The Patrice Muamba Story:Location Dependent

It was with great trepidation and anxiety that most football lovers witnessed the slump of a 23 year old Bolton Wanderers midfielder right there on live television a few hours ago. Patrice Ndala Muamaba, Congolese born midfielder who has represented the English team at Under-21 level, caused a stir in the football world as he collapsed in the first half of an FA Cup game against Tottenham Hotspurs. Football followers know Muamba to be a fiery and physical player who displays full commitment and dedication to duty anytime he lines out to play for club and country, he is by no means an easy opponent to play against and has received remarkable comparison with players such a s Micheal Essien, Paul Scholes to mention a few. My first time of watching Muamba in action was probably about 3years ago as a Birmingham City player and he left an impression on me after i saw him in action. Alas, my worry when i witnessed such a brilliant footballer slump in the middle of a game on live television.

Fortunately, he had cardiopulmonary resuscitation right there on the pitch and i even read the attending paramedics had defibrillators and eventually attempted to restart Muamba's heart right there on the green grass. A few hours after the incident, we hear the player is stable and is awaiting some diagnostic investigations. For this and many more and other mercies, we thank the Good Lord. It would have been heartbreaking and totally disastrous to have lost such a fine athlete in his prime. The football match was eventually called off and the players had an early retirement from work for the day, something the average Nigerian civil servant craves for on a daily basis.

A cardiac arrest is a life threatening and potentially fatal emergency which if not handled with precision and experience can lead to death in a matter of minutes. It may be easy to recognize and it is essential that an eye witness knows some form of basic life support whilst waiting for a medical or paramedical team to take over the management of such a patient. Thus, help might take a few minutes,ideally, to reach the victim and the eerily thin line between life and death might be tossed in the hands of a nearby standing totally ignorant fellow. Occasionally, fate strikes when the victim is in the midst of capable people for example in an Emergency room or at a well planned football game like today,as was the case of Muamba this afternoon. Muamba owes his life, first to God and second to the well trained and properly equipped paramedics who were on duty today at the White Hart Lane Stadium in North London. But for divine intervention, Muamba's lying place at this moment would be different.

Basic life support (BLS) is the basic protocol used to manage a victim who has suffered a heart attack. Usually, the event is unprecedented and strikes unannounced, thus quick recognition and quick intervention is the cornerstone of management. BLS typically involves a quick,audible and desperate shout for help, a brief primary assessment of the victim who may or may not be conscious and a few manoeuvres . The brief assessment will involve checking if the victim is breathing at all and if the heart is still beating as evidenced by a quick check of his or her peripheral pulses either at the side of the neck or around the wrist. This usually should not take more than a few seconds and prompt intervention can proceed. A jaw thrust or chin lift may suffice to open up the victim's upper airways and a cardiopulmonary resuscitation comprising of  artificial ventilation (mouth-to-mouth) and chest compression. Beyond this, there really isn't much a lay man can do until paramedics arrive and they can proceed to defribrillate the victim in order to 'jumpstart' the heart of the victim and probably commence intranasal oxygen therapy.

The events of this fateful afternoon got me thinking. I thought of the practice of medicine in Lagos and Nigeria. I thought of the thousands of 'Patrice Muambas' that die shamelessly everyday on the streets of Lagos. I thought of a typical sunny busy day at CMS bus-stop Lagos Island and the possible outcome of such an occurrence there. Knowing the typical Nigerian. his first instinct would be to take to his heels and watch from a safe distance how a 'possessed' man rolled on the floor so as to give an eye witness account to his housemates and kinsmen later in the day. A few good Samaritans may stop to ask the victim what the problem is but honestly except that Samaritan is a health worker (nurse or doctor), the best help he will offer to such a hapless victim is to arrange for transportation to the nearest hospital. Unfortunately a cardiac arrest does not afford such luxury of time to get to a nearby hospital.

The unfortunate truth is that Muamba would have been long dead if the incident took place at the Onikan stadium or the Teslim Balogun stadium Surulere. Kindly take note that the preceding statement is an assertion and not a probability except of course the Good God of Shadrack, Meshack and Abednego still has plans for his life. You'll ask why i am so certain and i will try to explain the best i can. I graduated as a Medical Doctor in 2007 from arguably the best medical school in the south-south geopolitical zone of Nigeria. In my six years of 'quality' basic medical education, not once did i see a defribillator not to speak of seeing a practical session of a successful cardiopulmonary resuscitation done. Occasionally while on taking call duties with residents, you are 'privileged' to see them try to resuscitate a gasping patient in the Emergency room, but the patients always died, right there on the hospital bed and the attending resident proceeds to certify the person dead. It baffled me as a medical student but i was more concerned about passing my professional MB exams and moving to the next class so i refused to worry myself about the fatalities and the futility of our resuscitation exercises. Note however that my not ever seeing a defribillator in medical school was no due to my truancy or by what some people call 'learning medicine by proxy'. I was a reasonably serious and studious medical student who never had a problem with making 75% attendance at lectures, clinics and operating sessions throughout the clinical lap of my medical education.

Eventually, i reached the 'Promised Land' and graduated as a doctor after which i moved back to Lagos to do my statutory one year internship and National Youth Service. In the cumulative two years i spent working and practicing medicine under supervision, not once again did i see a defribrillator. Strange you might think, but the veracity of this claim can be corroborated by my colleagues at the time at a Federal health institution in Lagos. Again, interestingly, almost all  the attempted resuscitation exercises i witnessed ended in futility and left me strongly doubting the effectiveness, if there was any at all, of the whole CPR thing. I moved on from there and became fully registered as a medical practitioner in Nigeria, i was now licensed to practice without supervision and thankfully there were pictures of defribrillators in textbooks and on television so i at least knew what they looked like. It was only recently, i finally got to see what they looked and felt like at a hospital i was working 'privately' in Lagos. Fortunately, i have not had any cause to need one in my practice or so the system has made me delude myself into believing.

