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Bedsores have become a thorn in the flesh for spinal cord injury survivors after a narrow escape from death from ghastly motor accidents. This preventable condition, coupled with the economic situation, leaves them in perpetual pain, JANET OGUNDEPO reports
On January 20, 2010, the Onuohas waved goodbye to their beloved parents and siblings at their ancestral home in Abia State.
They had come to the village a few days before Christmas to spend the holiday with them. It was time to return to the hustle and bustle of Lagos life.
After the pleasantries, the family of three found their way to the bus park and boarded a luxurious bus heading to Lagos.
While on the way, Favour Onuoha’s four-year-old daughter reminisced on the eventful activities of the last few days and regaled her parents on what she would tell her friends when she resumed school in Lagos.
As their bus approached Benin Road in the afternoon, Favour, told PUNCH Healthwise that the Policemen on the highway requested some money, which the driver refused to give.
“One of them threw a big stick at the bus’s windshield and the driver lost control of the bus and diverted into the bush,” she continued.
The jostling of the bus and the screams of several passengers as the bus somersaulted was the last thing Favour knew before the world went blurry and dark.
She was later told that she was flung out of the bus and found in a nearby bush unconscious.
“I was told that I was in a coma for one week before I awoke and realised that I was in the hospital. When I regained consciousness, I found out that I couldn’t move my legs and I was shocked about my state,” Favour said.
The doctor later explained to the Abia State indigene that the accident had injured her spinal cord.
“My spinal cord shifted and I was told to get a belt that would help to correct it but since I couldn’t afford it, my situation worsened and my leg began to swell.
“After three weeks in a hospital in Benin, I was discharged and referred to Igbobi Hospital, Lagos,” she said.
That accident led to an encounter with SCI.
“I was with my husband and four-year-old child, I was the only one that survived,” she said with a shake of her head.
Going down the sad memory lane of the uneventful accident, Favour told PUNCH Healthwise that she asked the good Samaritan how her husband and daughter were doing.
“Initially, they didn’t tell me what happened when I woke up at Benin Teaching Hospital. They said that I was the only one affected by the accident and that my husband and daughter had returned to Lagos. I requested to speak with them but was told to recover first that my daughter had resumed school and was staying with my sister,” she narrated.
But Favour’s constant dreams of playing with her daughter, who would then disappear when asked to go into the house, gave her constant worries.
Yet, she said that she was not told of her daughter and husband’s condition until her transfer to Igbobi when a woman came consoling her and saying, “Pele oo, it is God that gives and God that takes. Even the small girl who is ignorant also went. I then asked her what she was talking about. She then said my daughter and husband lost their lives in the accident.”
After hearing the news, Favour stated that she attempted suicide twice but was unsuccessful.
After the attempts, she found succour in the scriptures and discovered that God still loves her.
Today, Favour lives and works as a volunteer with the Spinal Cord Injuries Association of Nigeria centre, Alakoso, Amuwo-Odofin, Lagos State.
Spinal cord injury explained
A researcher on Spinal Injury and a professor of Physiotherapy at the Bayero University, Kano, Kano State, Ganiyu Sokunbi, explained spinal cord injury as an injury to any part of the spinal cord, whether the upper, middle or tail part.
He noted that the spinal cord is the part of the nervous system that receives signals from different parts of the body, especially those areas of the body that are below the neck, down to the toes and send it to the brain.
It then receives instruction from the brain and takes it back to different parts of the body.
“Therefore, an injury to the spinal cord, depending on the level of injury, would prevent signals from several parts of the body from getting to the brain.
“Since the function of the upper and lower extremities of the body is controlled by the spinal cord, as well as some other function, a total or almost total spinal injury would cause a loss of sensation in many parts of the body and loss of function in the upper extremity and the lower extremity,” he said.
Battle with pressure sores
“Spinal cord injury patients require love and care and it is not easy to manage,” Favour told PUNCH Healthwise.
Although Favour is grateful to be using a recommended wheelchair, she battles the fear of coming down with pressure sores.
The required pressure ulcer cushion to be placed on her chair is way above what she can afford.
She stated that she had to buy foam and a soft cloth and gave it to a tailor to make the makeshift cushion for her back and seat area.
