For two weeks, TEMITAYO AYETOTO embedded herself with patients at the accident and emergency centres of two of Nigeria’s biggest tertiary hospitals, LUTH and LASUTH. She uncovers how a lack of bed space leaves patients stranded at the emergency ward for dozens of hours, oftentimes days. With the motto ‘no bed space’, patients suspend their destiny on the hope that an in-patient is discharged, transferred or, rather sadly, dies. When this will happen, though, they have no idea.
The loitering began mounting under the car-park shade, where I observed proceedings from afar. Frail patients in desperate hunt for ease and tired legs of anxious relatives and friends flanked the main entrance. There was only one wooden bench on which an assortment of medical troubles squeezed in a row. It was Tuesday, November 12, at the Accident and Emergency (A&E) Ward of the Lagos University Teaching Hospital (LUTH), Lagos.
Beyond the glass-door ushering into the reception hall was a white iron gate manned by two security personnel. All distressed eyes were fixed on that gate in the utmost anticipation of being called in.
Randomly, a triage team of young doctors and nurses in green uniforms would stroll out of it within an average of 30 minutes to an hour to file in new cases and return.
Triage is typically the rudimentary phase of assessment that patients face. It includes key checks of vital signs and the identification of a chief complaint, chest pain, difficulty in breathing, or abdominal pain, for instance. Although the process is about assigning degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties, patients with evidently serious conditions, such as cardiac arrest, will bypass triage altogether and move straight to the appropriate part of the department. Moreover, the choice of the hospital was not arbitrary in the first place. Attendance was based on a referral, from private to general and state-owned.
So, after 30 minutes of waiting, I knew that triage attention was sure-fire. If the observing physician failed to notice one was dying, a friend or relative could scream or yell for attention. At least your case would make the list of pending issues. But nothing was guaranteed.
Why? “No bed space,” the doctors repeated, warning patients that opting to wait until an anonymous date or time when a bed space would be available is completely their decision. As a patient, you bore the full weight of the consequences “before you start saying these doctors and nurses are wicked or institute litigations against us, we told you beforehand: there is no space”.
Hence, there was no bed space for patients who were meandered through the horrid traffic of Lagos, on roads that rattled their soul and from hospitals that had made it clear to them that survival was in LUTH.
But in another tone of pity, as if the hunch of humanity stung them, the doctors sometimes kindly said: “If you can wait until space opens, we will take you in.”
Hearing this, patients’ relatives or guardians would switch into serious conversations with Jesus Christ, Allah or whatever thing their belief was reposed. The crux of all prayers was for a bed space to open.
In sight that hot afternoon were about 10 patients, scattered around the gate withholding their healing. While some were on the bench, others lay critically ill in commercial tricycles, taxis and personal cars. Some were fed up, so they left, but not without hurling insults and curses at the doctors, the hospital management and the government that usually fails the people. They had heard grim accounts that they thought would brace them up for the worst. Yet, they couldn’t seem to handle the disappointment when they learned the singular reason they might watch their loved one die in anguish was lack of bed space.
But they dare not! Those without alternative support dare not leave that gate. Of what use was a rage that won’t transport a sick one straight into the emergency ward?
So, they suspend their patients’ destiny on the possibility that an in-patient could be up for transfer to the appropriate wards for further care. Should that fail to happen, the prayer is that an in-patient is discharged. Without praying at all, the ugliest happens. Some in-patients die for some of the waiting patients to make it in.
In Africa, about 56 percent of deaths occurred due to Emergency Department (ED) overcrowding, an instance where the demand for emergency services exceeds the ability of a department to provide quality care within acceptable timeframes. In Nigeria, almost 60 percent of increased mortality occurred in children and elderly emergencies, according to research on Overcrowding in Emergency Departments of Referral Centres. In Lagos, it was discovered that patients admitted to the hospital during high ED overcrowding times had 5 percent greater risk of in-patient death than similar patients admitted to the same hospital when there was less overcrowding.
