© 2018 - International Centre for Investigative Reporting
How the Nigerian system failed a doctor who treated suspected Lassa Fever patient
By Chibuike Joseph Chukwudum
Whatever hope I had for, and whatever faith I had in, this country, especially its healthcare system, died a few days ago. The height of negligence and incompetence I came face-to-face with these few days left me shattered and lost for words.
Not just was I unduly exposed to a deadly virus, I was left with the headache of trying to contain its spread, a task that should have been the exclusive reserve of the ministry of health through its public health department.
And when I developed suggestive symptoms, I was refused treatment by a TEACHING HOSPITAL, and was left to fend for myself, even as I ran cross country, across the length and breadth of Nigeria, sick, exhausted, traumatized; and what more, possibly spreading the virus, as I travelled UNSUPERVISED!
Below is my story. I would be leaving out names, as the individuals involved may also be victims of a failed system just as much as I was. Also, for want of space, I would be leaving out core medical details, like examination and investigation findings.
Patient zero presented to the hospital where I work, at about 4pm, on Friday, the 12th of January 2018. She had been on admission in a clinic some 10km away.
She presented as a known RVD on HAART with complaints of Fever [even though on presentation, temperature was normal: 36.7°C], cough with occasional blood-stained sputum [hemoptysis], pleuritic chest pain, oral sores, joint pains, all of 4 days duration; irrational talk, that progressed rapidly to an altered level of consciousness, of 3 days duration; and jaundice [yellowness of the eyes], passage of coke-colored urine, and slight abdominal swelling, of a day duration. No leg swelling, nor swelling around the eyes.
After reviewing the systems, and carrying out a full examination, which included a VE [!]; I noticed a nose bleed, which the relatives claimed was the first incident of such. Based on the findings, I made an assessment of “Multi Organ Failure, query cause.” This means that her organs were already failing — that much I knew; but I was not yet sure what was the cause. Hence the “query cause.” My list of possibilities, however, included:
- Pneumonic Sepsis [for obvious reasons]
- Acute Fulminant Hepatitis [because of the quartet of jaundice, encephalopathy, coagulopathy, and abdominal distention]
- SLE [making a case for this here is beyond the scope of this write up]
- And finally, Viral Hemorrhagic Fever, in this instance Lassa Fever (this was only included for the sake of completion, because at this point, I honestly wasn’t thinking of Lassa Fever).
The plan was to resuscitate, and refer — a decision I would later regret.
IF IT LOOKS LIKE LASSA, IT’S SAFER TO ASSUME IT’S LASSA
After initial resuscitation, she started making adequate urine, the level of consciousness improved, and the acidotic breathing resolved. I wrote them a referral, but they said they had run out of cash as a result of the four days they spent in the CHEW-manned clinic they were referred from. And since it was already weekend, they couldn’t withdraw.
This meant that they couldn’t afford to transport her to a new hospital, and start paying for a new card, admission deposits, and all what not. Neither could they settle the bills they had incurred in our hospital.
So, we were stuck with her for the weekend, and had no option but to continue life-sustaining treatment.
Unfortunately, by Monday, she deteriorated again, and started bleeding from multiple sites, including the nostrils, mouth, vagina, and into the skin.
A liver function test we did over the weekend had ruled out Acute Fulminant Hepatitis. Also, an on-the-phone review of the case with a Senior Registrar in Rheumatology ruled out SLE, despite the striking similarities. So, we were left with Sepsis [+DIC], and Viral Hemorrhagic Fever!
By the time news filtered in that someone had died from a suspected case of VHF in her locality, Lassa Fever was looking more and more probable, even though I still made “Sepsis with DIC” my first choice diagnosis.
ATTEMPTS AT CONTROLLING AN OUTBREAK FROM THE SUSPECTED CASE
At this point, everyone was yelling “discharge and refer,” but I couldn’t, for the following reasons:
- This people didn’t have money. So, if I referred them at that point, they were definitely going home. And that would mean exposing everyone around them: the family, relatives, and friends, who’d come visiting!
- If they found money, by whatever stroke of luck [oh, I forgot to mention that they had lied about having money in the bank] , and went to a new hospital, that would mean exposing another set of doctors, and nurses!
The best way to prevent these two scenarios, I reckoned, was to keep her [since we were already exposed anyway], and then inform the authorities. They would know exactly what to do, and how to do it, without risking other lives. STUPID ME!
