having terrible stomach pains. Another antibiotic, crystalline penicillin was added to the Rocephin.

 

The father said that he noted that the medication being given to the child may have been inadequate as his weight was 24kg and not 12kg, as noted in his chart. For children, medication is usually prescribed according to weight.

 

Day 4: The Final Day

Just before 3am, the mother told Aunty Dr that the child’s breathing was laboured, 95bpm with 150 heart rate and he was sweaty. Aunty Dr thought he had a fever, the mother said that he didn’t. She was asking the mother a lot of questions, was there a Consultant present, the antibiotics etc. She was still insisting on an ultrasound to check if the child had fluid in his lungs, how bad it was and so on, and that the antibiotic should be changed to levofloxacin. She was however, not sure whether that particular medication is even available in Nigeria (Apparently, levofloxacin is not generally used for children, because it can affect their growth).

 

At 4am Aunty Dr told the mother that fluids, antibiotics, pain control and possibly a blood transfusion were necessary, depending on the child’s haemoglobin level. Two minutes later, the mother told Aunty Dr that the hospital was about to give the child a blood transfusion. The child’s breathing dropped to 85bpm. This worried Aunty Dr who said it was crucial for a Consultant to be in the hospital to attend to the child. There was none. She told the mother that she wanted the child transferred to the ICU of another hospital, because she felt that the child’s care needed to be escalated. The transfusion started and breathing was still laboured at 92bpm/142 heart rate.

 

Based on Aunty Dr’s recommendation, the mother wanted the antibiotic changed. The hospital said the antibiotic needed at least 48 hours for it to kick-in, after which it would be changed if there was no improvement. The mother contacted the family dr on this issue, for her to convince the hospital to change the antibiotics. The family dr told the mother that the 48-hour time frame was not unusual, as no antibiotic was so good that it worked instantly, it needed time to take effect.

 

By 9.35am, Consultant 2 told the mother that there was no improvement from the day before, and the child could get worse before getting better. The family Dr confirmed to the mother that this sometimes happened. The family Dr had also recommended another antibiotic if the present one failed, vancomycin.

 

A few hours later, the child was rushed to the ICU of the hospital.

 

The child died at about 5.30pm on Day 4. May his sweet, little, gentle soul rest in peace with the Lord. Amen.

 

What the Hospital Said: For the Hospital, Day 3 was their Day 1.

 

Day 3, Hospital Day 1

The child was brought to the hospital late in the night, into Hospital Day 1. The child had been given a Recophin antibiotic injection at the family dr’s clinic on Day 1. Recophin injection was not administered the next day (Day 2, before the child was brought to the hospital). Ideally, the injection should have been given daily during the sickness. The Young Dr nebulised the child and requested that the child be placed on admission. The Young Dr said that the father refused the admission, saying that the child was feeling better after the nebulisation. The Young Dr then advised the father to come back to the hospital if any problem arose later in the night.

 

The father arrived with the child at about 7.50am. The child was in extremis, that is, in some sort of breathing distress. The normal process before consultation/admission, taking of vitals and so on was by-passed. The child was nebulised, the intravenous line was set and the child was stabilised. The hospital said that stabilisation of the child was priority and it took some time to achieve this. The child was given another dose of Rocephin and the chest x- ray was done and reported on, before 11.30am. The child had lobal pneumonia. Crystalline Penicillin, the drug of choice for the ailment, was added to the Rocephin. The child was also put on oxygen. The child improved a bit.

 

However, by 5.30pm, the child was more breathless, wheezing. Consultant 1 therefore instructed that the child should be nebulised four-hourly.

 

During the night, there were three medical officers on duty (Young Drs). The hospital says that in most parts of the world, it is normal that Consultants do not do night duty. Medical

 

Officers, also called Registrars in the UK, do the night duty, and may contact the Consultant in charge of a case, in cases of emergency, during the night.

 

The hospital ‘s position is also that it is not normal procedure to take instructions from an unknown third party (Aunty Dr in this case), on how to treat your patient. The only other doctor that could have issued instructions on the treatment of the child would be the family dr, who was the child’s doctor.

 

Hospital Day 2: The Final Day

Consultant 2 had been contacted twice during the night, so he came back to the hospital about 5am.The child was given a blood transfusion in the early hours of the morning. The blood transfusion did not achieve the desired results.

 

Another antibiotic, Meropenem was added to the other medication that the child was on.

 

Consultant 3 resumed duty for her normal 10am-2pm shift. She had not been involved in the case. She however, coordinated the transfer of the child to the Intensive Care Unit (ICU) around 11am, when the child still showed no improvement.

 

The hospital states that the Intensivist, and not Consultant 3, intubated the child and put the child on a ventilator. Consultant 1 says that at a point, there were about eight doctors attending to the child, trying to save his life, 3 Intensivists, 2 Consultants and 3 other doctors.

 

The child went into cardiac arrest at 3.30pm and was resuscitated. He then had a second cardiac arrest from which he could not be resuscitated, and he died.

 

The child is presumed to have had Fulminant Pneumococcal Septicaemia, which can kill in 24 hours. That the rapidity of decline in the patient conditions is inherent in a sickle cell patient with acute chest syndrome. The hospital said that the child had previously been on admission in the hospital for a pneumococcal infection in 2012, an ailment which sickle cell patients are particularly susceptible to (as well as children under the age of five years). The hospital stated that abroad, some children with sickle cell take Penicillin V for life, apart from the vaccine which does not cover all the strains of pneumococcal infection, to protect themselves.

 

The hospital referred me to the book, “Sickle Cell Disease” by Graham R. Serjeant, for more information on the condition.

 

Unanswered Questions

What does one say in such a painful situation? The Parents felt that the hospital did not handle the treatment of the child properly, resulting in the death of the child. The hospital feels that the child should have been on admission earlier and insists that the antibiotics may have failed, which unfortunately is possible, but, they did all that they could to save the life of the child. The hospital believes that it treated the child with the proper standard of care.

 

The child’s situation, is too unfortunate for words. More investigation or an inquiry into the matter is certainly required to shed more light on the incident. Though I am a lawyer, and not a doctor, several questions come to my mind:

 

1) If the child was admitted to the hospital on Day 1 instead of Day 3, would it have made a difference

 

2) Why didn’t Young Dr contact a more senior doctor or Consultant to handle the case that night and ensure that the child was admitted immediately

 

3) Were the Parents made aware by the doctor at the family dr’s clinic or by the Young Dr that the condition of the child may be serious. Did the doctor at the family dr’s clinic recommend to the father directly that the child be admitted

 

4) If the hospital had carried out Aunty Dr’s instructions as to the tests and changing the antibiotic to levofloxacin, what would have been the result

 

5) Is there no quicker way to test and ascertain the efficacy of a medication that has been administered on a patient, like a blood test or something else, than just to sit and wait for say 48 hours to see the physical manifestations

 

6) Was the treatment plan that the hospital used the right one?

 

Doctors in Nigeria: Healers or Killers? Part 2