We decided to take things easier this week with a string of day shifts at Baragwanath - we needed a break from the drunk and disorderly of the night. The patient demographic may have been different, but there was just as much drama to take us from having a laugh to being upset, frustrated or simply exhausted in a flash, and then back to happy and cracking jokes again in no time. The emotional instability is concerning... we may be losing it.
***
Each morning as we drowsily arrived at a little before 7, the pit would be empty. Well, of patients that still needed to be seen at least. Let me explain, I have learnt the 24hr pattern for patient intake seems to be roughly the following:
8-11am produces the first patients of the day: motor vehicle accidents (MVAs) and pedestrian-vehicle accidents (PVAs) from the morning rush hour - this could require anything from a bit of paracetamol to full on emergency heart and lung surgery.
11am-2pm is a bit quieter, you might have a few work-related injuries like a brick landing on the head (guess helmets are a thing for a reason), or electrocution
2-4pm brings in patients that have gone to "clinic" (the S. African equivalent of general practices in the UK, except these clinics are generally run by nurses rather than GPs) earlier that day for minor trauma. This commonly includes broken bones, blistering second degree burns, and infected dog bites. I realise my definition of the word "minor" may have become a bit distorted after spending 3 weeks here...
4-8pm brings yet more car crashes and pedestrians hit by stupid taxi bus drivers during the evening rush hour
8pm-4am is non-stop alcohol-fuelled trauma: stabbed patients pour through the doors as alcohol disinhibits people's rage, and cars become the bane of our lives as we attend to drink drivers, drunk passengers who thought it was a bright idea to jump out of a moving vehicle, and drunk pedestrians who have lost any concept of a distinction between the pavement and the road.
4-7am the drunken patients all fall asleep as their treatment is completed and all that's left is for them to sober up or for a friend to come pick them up in the morning. On my first night shift I discovered this as I was walking back from a toilet break to a rather eerily quiet pit: I turned the corner to see it full of unmoving bodies on stretchers, covered in blankets from head to toe, reminiscent of the first day we walked into our dissection theatres 5 years ago... I looked around despairingly for a doctor to ask what the hell had happened, only to jump out of my skin as one of the corpses let out a snore that resonated through the corridors.
7-8am the daily ward round is done, the hungover patients clear out back home and the rooms are restocked (well, sort of) for the day ahead
Re-stocked saline solution (i.e. should effectively be table salt + water)... something doesn't seem right
Of course on top of all of this there's the background trauma where at any time someone may decide to shoot, run over, stab or mob assault a fellow Jo'burg resident for whatever reason: as part of organised crime, during a mugging, some vigilante justice, or maybe just because they refused to offer a cigarette (true story, sutured up a guy who got knifed for that - he survived and is now quitting smoking which is a plus!) In fact, if you're really unlucky you can sometimes experience more than one of these at once - I had one guy come in as both a "pedestrian-vehicle accident" and "mob assault". He explained that he'd got hit by a car that ran a red light, but because he had inconsiderately allowed his body to smash the car's windscreen upon impact, the driver and his passengers decided to teach the poor sod a lesson by beating him before speeding off.
So, what did we see this week? On Tuesday I started off clerking a woman in her 40s who had become confused and disoriented since falling in the bath the previous night, when a senior surgeon tapped me on the shoulder and asked me to come to theatre 9 when I was free as she needed a pair of hands to assist. After spending some more time with the patient completing their history, doing a full neurological examination and making a plan with the junior doctor, I strolled over to theatres. I scrubbed in and sauntered into theatre 9 to find a high speed pedestrian-vehicle accident patient with massive internal bleeding - the surgeons were about to perform an emergency laparotomy (slice open the abdominal wall, clear out all the blood, try to find where the blood is coming from and stop the bleeding)... why they hadn't indicated to me that there was a sense of urgency earlier I do not know. After opening up the abdomen, the surgeon asked me for my left hand - I put it out. She said fan it out - slightly confused, I did. She then took my hand and plunged it into the abdominal cavity - I looked up at her, bemused, as I felt the warm sliminess of the patient's blood-coated organs against my palm, and the aorta pulsating against my fingertips. "I need you to hold the intestines out of the way," I was told. That was my job. And I fucking loved it. Guess I really have found my dream career.