While we were waiting for that, I put the following measures in place:
- I had the woman transferred to an isolation ward. Thankfully, throughout her admission, she’d been alone in the particular ward section she was admitted in before we started suspecting VHF.
- We stopped admitting new patients into the ward she was admitted before.
- The two relatives taking care of her were advised to be using hand gloves, and face masks; and also not to leave the hospital premises.
- No visitors were allowed into her isolation room.
- I saw to it that provision for hand washing, under running water, was made at the entrance to her room. The water was always fortified with Jik.
- We minimized care to the essentials: changing her drip, and administering her IV drugs. No more taking of vital signs, changing of beddings, doing reviews, and all what not.
- Any staff who MUST GO IN, must do so with elbow length gloves, and face mask, and try as much as possible to minimize contact.
- All the vital signs equipment used on the patient were marked as potentially hazardous, not to be used on other patients, at least until we become sure of what we are dealing with.
The plan was to do this for few hours, at most a day, as we were expecting the authorities to sweep in, and take the huge burden of KEEPING HER ALIVE off our shoulders.
INFORMING THE AUTHORITIES, AND THEIR LACKADAISICAL RESPONSE
The authorities were promptly notified IMMEDIATELY we started suspecting Viral Hemorrhagic Fever [VHF]. The Department of Public Health, of the state’s Ministry of Health, was duly notified, and they promised to send a “team.”
The first day passed; no show. On the second day, they sent a DSNO (Disease Surveillance Notification Officer). So much for sending a “team!”
The woman who came was less equipped than we were. She came with NOTHING, but her hand bag, pen, and a form to fill. We lent her the gloves and face mask she wore when she went to the isolation ward to see the patient. And oh, by “seeing” I meant sightseeing on aproko levels!
When we came out, she said she was asked to get a blood sample to be sent to Lassa Fever Centre, Irrua, for screening. Yet she didn’t come with any PPE! Heck she didn’t even come with a sample container, vacutainer, or tourniquet. What am I even saying; weren’t we the ones who gave her the gloves she wore for “sightseeing?”
Because it was my life, and that of the staff I work with, on the line, I gritted my teeth, gloved up, and went to collect a sample from the patient, risking further exposure. But we had to know if it was Lassa fever, didn’t we? And that was the only way.
When I was done collecting the sample, we realized she hadn’t made arrangements on how to preserve it while transporting it. So, we got a Giostyle coolbox, and ice packs, from our immunization department, and gave it to her.
The Ribavirin we were expecting from them? Lol! It was obvious we were better off sweeping the Sahara!
The Department of Public Health called again, and said I should put the patient in an Ambulance, and transport him to the Teaching Hospital , some 118 Kilometers away! I cringed at the shamelessness, and audacity of that request.
They promised me a “team,” but instead sent someone that spelt jaundice as “joindis.” I was expecting PPE, instead I lent their staff gloves. And where I was expecting Ribavirin, they brought nothing, never mind I was doing their job for them, cracking my head on how to contain an epidemic! And they still had the audacity to make another request of me? And with absolutely no shame? I was livid with rage.
Pettiness aside, how do they expect us to transport the patient, without exposing more people, the driver of the ambulance inclusive? What about the logistics of the travel; who’s going to cater to that?
They later called back, and said they’d send a “team” to come and take her that evening.
We waited, and waited, but saw no one.
DEATH OF ‘PATIENT ZERO’ AND CONTINUED NONCHALANCE OF THE PUBLIC HEALTH DEPARTMENT
The following morning, the patient was still in a bad shape. We had transfused (yes, STUPID ME; I was still trying to save her life) with fresh whole blood, to correct the Thrombocytopenia shown in the FBC, and she was no longer bleeding. But she was still in a terrible condition.
We waited for the team that was promised to come and take her, but saw no one. A little after midday, about 72 hours after the Public Health department had been notified; she gave up the ghost.
I called the PH department again, to inform them of the development, and to remind them that the corpse needed to be disposed professionally, to avoid putting others at risk. They said I should get a body bag, put the patient in it, make sure the patient is buried ASAP, and what more, that I should supervise the burial. Yes; they actually said all that!
Question is, since when did it become the duty of a doctor to supervise the burial of a corpse suspected to be contaminated with a highly virulent virus such as Lassa Fever? Even if it was my duty, is it not meant to be done with the “undertakers” wearing PPEs, and someone following them, decontaminating the environment as they go? So, where was I meant to get PPEs, the whatever they use in decontamination, and the damned body bag?