In danger of triage delay
Akeem Sanni, 40, happened to be on that triage list on the November 12. His wife and friends ferried him to the A&E around 3:40 pm, based on a referral by the National Orthopaedic Hospital, Igbobi, Lagos, Sheriff, one of his friends, told me as I raised a conversation on the bitter wait with him.
Typically, one of the triage doctors came out after an hour of Sanni’s arrival, noted his case and served the sad news: “There is no bed space.”
“We met about five patients here. Some left in annoyance and desperation for treatment. The doctor came and told us there was no bed. He referred us to the spillover section. We went to the spillover but we were also told the same thing,” Sheriff groused bitterly. “And we don’t have another option. Before the doctor even came out to ascertain what was wrong with my friend, we had spent over an hour here.”
The day before he landed at LUTH, Sanni was crushed by a speeding commercial motorcyclist who rode against the one-way lane between Ijesha and Sanya bus-stops, on the Apapa-Oshodi Expressway leading to Mile 2.
The 32-kilometre road went under reconstruction over two months earlier, following the activation of President Muhammadu Buhari’s Executive Order 007. In the Federal Government’s bid to decongest Nigeria’s busiest port in Apapa, the Road Infrastructure Development and Refurbishment Investment Tax Credit Scheme was signed to permit companies interested in funding road construction to do so and recover expended funds through reduced tax.
Since construction work kicked off, traffic laws were automatically suspended on the road, with drivers moving precariously against traffic to escape delays.
It was on this same road that the father of one, an indigene of Ogun State, sourced his livelihood from electrically welding pieces of iron into useful shapes. But as he returned from withdrawing some cash at an automated teller machine centre, he encountered the fatal collision that enrolled him on the emergency list. It was dusk and he was unable to spot an adjacent movement when he crossed and found his body in a fist with the motorcycle on the asphalt-laid road. The collision left his leg ruptured at knee point and the left side of his eyes with a bashing that sent torrents of sharp pains to his brains. These were visible injuries that didn’t fully account for what had happened internally.
In the rear of the black SUV where he waited, Sanni’s body was swollen all over. He could neither sit nor stand upright. At a point, his breathing began to require more effort than necessary. Impressively, Sanni was that kind of patient who had about seven concerned ones rooting relentlessly for him to get attention. Each time a triage doctor came out, they sped in his direction and circled him. But at 5:59 pm that day, the awaited news did not arrive. This was more than three hours after he first showed up at LUTH.
In a letter dated November 10, 2019, Chosen Hospital and Maternity Home, the hospital that initially assessed Sanni, kindly asked the National Orthopaedic Hospital, Igbobi, to receive him and give him expert management.
“The above-named patient was brought into our facility last night (16 hours ago), on account of multiple injuries 2o RTA, nil history of LOC. Examination revealed deep laceration, supraorbital, multiple facial bruises and thigh deformity plus swelling. Investigations done are thigh x-ray, chest x-ray (CXR) and computerised tomography (CT) Scan,” Dr Abruche said in the referral letter.
Abruche based his conclusions on the report of Paramount Lifecare, a diagnostic centre in Festac Town, where Sanni was diagnosed.
A CT scan typically reveals anatomic details of internal organs that cannot be seen in conventional x-rays, according to MedicineNet.
When Paramount Lifecare ran a CT scan on Sanni’s brain, it found multiple areas of mixed density seen predominantly in the right parieto-occipital region, with effacement of sulci in keeping with contusion bleed. A biconvex hyperdense area was seen adjacent the left temporoparietal bone in keeping epidural haematoma. There was associated hydrocephalus. Opacification of the sphenoid sinus both ethmoid sinuses and thickening of the left maxillary sinuses were seen.
The impression: left epidural haematoma with right cerebral haemorrhagic contusions and temporoparietal bone fracture with opacification of paranasal sinuses.