I saw the mangled spleen and one of the kidneys get taken out in double time, and after repairing the liver they checked for any other damage before closing the patient up. I got back to resus after the operation to find Alex also walking around with a contented smile - he'd just done his first chest drain (sticking a tube into someone's chest to remove air or blood that shouldn't be there) and had similarly achieved enlightenment.
You can go from a high like this and crash down to the opposite end of the spectrum, completely at the whim of what patients come in and what happens to them. I had a father come in with his 5 year old daughter who had suffered some nasty burns to her right arm. On questioning the father about what had happened it turned out the child had suffered the burn a week ago and had not been brought to clinic or hospital, the story was inconsistent and didn't fit the pattern of the burn, and the interaction between the child and father felt a bit dodgy - I reported my first case of potential NAI (non-accidental injury). That was the worst case scenario, at best it was a genuine accident but the family had been grossly negligent for not bringing the kid in sooner. I'm happy to say that the paediatric surgeon that came to review the case knew exactly how to handle the situation in a professional manner: she contacted social services, booked a follow-up appointment to question the family further to assess the child's safety and, most importantly, gave the father a royal bollocking. It was a wonderful rant to behold... especially because the father didn't actually understand any English - he stood there a little dumbfounded since all he could tell was the surgeon was bloody pissed off and, backed into a corner, he looked despairingly to the translator to find out what kind of hellfire was being spouted at him.
Another thing we've experienced this week is that patients can deteriorate without any warning whatsoever. On one occasion, I was walking through resus when a stable patient suddenly started retching and throwing up bright green gooey fluid (kind of like the centre of those "Toxic Waste" sweets you'd have as a kid... ah, those days) - turned out he'd had a bleed on the brain. A few hours later, while taking a history from a patient I heard Alex next door, "Sir, please stay still I'm trying to examine your tummy." I popped my head around to see if he needed help with an uncooperative patient... the man didn't look quite right. He continued, "Sir, please stay still. Oh wait... shit, he's having a seizure."
Other good examples of unexpected deterioration are when people you trust to have assessed and monitored a patient properly, simply have not. Upon arrival, paramedics wait at the red line with their patient to handover the case to a doctor - the more ill your patient, the more urgency you ought to have in getting a doctor to come and have a look. There's a problem though in that paramedics in South Africa seem to vary massively in quality: some are great, but some have absolutely no clue what they're doing. Yesterday morning I noticed a couple paramedics sitting around with a patient on a stretcher but since they seemed pretty relaxed, I continued my work in the pit. I looked back after 15 minutes to see they were still there and that the patient looked, at a glance, pretty unresponsive. I fetched a senior and we took a handover:
"We found this guy unconscious on the side of the road so don't know what happened we're afraid"
"GCS?"
"GCS was 9/15" (i.e. indicative of moderate brain injury, not something you should be sitting around on) A quick assessment from the doctor revealed that the GCS was in fact 3/15 (the minimum score, representing someone in a deep coma) and we began to hear some gurgling and see frothing around the mouth. We rushed him into resus and gave him the full works, at one point his oxygen saturations dropping to 9% (generally if it ever drops below 90% you start getting worried, didn't realise it could even get that low... so yeah, very not good) largely because half the bag-valve masks and oxygen tanks around here don't flipping work. Somehow with all hands on deck the patient was stabilised. Not entirely sure how he survived, but I now know not to fully place my trust in these paramedics again.
At the opposite end of the spectrum, some paramedics go totally overboard - I saw a group of doctors sprinting by with a stretcher so I rushed after them out of the hospital in case they needed help. I was met with a blinding gust of wind and sand as the first helicopter I've seen at Bara appeared out of nowhere, carrying what was no doubt a critically ill patient. Sure enough though, the patient turned out to be pretty much fine - they just had a complicated case of jaundice and were being transferred to this hospital from another for more investigations and treatment. The reason for the helicopter was simple: they'd run out of ambulances.
Posing with the helicopter as any good Asian would. (I did a trade with a fellow East Asian doctor who wanted me to take a photo for her #orientalbond)
It's moments like these that have made me appreciative of the NHS staff of other disciplines back at home. I had taken the knowledge and expertise of paramedics for granted, as well as the existence of an administrative team working behind them using coding systems to ensure efficient allocation of resources and the avoidance of unnecessary highly costly helicopter usage (even if it is super cool).
Anyway, the life of a doctor/ student doctor shouldn't all be about blood and gore and gnarly trauma so we took a day off to fix a tyre puncture (perhaps Heidi didn't survive the trip up Drakensberg after all) and watch The Incredibles 2 - bloody great, go watch it.