Clearly, not just were this people running from their responsibilities, they also don’t know what their responsibility is!
When I asked about the sample I risked my life to collect the previous day, they said they were yet to send it to Irrua; that they planned on doing so the following day!
BETRAYAL FROM THE RELATIVES
The relatives refused to pay hospital bills. This was particularly painful, because this was a woman we all risked our lives for, and continued attending to until her death, even when we thought it might be a case of Lassa Fever! Not just that, I had paid for the investigations, blood transfusion, IV fluids, and IV antibiotics (all totalling about 15k) with my own money. So what they were asked to pay was just for bed space, and the other services. And yet, they refused to pay a dime.
Because of the circumstances surrounding the case, we had to let them go. So the hospital ended up with the lives of its staff on the line, and still had nothing to show for it. That’s what you get for trying to do good IN NIGERIA!
A WEIRD COINCIDENCE: THE SCARE
While all these were happening, I was never really scared, because, even though it was a strong differential, I wasn’t really convinced it was Lassa Fever. I can’t go into details about why I didn’t think it was Lassa; it would be beyond the scope of this write up.
However, 2 days after patient zero’s death, I suddenly developed fever, vomiting, diarrhea, malaise, headache, and sore throat. And for the first time, I was really scared to the marrow (details of this can be seen in an earlier post I made on this issue, titled ‘From Scare To Nightmare’).
I placed myself on ORS, Zinc, and antiemetics; and then called my friends, and colleagues to inform them. My plan had been to continue with the conservative management, and source for oral Ribavirin myself, while waiting for patient zero’s results; but after consulting my friends, the unanimous decision was for me to start going to Lassa Fever centre, Irrua, for admission, and outright commencement of treatment. They wouldn’t have me take chances.
And that was how the wild goose chase started. I hurriedly packed my things, had someone withdraw a huge sum of money for me, informed and took permission from the Hospital’s administrator; and in 2 hours, I was on the road in the Hospital’s ambulance, sick, tired, confused, as a thousand and one thoughts were racing through my head.
REJECTED BY THE TEACHING HOSPITAL
Before I left, I had contacted the Public Health department again, to let them in on the new development, and the fact that we should seriously start making plans of tracing other people that patient zero may have contacted, and exposed unknowingly. Stupid me! But that’s how I am wired; I am never really the type who looks out for himself alone.
The Department of Public Health gave me a contact to call in the Teaching Hospital, and convinced me not to embark on a nine-hour journey to Irrua, since I was sick and unstable, and they have an infection control unit in the Teaching Hospital that is well equipped to handle the case. I called the contact, and he said that they had been informed, and that they were READY and waiting for me. By being “ready,” they meant Ribavirin, PPEs, and all that. So, I took a detour, and embarked on a two-hour journey to the Teaching Hospital instead.
When I got there, I got a cold reception. I was kept in the ambulance for two hours, from 6.30pm to around 8.45pm, on the pretext that they were “looking for the keys to the isolation ward.” I was left out there unattended to, sick, tired from a long journey, and apprehensive. My friends were calling, yelling that I should leave and start going to Irrua. But I reasoned it was already late, and I didn’t want to take that risk.
At around 9pm, they finally “found the keys,” and I was taken to an isolation ward, in a huge deserted complex.
After one hour of waiting, and of having the clinical staff peer at me through the window, like I was some alien, someone fully kitted with a PPE came in to see me.
After asking a few questions, he told me outrightly that I was on my own. That the PPE he was wearing was the last in the hospital, and that no one would agree to touch me without it. He went further to say that as it stood then, neither him, nor the hospital, was “officially aware” that I was in there. Talk about “plausible deniability!”
I was shocked to the marrow. The irony of it — the fact that I risked my own life to take care of someone I didn’t know, who wasn’t even from the same state as me, without PPEs, and in a Community Hospital, in a remote village! And right there were people, who were meant to be my professional colleagues, my “Hippocratic” and “Nightingalean” brethren, working in a tertiary institution — supposedly the most equipped hospital in the state, and yet they couldn’t do same for me.
I wasn’t mad at them though, as I realized that they were as much victims of a shitty system, as I was; for in their eyes, I saw pity, empathy, and shame. Perhaps if they had PPEs they would have done something. Perhaps not. Truth is, we’ll never know.
“Okay,” I said; “now that you’re still wearing PPE, can you at least help me site an IV line, and put me on IV fluids?”
No, can’t do; you’re not on admission, and like I said, the hospital is not “aware” you’re here.