Favour further noted that she had to apply a cream to her body and change her position to avoid pressure sores.
She seeks government intervention in the purchase of the medical supplies SCI daily needs.
What is a pressure sore?
Sokunbi explained, “Pressure sore is the death of certain parts of the body as a result of prolonged exposure to much pressure. The parts of the body that are usually involved are those areas that we make contact whenever we are seated or lying down. This also includes the back of the skull, the back of the head, the posterior part of the shoulder, the part of the body where we sit on and the back of our heels.”
Accident cum spinal cord
Data from America’s National Spinal Cord Injury Statistical Centre revealed that about 294,000 people live with spinal cord injury and about 17,810 people have new spinal injuries every year.
Vehicle accidents, 39 per cent and falls, 32 per cent were the highest cause of spinal cord injury.
In Nigeria, motor vehicle road accidents accounted for 43.9 per cent of SCI cases while 8.3 per cent were passenger road traffic accidents and 18.9 per cent were caused by degenerative spine disease.
From accident to SCI
Also seated at the SCIAN premises was another SCI patient, Mr Samuel Ariyo.
Twenty-four years ago, he sustained a passenger road traffic accident on the Lagos-Ibadan Expressway, while on his way to school at the Federal Polytechnic, Offa, Kwara State.
The former student of Business Administration stated that all he could remember was what occurred before the accident as he became unconscious and was taken to a private hospital where he spent a few days before being referred to Igbobi.
Ariyo stated that if he had been handled properly at the accident scene, his SCI could not have affected his upper and lower limbs so much that he has to most of the time depend on his caregiver to help him with his basic tasks.
Despite this, Ariyo maintains a joyful attitude and has learned how to operate and run his Point of Sales machine business.
The middle-aged man stated that he was conscious of developing pressure sores after seeing the devastating effects it had on his fellow patients during his stay in Igbobi.
Ariyo called on the government to implement an accident fund, stating that this would ensure accident victims were immediately taken care of without the delay of settling hospital bills.
He noted that living with SCI was expensive, coupled with the lack of rehabilitation that has led many of them to be unable to function economically as their counterparts in developed countries.
Biting economic situation
When Joseph Onwudinjo was 17 years old, he never knew his world as he had known it would come tumbling down.
For years, he prided himself in his title, Young Engineer, as he worked with his older colleagues. But an accident on the site someday in 1984 would take away his ability to do work and uphold the title.
After his accident of over 40 years that affected his spine, Onwudinjo, who lives and is in charge of the SCIAN Lagos office, had his limbs amputated a few years ago due to some complications.
Despite the challenges, he goes about his daily activities, wheeling himself as he goes with a smile.
But he told PUNCH Healthwise, that the NGO, which runs on the goodwill of partners and donations was in dire need of rehabilitation.
He noted that since the economic downturn, many of their colleagues had to manage the little provisions and foodstuff as the frequency of donations had dwindled.
The 57-year-old pleaded for government intervention in the road leading in and out of the centre, stating that this had made hospital visits tedious for the members.
He stated that the premises needed repairs as the rain brought in flood and snake invasions.
No public rehab centre- SCIAN Chairman
Being a spinal cord-injured patient for 24 years, the Lagos State Chairman of SCIAN, Abdulwahab Matepo, wondered why persons living abroad with similar conditions as his, had better health and socio-economic outcomes than their Nigerian counterparts.
“They are more functional, gainfully employed, more visible and can be seen outside of their homes,” he submitted.
The difference, Matepo said, was the access to rehabilitation after their hospital discharge.
The injury, he continued, was one that most often causes the inability to engage in several basic tasks, noting that rehabilitation would foster relearning and uptaking new life skills.
The SCIAN Lagos chair further noted that the plan to build a rehabilitation centre on the premises had been impossible for over 30 years.
However, the SCIAN chairman said, “As I speak to you now, there’s no public rehab centre for spinal cord injury patients in Nigeria. If you see any, it could be those privately set up and targeted at stroke survivors and it is not affordable for the common people.
“The government gave SCIAN this property for free because we told them we wanted to have a rehab centre that is going to house the rehab building, the equipment and staff but it has not been done. This place has been given to us for about 30 years now.”
