Thursday, April 27, 2017

Cardiothoracic Surgery in Nigeria

Asishana Avo Osho, MD, MPH
Resident in General and Cardiothoracic Surgery at Massachusetts General Hospital

Cardiothoracic Surgery in Nigeria: Entry 1

Driving from Lekki to Ilishan-Remo (Ogun state) served as a reminder of the range of living environments that Nigeria offers. Starting in Lekki with its nice “roundabouts” and nicely constructed toll gates, I drove through Victoria Island and Ikoyi where opulent car dealerships and fancily named restaurants – the “Golden Gate” restaurant to give one example – line the streets. These areas constitute “Lagos Island” where much of the Money in Lagos is exchanged. The financial market share of the Island is soon to increase exponentially as the much advertised Eko-Atlantic city – heralded as the new financial center of Nigeria, and maybe even of West Africa – branches out from Victoria Island. The 25 km2 city, created in the Atlantic Ocean by land-fill is very much in its inception, but almost all the available land has been sold for upwards of $2,000 (US) per square meter. The transition from Ikoyi to the Lagos mainland is somewhat gradual, but still noticeable as the number of people lining the streets more than triples while the number of well-maintained buildings decreases.

As we get toward the outer edges of Lagos, the nicer cars including a few Porches, “Bmers” and “G-wagons” are replaced with an infinite number of Danfos – the yellow and black “open air” commuter buses that most “Lagosians” depend on for transport to and from work. The cars begin to take on this brownish hue as the dust from poorly maintained roads rises and settles all over them. Over-crowded shanty towns can be seen miles into the distance interrupted only by “Mega Church Cities”, patronized by swarms of Nigerians in pursuit of “salvation”. We then exit Lagos into Ogun state, via Shagamu, where there are few cars on the road at all. We got lost in a village – Google Maps had been faithful till that point, but let us down a few miles from our destination – but ultimately made it to Babcock university by mid-morning (Three and half hours after we set out – 58 kilometers or 36 miles in total)
Babcock University Gates
 The gates of Babcock university stand tall in Ilishan-Remo a small town in Ogun state. Operated by the Nigerian Seventh Day Adventist Church since 1959, Babcock University has faculties in various fields including medicine and nursing. The campus itself is somewhat of a mini city with separate buildings for primary and secondary school students, a university owned hotel, and a large store, also owned and operated by the university. Overall the feel is not too unlike my Catholic Boarding High School in Abuja, Nigeria, just on a much larger scale. Tristate Cardiovascular – my “home base” – is located just to the left of the Babcock University Emergency Department. With large signs in front of the building and doors that are styled quite differently from the rest of the teaching hospital campus, it is evident that Tristate is an independent entity within the University campus. I would quickly learn however, that Tristate is very well integrated with the rest of the teaching hospital sharing in addition to the location, patients, pharmacies, laboratories and imaging departments. 
Tristate Cardiovascular Entrance
Tristate Cardiovascular was established in 2015 to provide the full spectrum of cardiovascular care – including open surgical and percutaneous techniques – within Nigeria, on a regular basis. The dominant model in Nigeria for complex procedural cardiac care remains medical tourism, whether it be patients traveling for care or foreign specialists coming into the county for short term stints. The goal with tristate appears to be some degree of industry disruption as the whole team is based in Nigeria and provides routine and emergent cardiac care on a regular basis. Having completed over 100 open heart surgeries, it would not be premature to say that Tristate is making some meaningful contributions to changing the standard.    

My first interaction with Tristate staff was a gentle scolding from the security staff as I attempted to step into the center with my “street shoes”. I had seen the nearly full shoe rack just in front of the center, and the row of white sandals just inside the door, but it didn’t register that I wouldn’t be allowed in with my regular shoes. After trading my black Aldos for clean white sandals, I continued into the air-conditioned waiting room. I was then led into the main building which has a simple set up: a central physician call room surrounded by the rest of the core facilities including a large major cardiac operating room, a separate large cardiac catheterization lab with a standard control room set up, a two-bed step down unit and an open 9 bed intensive care unit with one isolation room. Besides the open set up of the Intensive Care Unit, the entire facility including equipment and operating rooms seemed on par with what I’ve seen at multiple major academic centers in the United States – testament to the lofty aspirations of the Tristate leadership. Through the course of my stay at Tristate, I would ultimately be involved as a first assistant in almost 10 major cases including adult and pediatric open heart surgeries. As with the facilities, the operating experience was not very different from what I am used to.
Operating Room Suite

Catheterization Lab Suite
Walking through the center and meeting the staff that first day, I wondered if there was a color code for scrubs – ICU nurses seemed to be in pink, OR nurses in blue, catheterization lab techs in brown and our lone cardiology fellow in green. Regardless of the color, everyone seemed very friendly and excited to be at work. At the time, we had only a few patients in house but I remained very excited about the possibilities. Admittedly I expected much less and was very impressed with what had been set up at Tristate. I went to bed that first night with one thought in my mind: So much to look forward to…  

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