Alex was bigger than everyone else but we didn't care. I on the other hand blended right in.
***
Each morning as we drowsily arrived at a little before 7, the pit would be empty. Well, of patients that still needed to be seen at least. Let me explain, I have learnt the 24hr pattern for patient intake seems to be roughly the following:
8-11am produces the first patients of the day: motor vehicle accidents (MVAs) and pedestrian-vehicle accidents (PVAs) from the morning rush hour - this could require anything from a bit of paracetamol to full on emergency heart and lung surgery.
11am-2pm is a bit quieter, you might have a few work-related injuries like a brick landing on the head (guess helmets are a thing for a reason), or electrocution
2-4pm brings in patients that have gone to "clinic" (the S. African equivalent of general practices in the UK, except these clinics are generally run by nurses rather than GPs) earlier that day for minor trauma. This commonly includes broken bones, blistering second degree burns, and infected dog bites. I realise my definition of the word "minor" may have become a bit distorted after spending 3 weeks here...
4-8pm brings yet more car crashes and pedestrians hit by stupid taxi bus drivers during the evening rush hour
8pm-4am is non-stop alcohol-fuelled trauma: stabbed patients pour through the doors as alcohol disinhibits people's rage, and cars become the bane of our lives as we attend to drink drivers, drunk passengers who thought it was a bright idea to jump out of a moving vehicle, and drunk pedestrians who have lost any concept of a distinction between the pavement and the road.
4-7am the drunken patients all fall asleep as their treatment is completed and all that's left is for them to sober up or for a friend to come pick them up in the morning. On my first night shift I discovered this as I was walking back from a toilet break to a rather eerily quiet pit: I turned the corner to see it full of unmoving bodies on stretchers, covered in blankets from head to toe, reminiscent of the first day we walked into our dissection theatres 5 years ago... I looked around despairingly for a doctor to ask what the hell had happened, only to jump out of my skin as one of the corpses let out a snore that resonated through the corridors.
7-8am the daily ward round is done, the hungover patients clear out back home and the rooms are restocked (well, sort of) for the day ahead
Re-stocked saline solution (i.e. should effectively be table salt + water)... something doesn't seem right
Of course on top of all of this there's the background trauma where at any time someone may decide to shoot, run over, stab or mob assault a fellow Jo'burg resident for whatever reason: as part of organised crime, during a mugging, some vigilante justice, or maybe just because they refused to offer a cigarette (true story, sutured up a guy who got knifed for that - he survived and is now quitting smoking which is a plus!) In fact, if you're really unlucky you can sometimes experience more than one of these at once - I had one guy come in as both a "pedestrian-vehicle accident" and "mob assault". He explained that he'd got hit by a car that ran a red light, but because he had inconsiderately allowed his body to smash the car's windscreen upon impact, the driver and his passengers decided to teach the poor sod a lesson by beating him before speeding off.
So, what did we see this week? On Tuesday I started off clerking a woman in her 40s who had become confused and disoriented since falling in the bath the previous night, when a senior surgeon tapped me on the shoulder and asked me to come to theatre 9 when I was free as she needed a pair of hands to assist. After spending some more time with the patient completing their history, doing a full neurological examination and making a plan with the junior doctor, I strolled over to theatres. I scrubbed in and sauntered into theatre 9 to find a high speed pedestrian-vehicle accident patient with massive internal bleeding - the surgeons were about to perform an emergency laparotomy (slice open the abdominal wall, clear out all the blood, try to find where the blood is coming from and stop the bleeding)... why they hadn't indicated to me that there was a sense of urgency earlier I do not know. After opening up the abdomen, the surgeon asked me for my left hand - I put it out. She said fan it out - slightly confused, I did. She then took my hand and plunged it into the abdominal cavity - I looked up at her, bemused, as I felt the warm sliminess of the patient's blood-coated organs against my palm, and the aorta pulsating against my fingertips. "I need you to hold the intestines out of the way," I was told. That was my job. And I fucking loved it. Guess I really have found my dream career.
I saw the mangled spleen and one of the kidneys get taken out in double time, and after repairing the liver they checked for any other damage before closing the patient up. I got back to resus after the operation to find Alex also walking around with a contented smile - he'd just done his first chest drain (sticking a tube into someone's chest to remove air or blood that shouldn't be there) and had similarly achieved enlightenment.