This lack of rehabilitation, Matepo stated, has led to the loss of economic productivity and affected mental, emotional and physical health.
Expensive condition to maintain
Due to long hours spent in a wheelchair, the SCIAN Lagos chair noted that it was necessary to use the specially designed cushion to support the back and resting areas.
But the cushion costs $400, over N600,000, he said, “And without this cushion here, if one is sitting on a hard surface, one can develop a sore. The only way to prevent soreness is to use the cushion and then use either a water or an air mattress. All this costs money and they are not affordable. That is why, even if anyone who survived the spinal cord injury is safe, we now fall victim to opportunistic diseases, like pressure sore.”
Killer pressure sores
Matepo further noted that pressure sore was the leading cause of death in injured patients, stating that the costly treatment made many patients stay away from the hospital consequently causing aggravated infections.
Citing the case of a colleague currently detained at a hospital over the inability to pay her over one million naira bill, the SCIAN chair noted that many colleagues were in such a situation and some have resorted to home management of the condition.
He also decried the lack of accessibility to public convenience and buildings, noting that this has discouraged and limited the places many patients can go to.
Matepo encouraged philanthropists and well-meaning persons who wish to donate items to spinal cord injured patients to request the specification from the beneficiaries.
The chair decried the bad roads leading to the centre, noting that it has led to a loss of revenue for the centre and heightens the risk during emergencies.
“We have an accumulated electricity bill debt of over N1M. Although we pay every month, but if we’re given a bill of N500,000, we pay N300,000.
“Also, we have an event centre built by the Central Bank of Nigeria as a way to generate income to run this place, which was a good idea but the road is so bad and people are no longer coming because of the bad road. If we have an emergency, it’s a serious problem because we can’t rush to board a car,” he said.
He called for government intervention in building the rehabilitation centre on the premises as initially planned.
Matepo also advocated social support in the provision of assistive devices, like cushions and wheelchairs, and making public buildings and infrastructure accessible in public places.
90% of pressure sores preventable –Expert
Speaking further, Sokunbi stated that 90 per cent of pressure sores were preventable through adequate patient education.
He added that patient education would compensate for the shortage of rehabilitation centres and inadequate facilities and manpower.
The don also stated that the level of care, in terms of facilities and manpower, for spinal injured patients was inadequate, further re-emphasising the need for patient education.
Seven in 10 deaths from pressure sores
The spinal injury expert noted that seven to 10 patients with spinal cord injury, died was related to pressure sore.
“So what happens to them invariably is that the area gets infected, the infection will trace its way into the blood, causing septicemia, and that kills very fast. So seven to eight out of 10 deaths amongst spinal cord injury patients are related to the management or complication of having pressure sore. So it has its own personal, economic and psychosocial implications,” Sokunbi said.
He urged injured patients to ensure that they had adequate nutrition, avoid tobacco intake and regularly check parts of the body, like the back of the head, the buttocks, the tail end of the spine and the heels, for any discolouration or some sort of pain.
The don advised the adoption of proper sitting and lying posture and changing position every two hours to prevent pressure sores.
“Always make sure that the clothes or the clothing materials and linen that go over this pressure area are always smooth because wrinkled clothing also could lead to shearing of the skin and exposure of that part of the body.
“They also have to deal with any condition that will lead to soiling or increased moisturisation like urine. If it happens at all, the skin should be kept clean and dry as soon as possible because wet or damping of this particular area of the body can predispose the body to pressure sores. And finally, on prevention, whenever they are on any medication, they should inform their spouse or their relatives about it because many of the medications that spinal cord injury people take make them feel drowsy and make them go into prolonged hours of sleep,” Sokunbi said.
He advised that individuals who could afford to check on the level of their testosterone should do so once a year or for two years, noting that low levels of testosterone were associated with the breaking down of skin.
The don stated that patients on urinary catheters were prone to urinary tract infections, advising that the area should be clean as much as possible.
Sokunbi advised spinal cord injured patients who could still have sexual intercourse to ensure they urinate as soon as they finish the activity to prevent UTI.
He urged the females who were on birth control methods to avoid the use of a diaphragm or condom to prevent UTI.