In plain terms, this meant the accident caused internal bleeding in the brain and the bleeding had formed a mass. Epidural hematoma is a traumatic accumulation of blood between the inner table of the skull and the stripped-off dural membrane. In 85 to 95 percent of patients, this type of trauma results in an overlying fracture of the skull.
Due to this, the orthopaedic hospital didn’t take him, arguing that LUTH would be in a better position to deal with the problem, Abdulhakeem Shittu, one of Sanni’s friends, explained.
Now, Sanni’s other friend who owns the SUV that brought him wanted to leave but he couldn’t because LUTH did not take over the care until about five hours after his arrival at the emergency gate when a bed space finally opened.
I pushed for an opportunity to stand in as one of Sanni’s relative but it wasn’t successful. Sanni’s wife was particularly soaked in so much apprehension that she had no room left in her mind to nurse the idea of a reporter following her husband’s case when it didn’t help with the medical bills or avail him special attention. The hospital rule also did not help, as a patient only had the allowance of an individual to monitor.
Failing to win the Sannis on my side, I returned to my initial spot behind the wooden bench. By then, more patients had joined a raft of squirming others. It was getting darker.
The black SUV that brought Sanni had moved out of the car park. Two cars were now occupying the space with patients in them. In one was a slender woman of about 60 years old lying in the back seat. She battled with a diabetes case that had advanced into a footsore. With her were her husband, daughter and friend. She arrived at the emergency unit at around 7pm, just about the time I returned.
But a more critical case of respiratory challenge had been queuing three hours earlier. Ebuka Ogbonnaya, 37, an indigene of Abia, arrived at about 4pm. Even without careful parsing, one could tell that he was so ill.
Pale and lean, his skin cringed ungracefully towards his bones. Conversely, his stomach, legs and feet were swollen. His breathing was heavy. Lying on his back was a huge luxury he couldn’t afford. And without taking on any strenuous task, he easily grew tired. He couldn’t even walk any reasonable distance. All he could do was sit and moan in discomfort. And while different doctors had noticed him, only one managed to grant him condition-specific attention.
“The doctor who initially attended to my husband only wrote his name and checked his blood pressure. Another doctor came complaining that the first should have asked us to go for an x-ray, because it’s the beginning of the treatment. He gave me prescriptions to the radiology centre,” Blessing, Ogbonnaya’s wife, explained in response to my inquiry, as our friendship started to gain ground.
“The result was released around 12am on Wednesday. I ran back to the car park to show any available doctor. When he came out, he insisted that there was no space. And my husband has been complaining of serious body pains since I brought him. No one listened. They kept saying there is still no space, since afternoon!” she said.
She could have reserved her annoyance if she knew how many hours more her husband would writhe while waiting in the queue. The dusk had finished falling. It was midnight and time to retire for the day. They moved towards the open area of the out-patient ward beside the A&E to secure a sleeping space as fellow frustrated patients did.
According to LUTH’s radiological report, Ogbonnaya wrestled with near-complete opacification of the right hemothorax with obliteration of the carbothermic angle and the hemidiaphragm in keeping with pleural effusion with the upper margin at the left of 2nd artemia rib.
“Right sided pleural effusion and left sided pleural effusion,” Dr Jayeola Adenuga stated as his conclusion on Ogbonnaya’s case.
Prior to LUTH’s assessment, the Federal Medical Centre, Ebutte-Meta, had described Ogbonnaya as a biventricular failure patient who presented on account of generalised body weakness, difficulty in breathing and leg swelling.
“He is currently being managed for biventricular failure secondary to dilated cardiomyopathy with congestive hepatopathy,” read the report. “Chest X-ray done today revealed massive pleural effusion. Please kindly review the patient for expert management.”
When asked, Akeem Olowofela, a resident doctor at Federal Neuropsychiatric Hospital, Aro, Abeokuta, categorised the case as an extreme one that required urgent attention. It involves vital organs that are averse to disturbance, although temporal stability is possible. It is a chronic situation that should be treated promptly.