You can go from a high like this and crash down to the opposite end of the spectrum, completely at the whim of what patients come in and what happens to them. I had a father come in with his 5 year old daughter who had suffered some nasty burns to her right arm. On questioning the father about what had happened it turned out the child had suffered the burn a week ago and had not been brought to clinic or hospital, the story was inconsistent and didn't fit the pattern of the burn, and the interaction between the child and father felt a bit dodgy - I reported my first case of potential NAI (non-accidental injury). That was the worst case scenario, at best it was a genuine accident but the family had been grossly negligent for not bringing the kid in sooner. I'm happy to say that the paediatric surgeon that came to review the case knew exactly how to handle the situation in a professional manner: she contacted social services, booked a follow-up appointment to question the family further to assess the child's safety and, most importantly, gave the father a royal bollocking. It was a wonderful rant to behold... especially because the father didn't actually understand any English - he stood there a little dumbfounded since all he could tell was the surgeon was bloody pissed off and, backed into a corner, he looked despairingly to the translator to find out what kind of hellfire was being spouted at him.
Another thing we've experienced this week is that patients can deteriorate without any warning whatsoever. On one occasion, I was walking through resus when a stable patient suddenly started retching and throwing up bright green gooey fluid (kind of like the centre of those "Toxic Waste" sweets you'd have as a kid... ah, those days) - turned out he'd had a bleed on the brain. A few hours later, while taking a history from a patient I heard Alex next door, "Sir, please stay still I'm trying to examine your tummy." I popped my head around to see if he needed help with an uncooperative patient... the man didn't look quite right. He continued, "Sir, please stay still. Oh wait... shit, he's having a seizure."
Other good examples of unexpected deterioration are when people you trust to have assessed and monitored a patient properly, simply have not. Upon arrival, paramedics wait at the red line with their patient to handover the case to a doctor - the more ill your patient, the more urgency you ought to have in getting a doctor to come and have a look. There's a problem though in that paramedics in South Africa seem to vary massively in quality: some are great, but some have absolutely no clue what they're doing. Yesterday morning I noticed a couple paramedics sitting around with a patient on a stretcher but since they seemed pretty relaxed, I continued my work in the pit. I looked back after 15 minutes to see they were still there and that the patient looked, at a glance, pretty unresponsive. I fetched a senior and we took a handover:
"We found this guy unconscious on the side of the road so don't know what happened we're afraid"
"GCS?"
"GCS was 9/15" (i.e. indicative of moderate brain injury, not something you should be sitting around on) A quick assessment from the doctor revealed that the GCS was in fact 3/15 (the minimum score, representing someone in a deep coma) and we began to hear some gurgling and see frothing around the mouth. We rushed him into resus and gave him the full works, at one point his oxygen saturations dropping to 9% (generally if it ever drops below 90% you start getting worried, didn't realise it could even get that low... so yeah, very not good) largely because half the bag-valve masks and oxygen tanks around here don't flipping work. Somehow with all hands on deck the patient was stabilised. Not entirely sure how he survived, but I now know not to fully place my trust in these paramedics again.
At the opposite end of the spectrum, some paramedics go totally overboard - I saw a group of doctors sprinting by with a stretcher so I rushed after them out of the hospital in case they needed help. I was met with a blinding gust of wind and sand as the first helicopter I've seen at Bara appeared out of nowhere, carrying what was no doubt a critically ill patient. Sure enough though, the patient turned out to be pretty much fine - they just had a complicated case of jaundice and were being transferred to this hospital from another for more investigations and treatment. The reason for the helicopter was simple: they'd run out of ambulances.
Posing with the helicopter as any good Asian would. (I did a trade with a fellow East Asian doctor who wanted me to take a photo for her #orientalbond)
It's moments like these that have made me appreciative of the NHS staff of other disciplines back at home. I had taken the knowledge and expertise of paramedics for granted, as well as the existence of an administrative team working behind them using coding systems to ensure efficient allocation of resources and the avoidance of unnecessary highly costly helicopter usage (even if it is super cool).
Anyway, the life of a doctor/ student doctor shouldn't all be about blood and gore and gnarly trauma so we took a day off to fix a tyre puncture (perhaps Heidi didn't survive the trip up Drakensberg after all) and watch The Incredibles 2 - bloody great, go watch it.
Alex was bigger than everyone else but we didn't care. I on the other hand blended right in.
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