Epidemiology of death in the emergency department of a tertiary health centre south-south of Nigeria.

BACKGROUND: The emergency department (E.D) of any hospital is an important entry point of critically ill patients. The initial management of these patients is often challenging, and for valuable lives to be saved, the in fracture and manpower should be up to date. OBJECTIVE: To analyze the epidemiology of death in our Emergency Department within 72hours after admission, the death rate, and to establish any contributory factors. METHOD: Demographic data, time of arrival at the ED, physical finding, the Glasgow coma scale(GCS), the injury severity score(ISS), the diagnosis, investigations done, treatment offered, the time of death and the autopsy report, were entered into a Proforma. These data was analyzed using EPI-Info statistical programme version 3.4.3 of 2007. RESULTS: Four thousand and eleven (4,011) patients were seen in the E.D during the period. A total of three hundred and fifty five (355) mortalities were recorded. Their ages ranged from 4-87years, with an average of 34.5years. The male: female ratio was 2.1:1. The overall mortality in the hospital during the period was 859: the E.D mortality figure representing 41.3%. Fifteen patients were brought in dead. The 355 deaths fell into two categories: trauma and non-trauma. One hundred and forty-seven (41.4%) persons died from trauma; road traffic accidents (RTAs) accounting for 118 (80.3%). Two hundred and eight (58.6%) persons died from nontrauma related causes, with chronic cardiovascular disorders been the most frequent cause of death 52[25.0]. Majority of the mortalities were between 26-50 years age range. 86.2% of the mortalities presented late, greater than 6hours after the incidence. Within the 72 hours period, only 129(36.3%) were able to do the requested tests. Out of the 355 deaths, only 4[1.1%] were autopsied. An in-hospital 72hours death rate of 8.6 was recorded. CONCLUSION: Road traffic accidents and cardiovascular disorders are the common causes of emergency death in UCTH. A recorded death rate of 8.6% is high, suspected contributory factors include systemic deficiencies such as the lack of a trauma system, prehospital care; late presentation, the role of chemist operators, traditional healers, and delayed referral systems.

Lower limb amputation in diabetic foot disease: experience in a tertiary hospital in southern Nigeria

The diabetic foot is characterised by the triad of neuropathy, infection, and ischaemia, which may ultimately lead to limb amputation. It is important to understand the factors that place diabetic patients at increased risk of amputation in our society, hence the need for this study. The medical records of all patients admitted and treated for diabetic foot complications over a 3-year period (January 2007 to December 2009) were retrieved. Relevant information was obtained from the case notes. Thirty-six (36) patients entered the study, 25 males and 11 females (M:F ratio 2.3:1.0). Mean age was 54 years (range 24­74). Patients presented with foot gangrene (58%), ulceration (31%) and infection (11%) with trauma being the most common precipitating factor (53%). Nineteen patients (53%) had lower limb amputation, the commonest of which was below knee. Of the patients that had amputation, 18 (95%) had type 2 diabetics. Adequate diabetic foot disease preventive strategies need to be designed and implemented to reduce the incidence of lower limb amputations

Footcare practices among Nigerian diabetic patients presenting with foot gangrene

Diabetic foot ulceration and gangrene is a major cause of morbidity andmortality. This study has examined potential preventive footcare practices in a cohort of diabetic patients presenting with foot gangrene. One hundred and two (102) diabetic emergencies presented during the study period. Diabetic foot gangrene accounted for 27 (26%) of these cases. There were 18 males and 9 females (M:F = 2:1), with a mean age of 52+13 years. The mean duration of ulceration was 4±3 weeks and mean ulcer­gangrene interval was 1.2±0.5 weeks. Only 9 patients (33%) had been exposed to any form of footcare education, 15 patients (55%) treated their ulcers by unorthodox means, and 63% of the patients practiced no significant footcare. More widespread education and awareness is needed to prevent the continuing and serious problem of diabetic foot gangrene and consequent lower limb amputation

Cutaneous squamous cell carcinoma in Calabar, southern Nigeria.

