Week 3 Kruger Park 28th Nov 11

Week 3 Kruger Park 28^th Nov 11

The last leg of the trip ends in Kruger National Park. Cruising the beautiful hot bush seeing the big 5- Lion, Rhino, Buffalo, leopard and elephant…. Not to mention…. Giraffe, baboons, impala, hippos, crocodile, wild dogs, fish eagle, water hog, kudu, steenbok, zebra, genet and hare just hanging around their bush land.

The last couple days chilling with cheeky monkeys and bush buck surrounding me like a character in the Bambi movie.

Finally as I lie swinging in my hammock over looking the Kruger park planning my return as I need my Bara trauma fix!

Not to mention there are more papers to write and publish for USAR and SA/UK trauma, more conferences… furthermore professional developments to pursue and friends/colleagues to correspond with in SA and advance international clinical working.

So like a duck to water.. a 3^rd return is scheduled.

Week 2 Trauma in Johannesburg – 22nd Nov 11.

Week 2 Johannesburg – 22^nd Nov 11.

After some interesting further days in Cape Town, I head back again to Johannesburg. The flight was entertaining I do meet an array of friendly and innovate people on my travels, here people actual talk to you therefore your encounters are opportunistic.

Arriving in JHB severe storms and lightening, rain does tend to follow me. Returning to JHB a second time I felt more confident and less apprehensive compared to my first visit with trepidation- familiarity breeds contempt.

This weeks my days consisted of pre-hospital response car on the roads of JHB, how I’ve missed bombing around the roads at 180kmph while experienced paramedic J is on 2 mobile phones and the radio weaving around heavy traffic who frankly do not move.

The days consisted of Motor Vehicle Accidents (MVA) and Pedestrian Vehicle Accidents (PVA), assaults, anaphylaxis’s,  medical conditions, collapses. Last MVA P1 off one of the days- entrapment in vehicle side been taken straight off, severe head injury and deep laceration anterior to posterior scalp, humeral and ? femur #, ? pelvis.

Only in Africa the tow trucks get to the accidents quicker than the EMS as they get paid to inform the companies and tow. It’s a confusing system but sometimes all EMS respond the private companies and government then depending on the patient and care needed either with ALS paramedic or ILS crew will go to the most appropriate hospital with the patient, but other days lone ALS responder attends just depends on how busy the city is. Patient today allergic reaction was unwell enough to go to a private hospital but did not have medical aid… however she was not sick enough for the government hospital…

Hilarious vision this am on a blue call to a incident- lights on and sirens driving fast on the slip road  as rush hour when some cheeky guy was following behind just to get through the traffic… so stopped the response car asked him what he thought he was doing in return he shrugged his shoulders then proceeded to get into the normal flow of traffic… Africa!

And so the days continue with picking up guns visiting the police station and many more pre-hospital calls. More MVAs, some P4 which in South Africa’s triage system is dead rather than in the UK it means lower priority and can wait for up to 2 hours.

Shame no Bara shift but that means I have to come back even earlier now- addictive Bara trauma unit needing that resus room and wanting to help those people...

Friday night 3.30am call- shooting with suspects still actively shooting. Location rural farm other side of town. Male, gun shot chest entrance and large exit  wound probably shot through posteriorly and shots x 2 bilateral femur. Lung parenchyma seeping through gun shot wound on the right chest, transmediastinal GS wound with trajectory, on auscultation fluid, bubbling sounds throughout chest. GCS 14/15, sats 90% o/a, 15 L 02 sats 92-94%, 90/54 p122, 2L hartmans insitu. With sounds of further shooting in the back ground, call for police assistance and the heli ordered. On arrival of the heli the road was closed and the patient eventually got air lifted.

We went to Jburg Gen the next evening to find out the outcome- patient went to theatre we think but we had some information he was waiting for CT chest report? Anyway he was on a high care ward- not ITU. That’s incredible- these folks are robust and do not die easily!

SA trauma return....

Arrived 13^th Nov 2011-11-22 – week one

Well  I have finally returned as I promised in April. A few tough months.

The 14,000 word paper has been written and some presentations delivered, the blog has been published and I spoke at the RCN conference in Birmingham 1 day before about the SA trauma experience, and the Florence Nightingale conference is next March as I have been asked to present the travel scholarship award section.

Returning is heart warming and familiar in Cape Town- the roads, the people, the culture and table mountain covering the landscape with such presence and power. Deep breath of the mountain and sea air, its good to be back in this beautiful city, especially as I know my way around confidently competing with the mini bus taxis.

Nervous and excited my 2^nd conference to present, this much bigger - the international emergency care conference in Cape Town.