“What of Ribvirin; can I get it and start treating myself?”
No, we can’t give you that; we can’t give you drugs without a definitive diagnosis.
“Excuse me? You’re saying that in the setting of a potentially life-threatening ailment, you’d rather wait for a confirmatory diagnosis that may take days, possibly risking the patient’s life, instead of starting life-saving treatment?”
And he said something I considered condescending about the drugs having numerous side effects.
I scoffed. Drug side effects my foot! As if we were not taught about what to do when benefits outweighs risk in medical school.
At this point, there was no need engaging further; it was obvious this people were playing “political correctness” with my life.
Before they left, they said I should continue self-medicating with the ORS and Zinc, that I CAME WITH, to stay hydrated; and that I should be monitoring MY OWN vital signs, and let them know if “something” happens. Right; like if I enter into shock, my ghost would pick up my phone and start making calls, abi?
That was how I was left ALONE in a vast one-storeyed complex, sick, with a thousand thoughts running through my head.
At around 11pm, I decided it was best to check myself out, and go to find a hotel, spend the night, and then continue my journey to Irrua the following day. And no, I didn’t care if I was going to be putting the hotel staff at risk; whatever selflessness, and misguided sense of patriotism, I had died in that hospital where I was left to my fate.
If their government didn’t care enough to protect them, even when I had tried to make it easier for them, why should I care? Besides, if I was dying, I would rather spend the remaining of my days in luxury, and comfort, and not in a deserted building where my only companions would be my thoughts, and the elements.
Old habits die hard. As I went to that hotel room, I still went with Dettol, and Jik, and made sure I was washing my hands regularly, to minimize the risk of putting anyone at risk. Lol. Stupid me.
FENDING FOR MYSELF: TRIP TO IRRUA
The following morning, we set out for Irrua as early as 6.30 am. It was a long journey that took about nine hours.
Throughout the journey, I was receiving calls, and prayers, from friends, family, and well-wishers. They made me feel loved; they made me feel there was good in humanity after all; and that whatever I had done was well worth it.
We arrived at Irrua Specialist Teaching Hospital at exactly 3.30pm. The first thing I did was to report myself to the Lassa Fever Centre, and have them look for patient Zero’s result. It happened that they hadn’t even started running the sample, as they were overwhelmed with samples from all over the country.
However, they were humane enough to understand my predicament, and the urgency it required. So, they made it a priority, and included it in the next batch of samples to be run.
THE LONG WAIT
I waited for long for that result. At a point, it was obvious that it was going to be a long wait, so I went and booked myself a hotel room. A consultant in the centre had earlier advised that it may be imprudent to admit me at that time, risking further exposure. Since I was no longer having diarrhea, vomiting, and fever,AT THAT TIME, he said we should wait for the results of patient zero first.
By 10pm, I was still seated outside the lab, waiting. Finally, the door opened, and they told me that they had made a mistake while running the sample, and would have to redo the test. Exhausted and drained, both emotionally and physically, I decided I couldn’t wait any longer. So, I went to my hotel room, switched off my phones, and dozed off.
A HAPPY ENDING
The following morning, at around 7.30 am, the lab called me: patient zero’s result was negative. And I heaved a sigh of relief. The first thing I did was to call my friends, and family — beautiful set of people — who had been more worried than I was, and tell them that the battle was over.
On my way back home, I got sick again. So, when I got home, I ran some tests, and it happened what I had was sepsis, and malaria with a very high parasite density.
I’m on drugs now, and recuperating fine. And yes, I’m also on sick leave, even though I’ve been reviewing cases brought to me by my junior colleague on my sick bed. Yea, they can’t take that away from me: love for what I do!
It feels like I have been given a second chance. A chance, not just to live, but also to see more clearly, and realize that this country isn’t worth it. Oh well, let’s just get well first.
I deliberately left out the name of any state on this write up, so “Ministry of Health,” “Department of Public Health,” and “Teaching Hospital,” as used here, could be that of any of the 36 states. This was deliberate, and was done so for legal reasons, in case anyone wants to get funny, as I don’t have any evidence to prove all I’ve written here.
But we know every bit of information written here is the TRUTH, our truth; and we know where all these happened. Don’t we?
Shhh, don’t tell.
There you have it, people; your NIGERIA!
And you, the medics; just know this: YOU ARE ON YOUR OWN!
This article was first published on Chibuike Joseph Chukwudum’s Facebook wall.