The entrepreneurship bug

So i caught the entrepreneurship bug!

It was the start of May 2014, I'd over the preceding weeks had a family member in Abuja, Nigeria who had some health issues. The travails we experienced in attempting to get quality care was distressing. Particularly as finances were not the limiting factor but rather systemic issues that conspired to provide mediocre care.

As  i pondered on this problem i suddenly got the bright spark of an idea that would improve the quality of the health system. The idea filled me with such excitement that i wanted to quit my job right away and jump on a plane to get started on my idea.

Unfortunately reality soon set in, I  had bills to pay, a family to raise etc. I was convinced however that i was on to something. In my mind's eye i had this vision of the wonderful change my innovation could bring. The next logical thing for me to do was to put it down in writing, my business plan was born! I spent hours and days without sleep working on it. I've subsequently gone on to find out the traditional business plan has fallen out of favour particular in tech ventures - my bright idea is a tech venture that aims to improves the quality of healthcare.

So while i had the momentum i bought a domain and webhosting on the 11th of may. Money had been spent i was committed!

Now this may not apply for others but for me, writing down a business plan was useful as it helped solidify my thoughts and forced me to do more research and gain more knowledge. The more work i did the more of a knowledge gap i realised i had. Next step thus was to hit my local library. I browsed the business and IT sections and picked up 2 books - 'the lean startup' by Eric ries and 'how to start a tech business' by Alex cowan. I went on to find out that the former book was a huge bible for tech startups.

...And so my study began.

Key performance indicators

Browsing the intranet of my hospital, I came across the quarterly hospital health target report.

The report consisted of parameters the ministry of health requires all hospitals to report. These parameters are in areas the ministry feel are important goals - so called 'health priorities'-  that are to be met in order to fulfill the need of the population accessing healthcare.

This is not a new phenomenon, the idea of key performance indicators (KPIs) is wide spread in business and is used to judge performance as well as highlight areas for improvement.

It is also a useful goal setting strategy that helps keep the goal always in focus. While it can be detrimental in that focus may start to shift to numbers than perhaps what the numbers are trying to achieve, it is felt to be generally a good thing that most organizations and governments imbibe.

A look at the KPIs for this particular health ministry, summarized in a webpage that houses the results reveal targets in:

- Shorter stays in emergency department - 95 percent of patients will be admitted, discharged, or transferred from an emergency department within six hours.

- Improved access to elective surgery - volume to increase by 4000 discharges per year

- Increased immunization - 90 percent of 8 month olds will have their primary course of immunization on time

- Shorter waits for cancer treatment - all patients ready for treatment wait less than 4 weeks

- Better help for smokers to quit - 95 percent of hospitalized patients who smoke and are seen by a health practitioner in public hospitals and 90 percent of enrolled patients who smoke and are seen by a health practitioner in general practice are offered brief advice and support to quit smoking.

- More heart and diabetes checks - 90 percent of the eligible population will have had their cardiovascular risk assessed in the last five years.

The data from different regions are collated and a quarterly reported published. One is then able to compare data across different areas and times for the whole country. The public are aware of it and have certain expectations when they access health care. Staff also have defined targets to work towards in their everyday roles

Over time it is easy to see where one needs to appropriately target interventions or employ different management strategies to ensure improvement. 

These indicators are obviously well thought out, with specific numeric targets. It shows homework has been done and the government has chosen priority areas to invest time and effort to improve the well being of the population. It is also safe to conclude that systems exist to gather this information.

Seeing this, i did a google search for any similarity in the Nigerian health system. To my surprise i came across a national health plan. The plan was laudable in that it was quite a detailed document that had reasonably specific targets and KPIs. The more i read the more obvious it became to me that quite a lot of work had been put into it. But as often is the case with Nigeria, many a great reports are left to rot on government shelves while the status quo carries on.

Where the plan was further let down was the lack of data. Several indicators couldn't be measured as the data just wasn't available. Furthermore the number of KPIs were large, this in my opinion defeats the purpose.

What is needed is something like the much maligned 7 point plan of former president Yar'adua (God rest his soul).

7 indicators with achievable goals, monitored quarterly, easily measurable and impactful in the day to day health of the average individual. This should then be easily accessible to the general public who can compare, contrast and put pressure on the right people when needs be to make sure things get done.