Day one USAR Urban Search and Rescue at the Disasters Management Centre Tygberg Hospital, so good to see Prof K again very pleased to see him, also met Trevor Glass chair International Search and Rescue Advisory group INSARAG  and disaster management Australia an experienced S African, among other lead Drs and profs. Excellent day lectures on USAR and then off to a disaster site for practical exercises- like my last weekend antics USAR training in the UK, nicer place though.

The warmth on my skin from the cape sun and the warmth from the SA people is delightful. And so prepping for the conference, and seeing old friends and influential leaders.

Now the international conference centre in Cape Town is an amazingly large grand professional high tech building stretching a part of the city – I looked up with a slight feeling of anticipation followed by a feeling of  exhilaration. The Emergency Care conference was a proficient affair, clinicians and profs from around the globe attending. The medical stalls and stands where impressive and displayed the latest technology and expert clinical management. Good to meet the medical/trauma leads again- EMSSA/ENSSA, Net.Care, kind hearted welcome backs from the organisers and praise on my paper they had read.

The ENSSA leads delivered powerful SA nursing presentations and even quoted Barleycorn 2011 in the lectures and thanked me to the crowd. The passion of the subject is something I agree with and hope to make a difference too. My humility augmented even more.

I have also been able to spend time with the INSARAG United Nations medical and operational working group- where USAR medical and operational leads representing different countries come together to discuss and create INSARAG methodology and guidelines. 

And so onto the conference day I spoke at 17^th Nov- my name published to present in the thick distinguished international conference document. No pressure then..

Nevertheless thankfully it went very well and the audience where receptive on my presentation on USAR- ensuring medical competencies. Prof K was very pleased who run the USAR seminars – that was really good, his praise is one from a experienced professional who is head of EM J’Burg and FIFA, USAR in SA and that’s just for starters. In a male dominated doctor environment I was a political pawn- my subject, gender and profession!

So now to relax, chill before I head back to J’burg to work prehospital and back to Bara!!

Saving Soweto - 24 Hours of Trauma - 9 Jan 09 - Part 2

Saving Soweto - 24 Hours of Trauma - 9 Jan 09 - Part 1

At the end.....

Rain followed to Cape Town! Alas…… so only tiny bronzing for me but rest in the Cape… sun appeared for my last two days though!

Last trauma meeting pleasure to meet President Trauma Society/Clinical head of trauma and transplant surgery Elmin Steyn what a lovely lady!! Very informative and knowledgeable, very lucky to have spent time with these trauma leads in SA. I also was shown around the Vincent Pallotti trauma/emergency unit and met the manager. J 

So 7 weeks later….

2 cities- Cape Town and JHB

9 hospitals private and government

4 airports

4 heli pads

1 response car

5 ambulances

Many prehospital shifts

Many more clinical hospital shifts

1 blogg

114 photos

£1000 on car hire

£400 on airtime

Signed numerous disclaimers on my life

9 meetings with SA trauma and medical leads

68 destinations into my GPS… and only 4 times dummy out of mouth in getting lost.. okay perhaps 5 J!

I recommend if you would like the clinical and cultural experience…. you have to come here! You need 3 prerequisites as stated by the infamous Prof K:

1) Thick skin

2) Sense of humour

3) Good personality

That man is always right…. You will then have a rewarding adventure!

Many thanks to the Professors, trauma leaders, EMSSA/ENSSA, Trauma Society, GS Hospital, Bara Hospital, Private Mediclinic, Net.Care, Stellenbosch Uni, Wits Uni, prehospital- western cape metro, Gauteng- heli, ER 24 ……and to all those who put up with me, looked out for me and the wonderful friends I have made and relationships strengthen ….. I am very sad to leave, very sad….!!!!! L

South Africa is beautiful and very moving, it encompasses all of the aspirations of the people to seek progress and improvement- with hope in its heart despite the challenges. I have had the pleasure to experience the real life of South Africans condemned to suffer extraordinary violence and disfigurement and disease, whilst the country itself is a beautiful landscape and offers great promise. You work hard at life here, but the rewards are endless, the South Africans love their country very patriotic and will fight for their rights, liberty and power. I have the up most respect for all here…. Be heard as you have to expel a voice here. It kind of reflects my own values.

The paper now needs to be written for journals international and UK …. Presentations carried out UK and SA- recommendations and experiences passed for others to learn.

I have learnt personally, spiritually and professionally I wish to pass this on sharing and growing, with international collaborative working for the nursing profession and the benefits of patients worldwide.

And so the travelling ups and downs, idiosyncratic moments, challenges, pushing the boundaries of the self, the achievements, the inspirations…

But most of all my humility has been augmented……

Homeward bound……. Not ready to leave… L

Who knows what will come of this….