Continuing, he said, “Kidney stones are usually a result of high levels of calcium and uric acid in the urine. So one way of dealing with that would be by drinking plenty of water. Also, eating or focusing on dietary calcium like milk, yogurts and cheese, rather than calcium supplements. Supplementary calcium can find its way into the urine and cause this crystal that eventually will lead to kidney stones. As much as possible avoid red beans and red meats and organ meats like liver, lung, and kidney.
“Also, avoid a large intake of salts because if you feed too much on salt, you will have too much sodium in the blood and the body will flush out calcium into the kidney.”
Mental health affected
A researcher on Brain and Spinal Cord Injury, Prof Blessing Jaja, stated road accidents were responsible for 70 per cent of spinal cord injuries in the country, adding that in developed countries, it was caused by falls.
He noted that although there was a reduction in the incidence rates due to the ban on motorcycles in some areas the affected population were people below the age of 40.
The professor of Neuroscience and Clinical Anatomy at the Rivers State University, Port Harcourt, further noted that the injury led to physical deformity and dependence on relatives, further impacting their mental health and economic life.
Jaja, who is also the Deputy Provost of the College of Medical Sciences at RSU, asserted that the poor rehabilitation services specifically for spinal cord injury and the lack of social network and employment opportunities worsened the health outcomes.
He stated that the three orthopaedic hospitals in the country were insufficient to cater to the over 230 million Nigerians.
“Rehabilitation is not just the physical aspects of the injury. It requires a holistic approach, and unfortunately, for us, those are not available. And for me, that is the pain of spinal cord injury,” the don said.
He further mentioned that pressure sores were one of the major complications of spinal cord injury.
“It has severe implications which include physical, emotional and psychological complications. We also talk about the economic burden and long-term complications. From a physical perspective, the biggest issue with pressure sores is infections, especially if the sores are not properly managed, they widen and get infected.
“Once they get infected, it increases the complications and the co-morbidities associated with the injury. Infections are a major worry for pressure sores. Literally, every one of them will have an infection. In Nigeria, it’s difficult to see a spinal cord injury patient with a pressure sore that does not have some infection,” Jaja said.
The neuroscientist noted that untreated pressure sores led to chronic ulcers, which do not get healed on time.
He noted that injured diabetic patients had an increased risk of pressure sores, leading to poor health outcomes.
He noted that the increased health care costs, hospitalisation and loss of productivity required special health coverage and social insurance to ensure adequate care of all spinal cord injury complications.
Speaking on how to prevent UTIs, kidney stones and pressure sores, the brain and spinal cord injury expert said, “The first and most important thing to do is access a qualified health care provider because spinal cord injury management requires special care. It requires a multidisciplinary approach.
“I think part of the issue is lack of patient education and access to quality care. For instance, the issue of catheterisation, presently, we don’t catheterise patients for too long. It is not a good practice to put a catheter in there for a prolonged period because once you do that, you increase the risk of UTI. So we tend to discourage that.”
Jaja advised the injured patients to regularly inspect and assess their skin and prevent injury to the immobile parts.
“Check to be sure that there is no patch of redness on any part of the skin. We must advise that because that is where the pressure sores start. The individual must ensure that they move the parts of the body, even the part that is immobile. Relatives or caregivers may help. Mobility is important because once that part of the body lies for a very long time, there is immobility for a long period, the issue of pressure on bony prominences comes in and the risk of pressure ulcers develops.
“As much as possible, they should pay attention to skincare and hygiene. They should keep their skin clean and dry and drink a lot of water and take heed to their nutrition,” the neuroscientist said.
He discouraged the injured from patronising traditional and unorthodox care, noting that it would lead to worsened health outcomes.
Quit smoking, alcohol
Jaja emphasised the need for lifestyle modification, noting that patients quit and avoid tobacco use and alcohol intake.
“Maintain a healthy weight, because we find that in persons who are obese, the outcomes are poorer. They have to be healthy and avoid smoking. If they are diabetic or hypertensive, they have to pay attention to their blood levels and blood pressure, because those co-morbid conditions worsen the outcomes for such a patient.
“They also have to maintain a positive outlook on life. It’s not the end of the world. It’s important that they also manage their mental health and maintain an attitude of positivity and as much as possible, work with their health care provider,” the don said.