Of course more systems for data collection needs to be put in place to facilitate this and people and healthcare workers need to be educated and carried along. All in all it's not that difficult, all that's needed is the will and we know that when there's a will there's a way!

Emergency medical service - As simple as ABC

I'm currently doing a stint in the Emergency department in a country in the Pacific working alongside great doctors and nurses. They all do a great job saving lives and providing good service to the local community. It made me think of what options exist in my beloved homeland Nigeria for people in need of emergency medical attention.

A Google search of 'emergency medicine nigeria' doesn't yield much evidence of a structured approach to the delivery of emergency care. Several websites allude to the non-existence of a working state ambulance service or a national emergency telephone number such as a '111', '911' or '999' (depending on where in the world  you are).

Thankfully some private groups have attempted to fill the gap but their attempts sadly fall short of what is needed. Their services while laudable are either not skilled enough or not well publicized. What's more deterring is the phone numbers they encourage people dial in case of an emergency. The numbers are often longer than the numbers on a lottery ticket! tough enough to remember on a good day, much worse when in the panic stricken state of an emergency. Reminds me of an episode of 'IT crowd' where '999' is changed to '011 899 988 199...' (See video here)  Perhaps they should try a similarly catchy song!

The poor state of  the existing situation is seen here in a Nigerian paper on Pubmed (read here). The authors tracked over four years how victims of rood traffic accidents presented to an emergency department in Ilorin. A whooping 52% of victims were brought in by relatives and 40% by police or FRSC. In the majority of these instances no intervention was given during transport, furthermore none of the transporters were trained in any type of life support, not even the police or FRSC officers! This paper makes dire reading!

So now one has somehow made their way - against many odds- to the emergency room, what service do they expect to receive? Stories abound on how patients are required to deposit large amounts of money before they are attended to (follow my friends blog http://amahzeeing.blogspot.co.nz/ who writes from the front line on some of the problems plaguing our hospitals)

When money is finally deposited, one obstacle after another surfaces. an instance of a fatal obstacle i read recently is that of a vibrant young girl (read here) who was having an acute asthma attack. She arrived at a hospital that had no supply of oxygen thus had to seek attention elsewhere but sadly passed away before she could be treated. Tell me please how can an emergency room not have oxygen! It's simple ABC - Airway, breathing, circulation. If an emergency room can't manage ABC it has no business taking emergencies or calling itself an emergency room.

A similarly sad story was told  to me during my medical elective in Nigeria. It goes as follows: a patient had come in severely distressed and was in danger of losing his airway. A call was made to secure the airway  through the placement of a tube that goes directly into the windpipe, to do this one needs a laryngoscope. Okay so people run around frantically searching for the scope and finally find it! yay, a life will be saved, not quite. The scope has no batteries to power it. Another frantic search for batteries ensues, yay! a drawer full of batteries found, a life will be saved. Not quite. The drawer is locked and the key holder is nowhere to be found. A life slips away.

The system (used here in the most liberal sense of the word) is broken from top to bottom, nothing works. Nil to few people really care. More must be done, life cannot be as trivial as it currently is. Other than the obvious setting up of an emergency number and a good ambulance service the following suggestions in my opinion can improve emergency care as it currently is:
 - All secondary school students should be taught the rudiments of life support,
 - Police and road safety officers should be required to learn basic life support and
 - Emergency departments need to be tightly regulated to ensure they possess a bare minimum of materials and services or be shut down.

I believe if the above are implemented a big difference will be observed in our emergency care in Nigeria. They are not too difficult to do and is not to much to ask, all that's needed is the will. It's really as simple as ABC

I recently came across a website that aims to build up the blood donor database in Nigeria. It's by a group called the one percent project who want to create a 10,000 strong army of volunteers who regularly donate blood.

This is a laudable project that i support fully. Read here my post on blood.

It's not everyday you get a chance to 'Be a hero, it's in your blood'.

Of medical errors

Here's a great anecdote lifted from the blog of Dr Kavanagh a rheumatologist:

In my first few months working as a rheumatologist a referral letter arrived from a local doctor about a lady with rheumatoid arthritis. She had recently moved to the West of Ireland from the UK, where her original diagnosis had been made. Her GP had originally referred her to a general physician in a small local hospital who had struggled with her care and she was looking for second opinion.