Traditionally, a man who slumps suddenly without apparent cause has been 'messaged' from the village and the average Nigerian is quick to adduce 'principalities and powers' as the reasonable explanation for the incident. Luckily, these powers cannot overtly defend or disprove their involvement in the drama. Cardiac arrest is a rather common occurrence and 'jazz' has made diagnosis of the condition seem remote. Back to Muamba, if he had been playing today's game at the prestigious Onikan stadium Lagos, he would have not had a whole paramedic team waiting on ground in the stadium. Lagos hospitals don't even have paramedical teams in the biggest hospitals not to speak of some football pitch. The best Muamba would have got at Onikan stadium would have been a bored and unmotivated Red Cross staff or a nurse with a 'First Aid box'. Now, unless the heart can be restarted with cotton wool, Evans glucose D and sachet 'pure' water, i see no way Muamba would have left the stadium alive. Another fact that would have hastened Muamba's sojourn to the grave would have been logistics of transferring him to a nearby hospital. I have not been to Onikan stadium lately but i strongly doubt there is a standby standard ambulance with BLS equipment being defribrillators, oxygen cylinders, intravenous access materials and a cardiac bed. Note that i am not referring to the beat-up Peugeot station wagons labelled 'Ambulance' that are only fit to carry firewood and red tomatoes from Mile 12 market. We all watch Hollywood movie flicks and series (Grey's Anatomy, House), kindly send me a message the day you see a 911 emergency operator dispatch a 'station wagon' ambulance to the scene of a medical emergency. I am dying to see that on television. The choice form of evacuation Muamba would have got would have been an 'okada' with a teammate sitting behind him and holding him seated vertically. If he is unlucky, he'll be pushed into a 'snail speed Keke Napep or Marwa' depending on your political affiliations. Muamba again, would have long settled in with his ancestors.

Now,if by some 'odeshi', Muamba makes it to the regular and typical government hospital alive, he'll be asked to get a card, either at a fee or for free as in some State owned General hospitals. The records clerk, if at his duty post will proceed to ask for Muamba's biodata and doing a proper registration and then pass the card to the Nursing Sister on duty who will then do Muamba's vital signs and then call for the Doctor on call to see Muamba. The Doctor then attends to Muamba, suspects a possible cardiac arrest but unfortunately there is no power in the hospital at the time, as the PHCN has not restored power all day and the hospital generator consumes a lot of diesel so has gone off till 7pm. Eventually, the doctor convinces the 'engineer' in the plant room to put on the generator for a few hours and returns to his ailing Muamba. He decides to commence oxygen intranasally since he had never seen a defribrillator in the hospital since he resumed there in late 2010. He then turns the knob of the oxygen cylinder and realizes it is empty. The Emergency room has no oxygen so he decides to do the chest compression for what it is worth while he urges the nurse to send the hospital maid to other hospital wards to 'borrow' oxygen cylinders. All the while, Muamba's cardiac arrest is having a filled day eating away the poor 23year old's soul.

Believe it or not, the picture painted above is not fiction. These are scenes i see day in and day out, but of course, there's 'jazz' and 'powers and principalities' so at least i know its possible i was up against certainly more powerful and ruthless forces. Bottom-line is our healthcare system is a joke in Nigeria. Nigerian doctors migrate and become wonderful practitioners, feats that are practically impossible in their own country. I still give a lot of credit to the overworked and improperly trained doctors who are unfortunate enough to remain in the country and practice the art of medicine. I give them credit because i know the number of lives they save on a daily basis even with the most hostile and negative conditions. Conditions where even the white colleagues would almost become neurotic if faced with. Day by day, they restore health to several thousands and try to save as many as possible. Unfortunately, the health system is a reflection of the general systemic failure of the Nigerian entity. How can the sector thrive when in 2012, Niger Delta militants are to receive 6billion naira more than all the heath institutions in the country. Together with the NDDC, the militants will gulp a whooping 118billion naira as against 60billion allocated by Mr President to Health. I can also tell you the amount allocated to education but the tears in my eyes sting and won't permit me to type the figures.

Unfortunately also, when the head fails, it is very unlikely that any other body part will work properly. There's a reason why the brain is located in the head and not the gluteal region. It is simply because the head is the 'center of action', all the other parts look up to the head for co-ordination. We can't stop doctors from practicing medicine in Nigeria because they have not been trained properly from their basics, certainly not, as the cure for a headache is not and will never be a decapitation. We can however begin to encourage the older and widely traveled Consultants to begin teaching and retraining their subordinates. We can beg the government to fund mandatory and intensive Basic and Advanced Life Support courses for all medical doctors on an annual basis to be facilitated by the best Consultant Traumatologists from all over the world. We can beg the Medical Directors to embezzle less of the running costs provided to the hospitals by government to get more oxygen cylinders and standard ambulances and who knows, maybe even a few defribrillators. We can beg the Medical and Dental Council to review the nature and modules of basic medical training in Nigerian medical schools, medicine is as practical as it is theoretical, the students must be taught applied medicine, not 'stuff' that can not do a jaw thrust or a chin lift or do basic CPR. We must beg the doctors and budding medical students to open their minds and develop their hands, we can beg them to apply themselves to the apprenticeship of medicine.

If we get it right, we will save a lot of 23year old Muambas from their early graves.



P.S: My sincere prayers remain with Patrice Muamba, he is too fine a young athlete to depart the world prematurely. Join me in wishing him total and speedy recovery from this hellish experience.