BACKGROUND: Several studies have shown that in Africa squamous cell carcinoma (SCC) is commoner than other skin malignancies. The risk factors are grouped generally into solar and nonsolar factors and their contributions vary with race, geographical region and site of lesion. This study attempted to identify risk factors and outcome of management of this problem in our region of southern Nigeria. METHODS: All patients with histological diagnosis of SCC presenting to the University of Calabar Teaching Hospital during the period January 2005 to December 2006 were evaluated. RESULTS: In total, 10 patients (6 male, 4 female, mean age 39.3 years, range 16-62) were seen. There were six patients (60%) with Marjolin's ulcer (MU) of the leg, with a male:female ratio of 5:1 and a latency period of 14.7 years, with trauma as the leading cause of injury. The other four patients (40%) had non-MU SCC. Two of these four patients (one man, one woman) were albino, and had lesions that involved the head. The other two patients were both women, and had vulval lesions. All 10 patients had delayed hospital admission, after poor results with topical herbal treatment. After hospital treatment, the results were satisfactory in three patients (two with MU and the male albino patient). The other seven patients had generally poor results from treatment, which comprised various combinations of excision, adjuvant chemotherapy and radiation. CONCLUSION: Ignorance and sociocultural factors were underlying issues in delaying treatment. Education highlighting the risk associated with chronic wounds and albinism, and the need for prevention, prompt treatment and proper surgical management, would improve prognosis with a reduction in the healthcare cost of this problem.

Lightning burns and traditional medical treatment: a case report.

BACKGROUND: Lightning strikes are relatively uncommon. In our culture where superstitions are strong and natural events often linked to evil forces, the traditional bonesetter/healer is often consulted first. Patients then seek orthodox care when complications develop. Patients also have difficulty accepting ablative treatment when indicated. OBJECTIVE: To present an usual case of bilateral upper limb burns caused by lightning and complicated by refusal to receive orthodox treatment. CASE REPORT: A 22 year old woman was struck by lightning while asleep. Instead of going to hospital, she was taken to a traditional healer where she spent two months before presenting with gangrenous upper limbs to hospital. Patient refused amputation and abandoned hospital against medical advice. CONCLUSION: This case report of bilateral upper limb burns resulting from lightning is rare. Importantly, the case highlights the role of ignorance, superstition and the disastrous results of traditional medical practice in our healthcare delivery.

Patients' Perception of Traditional Bone Setting in Calabar

Background: Patients with orthopaedic injuries patronize traditional bonesetters in our communities. This study was undertaken to find out and document the reasons and factors responsible for this patronage; who made the choice; the role of healthworkers; patients' perception of the practice and if their experience will encourage or discourage them from patronizing traditional bone setting in future. We also compared the cost between orthodox and traditional bone setting for close humeral and femoral fractures. Methods: A prospective study of patients in three traditional bone setting centres in Calabar . A pre-tested questionnaire requesting information on age; sex; educational level; type of injury; reasons for choice of traditional bone setting was administered. Other details included who decided on traditional treatment; perception of outcome; and the option of choice in the event of a future injury. Results: There were 98 patients with 106 injuries. The male: female ratio was 66:32 (2.1:1) and age range was 9 months to 60 years. There were 76 fractures in 68 patients; 28 dislocations and 2 brachial plexus injuries. Traditional bone setting was chosen in 50 patients (51.0) because traditional bonesetters were believed to be more skillful than orthodox orthopaedic practitioners; 32 patients (32.7) thought it was cheaper; 12 patients (12.2) believed orthodox orthopaedic practitioners have no empathy towards their patients and 4 patients (4.1) had no health facility in their locality. In 68 patients (69.4) the locus of decision was external; in 22 patients (22.4) internal and 8 patients (8.2) were encouraged by a healthworker. Complications including pain; mal/nonunion; joint stiffness and contractures occurred in 60 patients (61.2). Treatment outcome was adjudged satisfactory by 48 patients (49.0); fair by 40 patients (40.8) and unsatisfactory by 10 patients (10.2). Traditional bone setting for the management of humeral and femoral fractures was more expensive than orthodox management. Conclusion: Traditional bone setting is popular for varied reasons. The freedom to advertise may have helped to woo a public already biased towards traditional bone setting by cultural attachment. A paradigm shift is necessary to reverse the trend

