Medical Director, National Orthopaedic Hospital, Igbobi, Lagos(NOHIL), Dr Olurotimi Odunubi, says orthopaedic surgeons are trained to restore limbs and not to cut them. He said one of the reasons limbs are amputated is the severity of the injury.

He also mentioned late presentation of patients to hospital and complications that often arise from patronising traditional bone setters as part of the reasons. The Medical Director who saw the transformation of NOHIL into a modern orthorpaedic care centre explained how the  task was done. He spoke with AZOMA CHIKWE. Excerps.

Why do people associate orthopaedic hospitals with amputation of limbs.?

No orthopaedic surgeon will really want to cut a limb. For instance, our motto in this hospital is service, care and restoring. That is the reason you have restoring there. So, there are reasons why limbs are amputated. One of the reason is the severity of the injury. A limb survives based on blood supply. If by the time a patient comes to the hospital and the part of that body has not received blood for a long time and its dead, if you keep it, that dead part that has not received blood will affect the living parts.such patient will die from infection, so the dead part has to be removed. And that is based on the severity of the injury, or late presentation.

Some people have cancers of the limb and they don’t come to the hospital on time. If they come on time, that area can be surgically excised and replaced. But when it has spread and has destroyed other tissues, there is no other way than to amputate it.

Another thing is a lot of limbs that has been amputated are as a result of complications from traditional bone setters. A limb that is fractured, there is a tendency of that bone to heal (not all cases though) even if you don’t do anything, because what heals the bone is already in the blood. If you put POP in the limb, you are only using it to set the bone in position. If a patient has eaten good food and is well nourished, the blood will heal the bone, not the POP or operation. Those are not what heals the bone, they only set e bone so that they are in a proper position while it is healing.

The traditional bone-setters also apply spleen, but in the process of doing that they make the spleen so tight that they caught off the blood supply to the limb, and the limbs go dead. When they are brought to the hospital for salvage, at that point we have to decide either to amputate it or not. That dead limb will ultimately kill the patient because it’s a source of infection. So, we are to decide whether to retain the limb and the patient dies or remove the limb and the patient lives.

We have had patients that, despite the obvious dead situation in their limbs, they tell us not to amputate. And you will be seeing those patients dying. We have been trying to educate the traditional bone-setters on the apparent danger. In this hospital, we have had seminars and workshops, and we have noticed some remarkable decrease in the incidence of cases coming from them.

Unfortunately,those who often have these problems are children. A child whose limb is under a tight slit won’t be able to talk. Such child would be told to bear it by giving him drugs, until the leg goes very bad. If its an adult he can remove it and them come to the hospital.
For those whose their limbs were cut, when they go back to their communities, all they say is their limb was cut in Igbobi. They won’t say they went to the traditional healers. So the antecedent activities will not be related.

When you came in as the CMD, what were the challenges you met on ground and how did you overcome them?

The challenges we had were related to patient care, infrastructural problem and mainly finance for maintenance of services and the ongoing projects. On patient care, the major challenge was that here, we were operating basically as an orthopaedic hospital without sub- specialisations before. But we had to now focus on development of sub-specialties so that we could raise the level of practice in the hospital in orthopaedic and trauma care so we could really serve as a referral centre.

Though there was an ongoing discussion on these sub-units before we came, but they were now actualised when we came in. And consultants were now divided into sub-specialty units. For orthopaedic, five sub-specialties were identified and consultants had to get trained in those specialties. Some trained themselves while some were sponsored by the hospital. So, we now have sub specialties like androscopy and sports medicine, orthoplasty, spine surgery, special trauma units, and paediatric orthopaedics. Of course the bones and reconstructive department still exist. So, the general focus has been to increase the skill and level of performance, and the patients have benefitted from that.

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The other thing we tried to do was to minimise the waiting periods for patients. So we had to introduce an afternoon clinic, instead of just morning clinic for everybody. We also used to attend to all new cases in the emergency service point, but now we built a separate outpatient department for patients that are not really emergencies but are new patients. They are seen in that Out Patient Department(OPD) and the emergency cases are seen in the emergency units. So, the doctors attention is not divided between seeing patients that are not really emergencies and the ones that are really emergencies. This is to ensure the patients’ waiting time is reduced and are attended to by physicians.