After assessing her, it quickly became apparent that original diagnosis had been incorrect. The patient had numerous explanations for her pain other than rheumatoid arthritis and the investigation that was likely to have prompted her original diagnosis (a positive rheumatoid factor test) as due to the fact that she had Sjogren’s syndrome (a condition which causes dryness of the eyes and mouth).


My specialist pride congratulated itself on making such a clever diagnosis and for being smarter than either the physician who had cared for her of late or the rheumatologist who had made the original diagnosis. Gosh I’m good, I thought.


‘That’s wonderful news Doctor. You mean I don’t have rheumatoid arthritis after all?’


‘Not in my opinion you don’t.’


‘Its great to see someone who knows what he’s talking about. Do you mind me asking where you did your training?’


‘In the UK. In Cambridge mainly.’


‘Really Doctor? In Addenbrooke’s?’


‘I was there for 4 years.’


‘That’s amazing. That’s where I was told I had rheumatoid.’


With that she thanked me, stood up to leave, and just before she left the room, turned to me and said;


‘I knew you looked familiar.’


It’s never a bad idea to get a second opinion. Even if it’s from your self.

Blood

Blood courses through the vasculature of mammals bringing vital nutrients to every cell and ferrying waste substances away to be excreted. Blood flowing is synonymous with life, a lack of or stagnation of blood similarly signifying death or at least its proximity. Blood is central to all that the body does. A simple biopsy of it with appropriate testing can reveal the onset of disease, its severity, rate of progression and whether or not disease will respond to treatment. When lost it must be swiftly replaced with a suitable type.

Pro reason

The recent death of a pregnant woman in Ireland has caused huge furore in the polity of the republic. While the exact details of the case are yet unknown many have been up in arms over the claim that the pregnant woman's life was lost as a direct result of the prohibition of abortion in Ireland. Many pro life and pro choice groups have clashed repeatedly and the debate rages on. This series of events resurrected in my mind the thoughts I've had regarding abortion. 

Abortion is always a difficult topic and with most difficult topics there usually isn't one right answer. In my mind's eye i can see situations where i will be in favor of abortion. One such instance is that of rape where contrary to Sen. Todd Akin, pregnancy can and does result. Conversely i would be against situations where a pregnancy is unplanned and abortion is used as a form of contraception. Grey areas exist in my mind regarding abortions for fetal abnormalities and severe congenital/ genetic conditions. I can understand why a parent may want an abortion in these cases but I can also see how permitting that would begin a descent down a slippery slope towards eugenics, a practice many will agree is less than desirable. 

I believe that a baby has a right to life. The real issue is determining when that life actually begins. Is it when the sperm fertilizes the egg, when the morula is formed, when the fetal heart begins beating or when... i could go on. The bottom line is we don't know and we probably never will. What i do know though is the immense joy children bring into the world often regardless of the circumstances surrounding their conception or the state of their health at birth. Children bring hope and joy, the possibility of change and a new beginning. They also bring lots of poo and tears but we'll gloss over those! Abortion on the other hand in my experience brings adverse emotional and psychological  effects to not a few women. Some psychiatrists argue that research hasn't revealed measurable difference in the mental well being of women who have undergone abortion. I however still have my doubts probably due to the anecdotes i have come across that suggest otherwise. 

Finally you ask, so what should we do? legislate for or against it? What i have thought up is an independent panel that consists of legal and medical experts that women can apply to and have their case for an abortion to be heard swiftly. They'll always be available, take into consideration all the potential issues and ramifications and give a decision accordingly. I know this will give rise to many new issues but that's my little stab at the problem. The real answer: I don't know. I spare a thought often for women who have to consider this difficult option.

  

Our very own prof

Prof Osotimehin, former Nigerian health minister is now executive director of the UNFPA.

After the break is his profile and an interesting interview with him, Culled from the BMJ

His response to the last question is one that resonates with me.

The end is in sight

As i sit in my room procrastinating another study session for my fast approaching exams, i mull over the journey that medical school has been so far. After 5 years of hard work and studying, i complete my undergraduate medical training in 4 weeks. The time has flown by so quickly, it's been full of many great and memorable experiences as well as many hard times.

Now it's on to the intern year. I don't yet know where that'll be, maybe in the first world, maybe in the third world, either way i know it will be fun and eventful and full of stories for this blog.

