Lost a patient due to shady practices; Case Narrative

This past week has been a very disappointing one both socially and professionally for me. It Started with the awkward experience I had on hive here, to an emergency in the health care facility where I am currently on a National assignment at rural community in the southern part of Nigeria. Challenges abound, how you deal with them is what matters the most. When you are hit, just ensure you don't fall face down; as long as you can look up, there is always hope. Not a motivational speaker anyway, just my mantra for life challenges. Let's get on with our medical narrative, will make it an easy read.

A hospital ward

It all began on a faithful Sunday evening last week when a patient with her siblings visited our facility for medical attention and care. As usual, the clinical details of the patient were collected, aka clerking. The patient presented with abdominal pain, fever, and headache. In addition to the complaints by the patient, she also has a history of stomach ulcers.

Upon laboratory examination, the result came out positive for malaria, with a degree of (++), quite serious. Malaria is normal here. It is always done to rule out the chances of the patient being infected. The reason is that it is the most prevalent disease, particularly in riverine states in Nigeria. They are highly prevalent where I am currently. Her typhoid test (WIDAL) also came out with a significant titer of greater than 80.

Positive WIDAL test results

A WIDAL test is done to detect the presence of Salmonella antibody produced by the body against the pathogen Salmonella typhi - the causative agent of the well-known typhoid disease (fever). The presence of the typhoid antibody in large amounts gives you an idea of the severity of the patient's problem. Most times if left untreated, the bacteria eats through the intestine and finds its way into the blood.

Over here, we use the qualitative method for detecting and grading the antibody titer because it is less expensive (the patients may not afford the more expensive techniques), less time consuming and relatively less demanding, this method though is not as reliable as the tube method which gives you the quantitative measure of the actual amount of the salmonella antibody titer in the patient.

The test is pretty simple and similar to the blood group testing which I explained in detail in one of my previous articles. You can read it here. It is done by simply mixing and reacting the commercially prepared salmonella antigens with the patient's serum (best) or plasma (in cases where serum is not readily available).

The serum (fluid portion of the blood that is seen when the blood is allowed to retract in a plain tube) is preferred because it contains more concentration of the antibody we want to react with the antigen than you would find in the plasma (fluid portion of the blood gotten when anticoagulant is added to the blood). If the salmonella antibody is present in the patient, it will react with the commercial antigen to form a visible agglutination and if the antibody is absent in the patient, no agglutination is formed. The level of the agglutination (In cases of positive results) will give you an idea of the concentration of this antibody and invariably, the level of infection.

The fever or increase in temperature above normal experienced by the patient is due to the response of the body's natural defense mechanism while producing antibodies (this process is usually associated with fever) and due to the chemical toxins released by the bacteria. The presence of toxins or these bacteria in the blood causes septicemia and the whole cascade of events still boils down to one unique thing - fever. This is why is commonly called typhoid fever.

Upon looking at the typhoid test, I was not much surprised because from experience in practice, malaria antibodies if in abundance in the blood tend to exhibit antigenic similarity to typhoid antibodies. In essence, the malaria antibodies can cross-react sometimes with the typhoid antigens thus, producing a false-positive result. To circumvent this in diagnosis, most times it is always advised to treat malaria first before proceeding to a WIDAL test. This is aimed at reducing and eliminating diagnostic errors or missed diagnoses.

The percentage cell volume (PCV), the volume of red blood cell measured in percentage) was normal in addition to the above investigations. She also complained of sharp pain around her navel towards the right. This information changed the entire narrative and one thing that we queried was appendicitis. Usually, patients with appendicitis (inflammation of the appendix) are known to complain of pain in the region between their navel and the right side of the stomach.

After further investigation and scan, the patient was booked for emergency surgery after we confirmed it to be a problem associated with the appendix. All the necessary documentation was done, one of which is the surgery consent form, signed by the relative of the patient. This document is more like a go-ahead order and vindicates the surgeon from any case of unlawful consent allegations. The surgery was performed by the most senior medical officer in my facility and lasted for about one hour thirty minutes. This was even longer compared to the normal time appendectomy (surgical removal of infected appendix) should last (1 Hour). There was a reason for the long duration and we will come to it later.

Surgically removed appendix

While clerking (the process of collecting clinical data ad information from a patient and aimed at assisting diagnosis) of this patient, we discovered that she had already visited traditional medicine practitioners that massaged the region of the pain before she visited our facility. A very dangerous act many of the inhabitants here are fond of engaging in. We will later in the course of our discussion highlights some of these acts and explain the consequences and risks associated with them.

Upon cutting her open, it was discovered that she had an appendicular mass that had already ruptured thus, had pus exudates (fluids that usually come out of blood vessels or organs and flow into body tissues). One of the obvious reasons for the rupture, all points to the unprofessional blind massage done on her by the traditional medicine practitioners. A very sad and pathetic situation. The massage complicated the issue of the patient because the ruptured mass in the body had already released its toxic content into the lining tissues, one of which is the peritoneum (a thin double membrane layer that covers the entire content of the abdominal cavity).