Giving similar verdict, Babayemi Osinaike, head of emergency at LUTH, confirmed that Ogbonnaya should have had access to treatment in less than two hours after he was triaged. He categorised his case as Level 2, only next to an acute condition.
“On the average, something should be done within four hours. For a pleural effusion, in fact, they should have responded to you as quickly as less than four hours,” Osinaike said. “Once a chest x-ray is done that shows that there is an effusion, a chest tube should be inserted first and foremost into the patient’s chest while the other root causes are being addressed. It shouldn’t take more than an hour to two.”
A&E Ward: Intensive care, extensive problems
Two options are available to access the A&E ward: using the main entrance or the back channel connecting to the rest of LUTH. Under an arrangement to access the ward as a nursing student, I took a trip via the back.
Signs of renovation undertaken by Stanbic IBTC Bank in February 2018 were still fresh, especially at the reception. There was a colourful wall poster attempting to cheer every eye that met it. It had different characters on it, from smiling doctors to a playing kid, two aged elders, and a police officer by the road. “We are happy to know that everyone is getting on well”, “We hope to see you back in full fitness”, “Your recovery means a lot to us” and more were thoughts ascribed to each character.
All the modern patient beds in the hallway were those donated by the bank. But moving further into the wards, evidence of old, rusting beds hung around. The shock: the accident and emergency ward has about 35 beds. Ten of them were available in the medical emergency unit, 10 in surgical emergency and four in the gynaecology unit. The Intensive Care Unit boasts of only four beds and all were occupied, except for a few bad ones. These are units responsible for tending to referral cases from various federal medical centres, general hospitals, private hospitals and more in Lagos, a state populated by over 20 million people!
For context, about 60 to 65 patients seek care at the ward every day, according to Osinaike. Out of these 65 cases, investigation based on in-patient registration revealed that only 20 were pooled into the ward daily. The register accounts for only those that make it into the reception as new cases and are registered.
What this means is that if a patient admitted earlier into the ward does not leave at the appropriate time for one reason or the other, the next person who requires that service will continue to writhe in pains at the car park. This happens often.
With a National Health Insurance Scheme (NHIS) that caters to less than 5 percent of the country’s population, many patients are so overwhelmed by the cost of diagnosis, surgery, drugs and admission into wards that their relatives and friends spend considerable time raising money. Some patients spend two to three days scampering the town for help, directly blocking access to others waiting outside.
In terms of the concentration of doctors for every shift, accident and emergency ward happens to be the ward with one of the highest. About 10 doctors were officially assigned: two in triage, three in obstetrics and gynaecology, three in medicine, two in surgery and four as house officers. But they are all never available.
Spillover filled to the brim
Ebuka Ogbonnaya and his 28-year-old wife, Blessing, were back on the wooden bench. This time, it was with severe depression. There was no bed still, but some patients who met him there were making it into the reception.
A light-skinned, slender lady was the triage doctor on duty that day and she had begun taking trips from the reception to the car park, singing the no-bed-space rhythm. By then, Ebuka could not conceal his fears any longer. He broke into tears and sobbed carelessly, although muffling his tone.
“Abeg, no cry o. No be now you go cry o. Since all these days, you no cry. Na now you wan come dey cry? No be now o. Just look for the sake of your children,” his wife admonished him.
Ogbonnaya’s tears triggered a fresh wave of discomfort about the length of the uncertain wait. Blessing and I resolved to intensify pressure on the doctor. By then, I had won the couple’s heart, and it didn’t amount to going overboard when I introduced myself as Ogbonnaya’s younger sibling the moment the doctor showed up.
I reminded her that Ogbonnaya had been struggling with pains since Tuesday. But this time, her response was a piece of paper recommending that I try the spillover section, a privately-run emergency just behind. The section is a private wing where patients not admitted to the emergency ward are forwarded. On the spot, the admission fee is N50,000, a fee without which nothing gets done.