We also noticed that the hospital is very old. It was established in 1945, so it still has a lot of wooden buildings that outlived their usefulness. We were able to convert some of these buildings to more solid structures. For example, the former prosthetics and esthetics department which is now the National Health Insurance Scheme clinic. We had the old physiotherapy department which was expanded and reconstructed. Where we use as a GOPD now used to be the prosthetics and ordontic workshop which we converted to a more decent environment, because our patients deserve a better ambience. That was also achieved.

We realised the drug revolving fund we met was very functional. Those who were  managing it before had done a good job, in many hospitals drug revolving funds collapsed because the scheme set up by government years ago to ensure drug supply was assured in all hospitals, but our own was running well, and was making good money. So, since the scheme emphasises that what ever is made from that, apart from the percentage that goes to government should also be used to develop hospital services, we used the money to put up a building for them, and also furnished a quality control laboratory, so they are equipped to test for fake drugs and ensure the supply of drugs. The future expansion in that building makes provision for manufacture of some of the basic drugs. So, the infrastructure is available now, so is just for funds to be available to fund that aspect of the building.

We are also a training centre. In the last five years, what has happened is that the school of P and O (prosthetics and orthotics) which is the only school in West Africa for training technicians fabricating artificial limbs, and support for the limbs was established in 2010. We met the school then and they were running a national diploma programme, so we succeeded in getting an accredited HND programme. So, they have graduated two sets already. And we also got the school of cast technology accredited. Those are the people that apply POP and other cast on patients. They are training at ND level. There is also a school for post basic nursing in orthopaedics, and  post basic nursing in accident and emergency. Those programmes are running. Even recently in the West African College of Nursing recognised the school as the best post basic nursing in Nigeria.

Then there is the residency programme for doctors who are specialised in orthopaedics, bones and plastic programmes is also ongoing and we have full accreditation. For postgraduate colleges, our residents do very well in the exams. Those basically are the challenges and what we have done to address them.

Although finance has been the main challenge for instance I give you an idea of the budgetting constraints that we have had. There are three sources of government support. There is the capital which are for these ongoing projects. We met four ongoing projects. The administrative block, the theatre complex, a new general patient clinic and a new accident and emergency. All those projects were started between 2010 and 2011, some with a completion period of two years or three years, but they are still not completed till date, except the administrative building.

So, the budgetary provision for their completion was not available. Before we took over, for instance, capital vote used to be between N340m and four hundred and something million, but in the last few years, we only get hundred million. Yet the projects are just there. The contractors have not been encouraged to come back to site. They only get paid based on evaluation that is done and money available.

Last year, for instance, we had the budget of N127m for capital, at the  end of the year only N82m was released. And the evaluation that was available were over N100m. We are still owing the contractor about N20m for the administrative building, because he used his money to complete the project. There has been some drastic cut in allocation.

The same thing also happened to overhead. When we came in we were still getting about N7 to N8 m per head, but now we are getting only N3m. And not all the months are paid. Last year we got overhead for only eight months. The PHCN bill per month alone is between N6m and N8m depending on how much supply of light we get during the month. And we buy diesel of between N12m to N14m monthly. So you can see that on energy alone we spend up to N18m, not to talk of generator repair, and all other repair of infrastructures in the hospital. So that is a big constraint. Considering that budgeting provision has come down.

The alternative of increasing patients fee and they will run away because they can’t afford it. We have a lot of patients that are brought here as trauma victims. The government policy is that you must treat them and give them a bill after. Many times they don’t pay, and there is nothing we can do. Some, we even have to beg them to leave the hospital after they get well so that the other patients can have space. These are the challenges of being a trauma centre. Military, police FRSC just bring these victims and go. Its left for us to look for their relations, look after hem, feed them. In terms of funding, that is a big problem.

The main solution to that is when the larger percentage of people are on health insurance, so that they don’t need to deep their hands into their pockets to pay for health services.