The pus exudates (pus is a fluid made up of dead white blood cells and possibly bacteria) from the appendicular mass must have leaked into the peritoneum of the patient during the shady practice. As the fluid leaks into the peritoneum, it results in infection and inflammation of the peritoneum. This ends up complicating the problem of the patient. The infection had already caused severe damage to tissues before the operation. This was the case of our patient whom we lost to the cold hands of death yesterday night after much effort ranging from doses of antibiotics (drugs that eliminate bacteria) to cardiopulmonary resuscitation (a technique applied on patients that have issues breathing or are unconscious due to trauma). It was a sad one for us at the hospital.

It was no doubt a very challenging one for us all, but one thing we all could boldly admit is the fact that we did our best to save her from the cold hands of death. This is one consequence of blind diagnosis and treatment. If she had sort proper medical attention by visiting the hospital first before any other thing, she wouldn't have lost her life. It's a pity. Besides this case, let's take a look at other shady practices people in this community engage in and their respective consequences. Let's begin with the constant visit to local patent drug dispensers by the community people.

Illegal medical treatment by patent drugstore owners

By right and standard, patent drug dealers are not meant to prescribe drugs nor even diagnose and treat patients without laboratory investigations, diagnosis, and drug prescription from a physician or the pharmacist who are well trained to understand the pharmacological potency and mechanism of these drugs. Patent drug dealers are erroneously commonly referred to here as "chemists". Some of these patent drug dealers, mostly are not fully trained or have any professional training on drug functions.

Over the counter drugs

They get knowledge about drug combinations by learning from their masters. They practically learn drug mixing by doing either a two or three years apprenticeship under their boss and after the agreed period, the apprentice gets settled by his master, also referred to here as freedom. They go on to open a shop in mostly rural communities and dispense drugs to local community dwellings. Funny enough, some pose themselves as doctors and braggingly accept the title by confidently answering.

No doubt they are very much needed in rural communities because they make over-the-counter drugs (OTC drugs) like Artemisinin Combination based therapy (ACT) - the common Malaria drugs around, paracetamol, Vitamins, etc. readily available to sick or needy patients in the community. Strictly, they are not meant to go beyond over the counter drugs because it is the only drug they are licensed to sell since they practically have little or zero knowledge on drug pharmacodynamics (how drugs interact with the body system) and pharmacokinetics (how the body handles drugs through absorption, distribution, metabolism and the excretion of the drug).

I intentionally visited one about two weeks ago and complained of having an issue with my ear. Of truth, I had some ear discomfort but I already knew the problem - ear qualification (accumulation of ear wax in the ear due to excess ear wax production). This was confirmed after a colleague of mine specialized in ear nose and throat examined my ear with an orthoscope. What I simply need is ear flush. A procedure that involves the use of normal saline to dislodge and flush out the softened wax that is causing the discomfort.

After laying my complaints, it didn't take long before I received over 5 drug combinations, it was hilarious to me. Prescription without any form of diagnosis or examination. It dawns on me that, these people don't have an inkling of the implications of their actions. The drugs were quite cheap, so I assume it is another reason why most of the villagers go to them rather than seek proper medical attention.

PS: Reduce cutton bud usage for cleaning the ear, the tendency to push some of the wax produce by the ear gland deeper into the ear is high, most especially if the cutton bud is big and offer some resistance before entering the ear. Go for the softer and smaller ones if you must use them.

Care is take when mixing drugs because can exhibit a competitive inhibitory effect when two antagonistic drugs are taken. The results could be inactivation of the other drug. They as well can exhibit a potentiation effect. Here one drug causes overproduction of drug metabolites in the body system leading to drug toxicity. These are some of the dangers of blind drug combinations which are ignorantly practiced by these patent dealers. You can read more about drug-drug interaction here

Some even go as far as admitting patients in their shop, giving injections, setting IV lines, and administering oral drips to these patients in the name of treatment. The issue with curbing this illegal practice is that the innocent rural communities dwellers find these 'chemists' more trustworthy, cheap, and easily accessible than going to the hospital. They only and mostly go to the hospital when the case becomes critical and this is why in my facility, we get more critical cases. Some are even brought in dead (BID) to the hospital. The patients remain in the 'chemist' shop for weeks and months hoping to get better, when supposed treatment fails, they then send the patient to the hospital half dead, while we try to stabilize these patients, some die because their disease has probably reached its end-stage. We end up having more deaths in the hospital.