I hope to write more in the coming months and years

Communication skills

So I'm back writing again thanks to someone whom I spoke to sometime ago who had read the blog and liked some of it. I'm sure she's representative of millions of others (in my dreams maybe).

Well speaking to her reminded me of several experiences I had while doing a rotation in surgery at the national hospital Abuja that I'm yet to write about. One such experience I relate below.

I've been doing psychiatry for the past few weeks and there's been an emphasis on communication skills and its importance in the interaction with the patient. So why tell us about it I hear you ask. It's simple, learning about communication reminded me of the awesome skills of the great surgeon I worked under in the hospital. This is an excerpt of how a consultation with an elderly cancer patient went.

Says he: 'ah na cancer oh! Wetin we go do!'

Patient (replies with some trepidation having heard for the first time she has cancer): whatever you say doctor.

Doctor: we go cut am off.

Patient: ah! Cut am off?

Him: yes na. Abi you day use am for anything!

Where was the cancer I imagine you asking. Well wait for it... it was in her left breast!

GNIB

I sit now in the waiting hall of the garda (irish police) national immigration bureau waiting to dole out 100 euros to the government for letting me stay in their country. This whole process irks me in so many ways. Why doesn't the Irish government operate a sensible student visa system as most other countries have. What's worse is the treatment one gets is so shoddy, hours are wasted and no real service is given. I wish they'd scrap it altogether. Hardly gonna happen though, think of all the jobs that'll be lost!

Back in Dublin

I'm back in Dublin after a rather short six weeks in Nigeria. I've much better internet here so i'll put up some pictures from my time in Nigeria. I'll as well post my thoughts and experiences from my two weeks in surgery, that's if i can remember much at this point.

On the left are house officers of the general surgical team and the two females are students just like myself

Hiatus

I apologize for not writing anything for the last couple of weeks, I've been both tired and lazy. I finished my two weeks in surgery today, it was quite eventful. The cases and the stories behind them were bizzare, sometimes bordering on outright madness. The cases would fit quite nicely into an episode of ER or Grey's anatomy.

From gunshot wounds to stab wounds to machete cuts and road traffic accidents, We saw them all. Late stage breast cancer was a regular occurrence and lumps only appeared in two sizes: large and extra large.

I'll give a retrospective account of my experience in the coming days. for now it's time to rest and enjoy the rest of my holiday.

Weekend

It's the weekend finally, looked earnestly to this weekend to take a break from getting up early and going to the hospital. This week started out slowly but ended up being quite eventful. It was filled with house officers being berated by their seniors left, right and center, rows breaking out between the team and a patient's mom and vehement abuse from a family who lost their mother.

Back again

I'm back finally from the short hiatus. The lazy bug bit me as well as the network problem blog. Over the past week i've been able to attend a conference hosted in Abuja by the association of Nigerian physicians in the Americas. It was quite an interesting and enlightening conference. I met so many Nigerian doctors, specialists in their fields from all over the world. What delighted me the more was meeting several medical students like myself. Overall it was encouraging to find that a large number of people are interested in the well being of Nigerians and are indeed taking active steps to improve the standard of health care delivery. Some government officials attended the conference and as usual were full of talk about health sector reforms, it remains to be see if all the talks and plans will result in improvement of the health indices of Nigeria.

... and the strike continued

Drove into hospital today alongside some crazy drivers, Yes that's what most of the drivers in this city are, crazy. Dodging and weaving through traffic was the norm, cutting in and out of lanes a regular occurrence. Had to avoid several people so many times. I got to the hospital finally only to learn that the strike was still on . Today no nurses were in and those that came only did so to insist that all patients be discharged. I went to the seminar room to join the team in their morning presentations. The seminar room was small and jam packed with people. No air conditioning was available so it was sweltering. Finally the meeting came to an end with me drenched in my sweat.