Patients' perception of traditional bone setting in Calabar

Background: Patients with orthopaedic injuries patronize traditional bonesetters in our communities. This study was undertaken to find out and document the reasons and factors responsible for this patronage; who made the choice; the role of healthworkers; patients' perception of the practice and if their experience will encourage or discourage them from patronizing traditional bone setting in future. We also compared the cost between orthodox and traditional bone setting for close humeral and femoral fractures.Methods: A prospective study of patients in three traditional bone setting centres in Calabar. A pre-tested questionnaire requesting information on age; sex; educational level; type of injury; reasons for choice of traditional bone setting was administered. Other details included who decided on traditional treatment; perception of outcome; and the option of choice in the event of a future injury. Results: There were 98 patients with 106 injuries. The male: female ratio was 66:32 (2.1:1) and age range was 9 months to 60 years. There were 76 fractures in 68 patients; 28 dislocations and 2 brachial plexus injuries. Traditional bone setting was chosen in 50 patients (51.0) because traditional bonesetters were believed to be more skillful than orthodox orthopaedic practitioners; 32 patients (32.7) thought it was cheaper; 12 patients (12.2) believed orthodox orthopaedic practitioners have no empathy towards their patients and 4 patients (4.1) had no health facility in their locality. In 68 patients (69.4) the locus of decision was external; in 22 patients (22.4) internal and 8 patients (8.2) were encouraged by a healthworker. Complications including pain; mal/nonunion; joint stiffness and contractures occurred in 60 patients (61.2). Treatment outcome was adjudged satisfactory by 48 patients (49.0); fair by 40 patients (40.8) and unsatisfactory by 10 patients (10.2). Traditional bone setting for the management of humeral and femoral fractures was more expensive than orthodox management. Conclusion: Traditional bone setting is popular for varied reasons. The freedom to advertise may have helped to woo a public already biased towards traditional bone setting by cultural attachment. A paradigm shift is necessary to reverse the trend

Gunshot injuries in Calabar, Nigeria: an indication of increasing societal violence and police brutality.

BACKGROUND: Gunshot injuries were rare in Calabar before the Nigerian civil war. This has changed in subsequent years and has reached a near epidemic proportion in the last three years. These are caused by civil violence, police brutality and armed robberies. OBJECTIVE: To evaluate the incidence, pattern and causes of gunshot injuries in this region and draw the attention of Nigerians and the Government to the above problems for a possible solution. METHODOLOGY: Records of patients admitted into the University of Calabar Teaching Hospital (UCTH) with gunshot wounds between April 2002 and May 2004 were extracted. Parameters analyzed included patients' biodata, sources of injury, anatomical site (s) of injury, modalities of treatment and the outcome RESULT: There were 51 injuries in 49 patients as follows: The lower limbs 25 (51'), upper limbs 6 (12.4'), upper limbs/ chest 2 (4.1'), chest 4 (8.2'), abdomen 7(14.1') and head/neck 5(10.2'). Male/female ratio was 48:1. Twenty-four (49') sustained their injuries from either accidental discharge or deliberate shooting by the police while armed robbers wounded 10 (20.4') and cultists, 2 (4.1'). Two patients had amputations and mortality was 8.2'. CONCLUSION/RECOMMENDATIONS: The police should be cautious with guns;they and the Government should be alert to the menace of robbery, political violence, cultism and communal clashes. Good Governance, creation of employment, eradication of corruption and political violence may help.

Acute bilateral anterior shoulder dislocation following domestic assault--case report.

A rare case of acute bilateral anterior shoulder dislocation in an elderly woman is presented. This injury resulted from domestic physical assault by her daughter inlaw. Patient defaulted after initial treatment--a common practice by patients in our society. This case is being reported to highlight the occurrence of this rare orthopaedic emergency.

The use of external fixators: a review of literature and experiences in a developing world.