The impact of these shady acts by these 'chemists' is that it paints a bad image of the hospital. Once the patient dies in our facility, we automatically are responsible for their death. They spread false information to their neighbors about the death of their patient and in the process advise them not to visit the hospital. By chance, some of these chemists may successfully treat an ailment. This then falsely gives them more credibility in the eyes of the community over the hospital. So invariably, the hospital is the land of death. An issue that is still lingering to date and the death of the patient I earlier discussed happens to be one. Generally, some of the villagers have the wrong impression that once they enter the hospital with their patients, the chances of survival are very minimal.

Womb (uterus) resetting

Womb resetting is a common practice in the Southern Ijaw tribe and those in the Niger Delta region of Nigeria. It involves the manual process of relocating and adjusting the positioning of the womb. The day I heard this from a patient that visited our facility for medical care, I was marveled. This is a blind procedure that is aimed at shifting the womb from its natural position to a supposedly correct position to promote fertilization and conception. They believe that some women who are unable to bear conceive are a result of the inappropriate location of the womb, hence they manually try to reset it.

The uterus

They press and palpate very hard against the stomach, the lower abdomen, and around the pelvic region. Some do it by sitting and also pounding on the stomach using a mortar, all in a bit to shift the womb to the assumed correct position. The ignorant women of childbearing age and even the men in the community believe in this practice and thus they allow it. If only they understand the dangers associated with this practice. The chances of rupturing the uterus in the process of the massage are high, thus making the procedure a dangerous one.

They blindly carry out this procedure without any physical sight of the uterus. One would wonder, is it possible to feel and touch the uterus without any form of invasive procedure and without having to go through the cervix. The answer is an emphatic NO. They may feel they are touching the womb, but in the actual sense, they are holding on to muscles.

Image adapted from BBC video

They might even end up overstretching the muscles that support the uterus, making them overstrained, and in the end, this could lead to uterine prolapse (a condition in which an organ protrudes from its natural location due to loss in muscle strength surrounding it). Should they even succeed in holding on to the uterus, how do they know that it is now in its right place without a visual image of it, do they now have natural eye CT scanners to view human internal organs. The practice by these people is just a sham and has no medical proof, they succeed by mere luck. No human life is worth playing a game of luck. Definitive diagnosis ensures proper medical treatment.

Bone setting, also known as fracture reduction

This is also a commonly well practiced procedure, well recognized medically but done mostly after x-ray examination of the bone to determine the extent of the fracture or bone injury. The traditional bone setters do this locally but the problem with their method is that it is not done with proper examination of the bone.

They practically realign the bones blindly. The procedure is commonly done on patients and victims of fracture or bone dislocation. This practice to some extent is believed by many individuals to be very effective. Arguably it is true to some extent but the way they go about it has major consequences, one of which is damage to the nerves innervating area of the body affected and they could even worsen the already existing problem.

Sometimes they are very successful with realigning dislocated joints and bones but not in the case of fracture. They carry out the procedure by first doing a physical examination of the area affected, feeling the bones, and then through imagination, detecting any unusual arrangements. After the physical examination, they then manually reset and align the bone, an excruciating procedure.

X-ray of leg fracture

The reason a bone x-ray is always requested in cases of fracture and dislocation is that a physical view of the bone alignment helps to guide the orthopedic surgeon on the next line of action. Sometimes pain could come in the form of muscle twisting and without any bone misalignment.

Funny enough, the way this
medical practitioners go about alignment in that they first dislodge the remaining bone by hitting it. A very painful procedure. After doing this, they then begin the blind realignment. The fact that they carry out this procedure, without any form of training poses danger. The risk associated with their method usually involves muscular injury, strains, etc. Besides the injury, the way they go about the whole procedure of setting the bone is unprofessional.

Since they blindly carry out some of this procedure, they might end up compounding the patient's problem. Proper diagnosis is of the essence before any procedure is done on patients. Failure to realign a bone that has dislocated or has been fractured will end up making the movement of the affected part of the body difficult.

The above are some of the shady practices. There are more to these few ones explained above. It will only take wide public awareness campaign against these practices to stop them. On our end, we are employing the one on one technique of discouraging the practice because the wider approach seem not be much effective. This approach will reduce the morbidity rate (cases of disease and health issues) in the community.

Ensure to seek proper medical attention and never engage in any practice that will worsen or affect your health condition. The cost of compounded health issues and death is more more than the cost for quality health care. Choose quality health care!

Until I come your way again, stay awesome!

References

_{•Cardiopulmonary resuscitation (CPR): First aid
•How to start a patent medicine store in Nigeria
•Traditional womb ‘resetting’ can cause recurrent miscarriage, uterus rupture —Gynaecologist
•Traditional womb setting massage: See places wia dem dey practice am to 'help a woman get belle'
•Womb massage for fertility in Nigeria
•Complications of traditional bone setters (TBS) treatment of musculoskeletal injuries: experience in a private setting in Warri, South-South Nigeria}