Dr UE called me aside and advised me to go somewhere else for the duration of the strike as the hospital was slowly grinding to a halt. We proceeded on a ward round around 4 patients whom were all advised to make arrangements to transfer themselves to another hospital. I conducted a general examination on the Aids patient with really bad bed sores that began to ooze a greenish, foul smelling liquid. His tongue had a black discolouration on it and he had sores all over his mouth. In summary he was really ill! it never ceases to be a sorry sight every time i go in to see him. AIDS is now a real sight to me as evidenced by this patient and no longer a thing in the books. Rounds didn't last long and i soon left for home. Now to look for somewhere else to continue my hospital attachment

...wednesday

Today was a short day, After my experience yesterday i didn't go in to hospital till 9. Result was i arrived late for an emergency consultant ward round. The consultants weren't scheduled to conduct a ward round today however they had to come in as the news of a nurses strike broke. The nurses went on strike at midnight bringing most activities in the hospital to a halt. Heard a story from someone that a woman was in the height of labour in a delivery suite being urged on by a midwife to push. At the stroke of 12 she left to wash her hands and commence the strike, abandoning the groaning woman in labour. Said she: ' I told you to push hard for a reason before 12 now it's past 12 i'm gone on a strike'. Doctors had to be drafted in to do the midwife's job. Same was the case on the wards as the doctors had to take over the duties of the nurses. The team discharged who they could. For those they couldn't, they encouraged the patients' relatives to be involved in the nursing care of their patients. Intra venous drugs were discouraged and no new patients were taken in.

With the nurses strike most of the activities of the hospital were paralysed. The team now had time to critic my history and give me tips on how to improve my technique of interviewing patients. Downside is that patients care suffered and the doctors had to stay in till later than usual. With nothing else to do i left for home today earlier than i'd done before.

Hopefully the strike ends soon and normality returns. However speaking to several doctors didn't reveal a huge amount of optimism. They indicated that things had been deteriorating for a while and that indications were that change is far away from the horizon. I feel that it is rather unfortunate that a government would treat its front line health care workers with such disregard and impunity that they have to resort to strikes to gain their attention and force them to effect change. It's bad enough the situation that they have to work in, but with the relatively meagre pay and unfulfilled promises of raises and allowances a poor situation is made worse. Conversely the leaders get paid all their salaries and allowances well before they are due when the only thing they do really is sit and talk. If they talked about how to affect peoples lives positively maybe they'd deserve their fat pay checks, however they talk about laws banning homosexuality, indecent dressing and certain television programs. Seriously! in a country where many people live on less than a dollar a day surely there are more important and pressing matters to address. I don't support any of the aforementioned vices but a government of many poor people should seek to improve their well being before legislating on how they live. That's my 2 cents!

Tuesday and wednesday

Tuesday the 7th came around and i dragged myself out of bed to get ready for my first hospital consultant ward round at 8 am. I got there on time, not the case for the other members of the team who were vital to the ward round. We waited for everyone to arrive and finally commenced at 9.30 am. Dr UE introduced me to the team, we then proceeded to our first patient.

Patient A was a schizophrenic who had a myriad of problems that i couldn't quite grasp. The consultant spoke to his mom for a few minutes and ignored them for the rest of the time we were there as he quizzed the residents and house officers about the case. The patient lay asleep on the bed, noticeable on his ankles were bruises from being tied down the last time he was in a hospital. I didn't know that such crude methods were still being used to restrain psychiatric patients. We moved on from patient A to Patient W. Patient W is a patient with HIV that has progressed to AIDS. His CD 4 count was 5! (normal range is 500-1600). He looked really sick and cachexic (thin and emaciated) . Worse still he had a bed sore from lying in bed all day. Dr UE called me around to take a look at the sore. Suffice it to say that it was one of the more disturnbing things i'd ever seen and i've seen quite a number of disturbing things. I am beginning to see that HIV is indeed endemic in Africa.

First day of elective

Finally monday the 6th of july has come around. This day marked the beginning of my 5 week elective in the National hospital Abuja. I woke up brimming with excitement and expectation with a slight dose of uncertainty as to what to expect. I left home with enough time to get to the hospital for 8.30 am. Took a taxi and arrived there within 20 minutes of leaving my home, the hospital turned out to be closer than i expected. I found my way- with the help of a couple of people- to the office of the director of clinical services., where i was expected to report. Emmanuel welcomed me into the office with a cursory greeting. He gave me a letter to pass on to the secretary of clinical medicine, the department to which i had been requested to be attached.

Back Home

Yay! I finally made it back home to my beloved city of Abuja, the capital of Nigeria, the heart of Africa. Well so the sign said that welcomed me to the Nnamdi Azikiwe international airport Abuja. Dr Azikiwe is one of the most distinguished Nigerians to grace the earth, that's a story for another day. Now back on point i'm back home yay! oops said that already.