BACKGROUND: The introduction of external fixation devices has brought significant improvement in the management of complex open fractures. Its importance and versatility ranges from its use as temporary fixation device in fractures with soft tissue and vascular injuries to its use in definitive correction of limb length deformities and congenital malformations. It avoids extensive soft tissue damage and enhances easy management of associated soft tissue injuries. METHOD: This was an overview of the clinical experience at the University of Calabar Teaching hospital and a review of literature. RESULT: The paper highlight the usefulness of external fixation devices and the need to encourage its use in the developing world. It also stresses the constraints encountered in a Nigerian teaching hospital. CONCLUSION: A call is made to all surgeons particularly those in rural areas to make use of this simple appliances after due training. Government should equip the hospitals with these tools and encourage the fabrication of such in our environment.

Incidence of leaving against medical advice (LAMA) among patients admitted at the accident and emergency unit of the University of Calabar Teaching Hospital, Calabar, Nigeria.

BACKGROUND: The causes and incidence of the commonly observed phenomenon of leaving against medical advice (LAMA) in our hospitals have not been studied. This retrospective study was aimed at evaluating its incidence and pattern in order to suggest possible solutions. METHODOLOGY: The case files of patients who left against medical advice at the Casualty unit of the University of Calabar Teaching Hospital between July 2002 and December 2003 were retrieved from the Medical Records Department and information regarding age, sex, education/occupation, religion, diagnosis, reason(s) for leaving and duration of stay in casualty were extracted. RESULTS: A total of 3708 patients were seen at the casualty unit within this period. Ninety-seven patients left against medical advice but only ninety case notes were analyzable. Seven folders had incomplete information. Male/Female ratio was 2:1 and the ages ranged between 7 and 70 years (average 31.5 years). The average duration of stay in Hospital was 2.4 days (110 days). Sixty-five patients (72.2%) were those who had various forms of trauma while 8 (8.8%) had general surgical problems. 19% (17) patients had medical emergencies. CONCLUSION: The youths are the most vulnerable group and the principal causes in our environment are ignorance and poverty. Because of poor documentation in our centres, it was not possible to know where these patients go and the results of their treatments. There is therefore a need for further studies.

Chronic foot ulcer complicating a traumatic arteriovenous fistula

Background: Chronic foot ulcers could be a complication of traumatic arteriovenous (A-V) fistulation. We report a rare case of chronic foot ulcer and deformity resulting from arteriovenous fistula of the anterior tibial artery. Method: The clinical presentation and the outcome of treatment in a patient treated at the University of Calabar Teaching Hospital (UCTH) Calabar are reported. The relevant literature on this subject matter is briefly reviewed. Result: A case of chronic foot ulcer and oedema secondary to traumatic arteriovenous fistula of the anterior tibial artery was managed by the authors at the University of Calabar Teaching Hospital. The diagnosis was mainly clinical as sophisticated equipment was not readily available and satisfactory healing was achieved by exploration; quadruple ligation; skin grafting and cast application. Conclusion: Prompt diagnosis and treatment of difficult cases should warrant sophisticated equipment to make diagnosis

Review of Seventy consecutive cases of limb injuries in calabar the role of motorcyclists

Background: Limb injuries are common. The aims of this study were to evaluate the pattern of limb injuries seen at the University of Calabar Teaching Hospital (UCTH); Calabar and the role ofmotorcyclists in their causation. Methodology: Prospective study from 1st January; 2005. Seventy consecutive patients with limb injuries presenting at the accident and emergencyunit of UCTH were evaluated. Results: The seventy patients who entered the study presented between 1st January 2005 and 31st May 2005. They sustained eighty five (85) limb injuries.Ages ranged from 4.5years to 68years with mean of 30years. Male to female ratio was 2.7:1. Road Traffic Accident (RTA) was the commonest cause of injury accounting for 76.8of cases withmotorcycle accidents constituting 52.8of these. Fracture was the most common injury accounting for 54 cases (63.5). Fracture of the tibia and fibula (combined) was the most common fracture (37.0). Head injury was the most common associated injury (66.7). Conclusion: Motorcycle accidents are important causes of limb injuries. Appropriate measures to reduce incidence of road traffic accidents would significantly curtail the rate of occurrence of limb injuries