However, after a quick sizing up of Blessing and I, the receptionist did not delay to tell us there was no bed space. The same song echoed from a private emergency centre. In fact, it was hard to swallow that a private wing where we would be paying for special attention would turn us away on account of a lack of bed space.
But, again, we probably just didn’t measure up as persons capable of coughing up N50,000 all of a sudden. Blessing’s low-cut hair was tastelessly wrinkled. My plaited hair had lost its fine lines to bushy undergrowth and edges.
We couldn’t just quit. So, we appealed to them again to please double-check for the latest development. But the receptionist, frantically this time, asked us to check back later. When is later? She couldn’t answer. But just keep checking back, she said.
LUTH’s ‘second to none’ spillover ward is a sham
Under a scheme labelled LUTH Initiative, the Accident and Emergency Spillover Ward was inaugurated in 2009. It was designed as a 36-bed facility to save patients that can’t be absorbed in the main emergency ward, according to the details provided on the LUTH Initiative’s website.
The original layout of the department is three wards each with the capacity to accommodate 12 patients. The first ward admits critically ill patients and those in row for resuscitation.
The ward is touted as having a fully-equipped emergency cart in the resuscitation bay, two multi-parameter monitors, and oxygen supply guaranteed at all times with the presence of an oxygen concentrator for backup to the regular cylinders.
“The nursing care available at the spillover ward is second to none, with caring, dynamic, ready and eager-to-assist nurses available just a few feet from the patient. Doctors in the regular emergency department also provide cover for the ward, alongside the various specialty unit doctors,” says LUTH.
But striking as these features are, all that glitters is not gold.
At 7:11pm on Tuesday, November 12, only eight out of 12 beds were occupied by patients. Three were empty. There was a particular corner that naturally ought to nest about two beds but it was choked with four bare bedframes without mattresses on them.
It was unlikely that all three of the empty beds would have been occupied as at 10:47am on Wednesday when we went seeking admission.
According to the attending nurse, what started out as a 36-bed facility was now operating with 20 beds. Therefore, more often than not, the spillover centre would turn down patients almost twice as much as the main emergency ward would. Refusing a patient was not unique to Ogbonnaya. I had become friends with five different relatives of patients whose efforts to get admitted to the spillover I monitored.
Death, resurrection, no oxygen, second death
Two weeks before this investigation, Mrs Adeniran literally died twice with the support of the unresponsive main emergency ward and the profit-centred spillover ward.
The sweeper was a septuagenarian who worked 35 years in LUTH and still returned under locum staffing in the Ear, Nose and Throat (ENT) clinic. Suddenly, her health took an awful turn and she began incessant stooling, one night. She got worse and was rushed to the A&E, but was referred to spillover for lack of bed. In no time, she was declared dead.
At the mortuary, however, an official who was to file her in noticed a strange gesture: a dead body breathing. Mrs Adeniran herself mustered a great deal of strength to wave her hand and the official was forced to announce to her relatives that she didn’t belong there. Another race to save her began, and she was back at the spillover.
But the ward, which prides itself as having a guaranteed oxygen supply at all times with the presence of an oxygen concentrator for backup to the regular cylinders, could not immediately provide oxygen for Mrs Adeniran. The ward asked her daughter to quickly get oxygen from outside and before she returned, Mrs Adeniran finally died a death that many familiar with the case believe would have been averted. She had the opportunity to live but there was no emergency response to seize the day.
“She had no business dying,” a nursing official who cannot be named for fear of retribution told me.
In Ogbonnaya’s case, the ward didn’t even give us the opportunity of admission; we were only assessed. By the time we returned about two hours after the initial visit, the receptionist had to come out clear that she doubted our ability to pay.
One of the two security personnel at the gate offered to help, after explaining our frustration. He told us he saw some patients leaving earlier, meaning a space was possibly available. Once he led us in, reintroducing our case, the receptionist snapped at him, sternly reminding him that his duty post was at the gate.
To be continued next week…