I certainly will be back that’s booked already….

The journey hasn’t ended its only beginning……. J J

JHB.... WILL and onwards

Now my car…. Firstly I have got a speeding fine and secondly when my hire car was delivered in JHB it was brand new … yes brand new. On returning huge dents which look like I have run someone over as red sand is splashed up the side…. I didn’t nor did I crash it!

I did go out and see Goldfish live... well done SA!

My flight from JHB... jeez its a confusing airport I had to pay a dude to direct me to the car rentals. Anyway as I boarded the flight as I was the last on because I let everyone else get on first?! There then appeared to be no overhead bag storage, so the air stewardess preceded to march of with my bag, laptop and all- I did spit a small dummy out as I felt slightly uncomfortable about all my belongings taken off me after all I had survived JHB so far. My fears where somewhat confirmed 1 hour into the flight when I asked the girl for my bag... my bag please... where did you put it?.... silence then denial she took it for me... so I had to go through every overhead locker in the entire plane. As you can imagine after 45 locker heads later and lots of banging and redness from the air crew I finally found my bag.... incidentally the whole plane clamped with relief... probably because I didn't take their bag!! Note to all please...

Wow I am exhausted from JHB and worked so much but what an amazing experience…. the culture, history, violence, crime, the disregard for life, corruption, inequality, poverty, expectation, racism and classism- an anthology all living side by side. The differences are vast and I have understood why it is that way - culture heritage seasoned with a long history of apartheid and some politic drives- its all multifactoral! A stunning country full of contrasts embedded in a beautiful land.

Onward to Cape Town to rest, see the sun, table mountain and one more trauma meeting …. wonderland city at its been quoted, one of the most beautiful place’s in the world I believe. J

I would like to reflect on one of Nelson Mandela’s quotes;

WILL

“There are few misfortunes in the world that you cannot turn into a personal triumph if you have the iron will and the necessary skill’

That’s why I am here, how this adventure came about, in your darkest moments you can conquer and grow stronger but hey that’s another story!...

And it’s not over yet!......

Lasts days at Bara trauma unit

Prehospital- house fire,  father and triplets all died, mother watched after trying to pull them all out.

Just got in and missed a emergency room thorocotomy! Gutted! I’ve seen all other text book conditions now… that was left!

Haemothorax secondary to stab…. Unstable dropping BP despite fluids and bloods… for theatre. Another ICD!

Paediatric PVA

Another adult PVA…. Immediate tube and full resus as airway severely compromised.  

Burn patient from petrol fire fully conscious... full facial burns, swollen eyes/face, singed nasal hairs, soot.... rightly so we intubated immediately.

Pleased I saw Prof Frank P, amazing surgeon and man- the dedication and skill. Big hug from him his protégée he says…. Hardly that!!

The weather has been thunder and lightening with severe rain… its very scary driving in this weather while lightening is striking apparently its common to have fatales due to lightening here! 

The day I finished I drove back through Soweto township, found the poorest mama I could and gave her all my new polo t- shirts…… she was so happy J!!!

Special thanks to Prof Efraim K, the SAISAR team all flew off to Japan, all the SA medical and trauma expertise went! Good luck!

Prof K another incredible man….. nicest compliment from him too…. SMS  ‘Its been great having you, please come back soon and keep up your incredible drive and passion’….. J

JHB has been tough and I do not mean clinically.....so that SMS was so great to receive. JHB is so different from the Cape you cannot compare them……

Days at Bara trauma unit JHB.

Final days consist of the same conditions and injuries. Severe MVAs, PVAs and stabbings…. Full resus traumas!

One 6 year old girl… hit by car… again full trauma.

MVA- full trauma resus and gross # tibia compound segment.

Pneumo’s

Haemo’s all secondary to stabbings.

One agitated patient stabbed 4 times who had taken drugs.... unsure what though.. we put a ICD in 3 times as he kept pulling it out…. He also bit me!!!! As well as being difficult to manage he become severly bradycardic after he was given more morphine? The ICD was situated okay at 20 so it might have been the drug interaction?? In the end we sedation and tubed him then we had peace and haemodynamically resolved!

Severe assaults- all ventilated and tubed due to the gross injuries in a row in resus until CT or a bed was ready on the wards. All prognosis=  bad.

Lower threshold to tube patients here as tubed patients are looked after on the wards by all staff.

Patients waiting 16 hours plus to be seen in the trauma and surgical area. All have idiosyncratic infections, tumours and conditions which we would not put up with but these people have them for a long time before they seek treatment.

We found a diabetic patient unconscious in a cubicle BM 0.7… brought her into resus… well the reaction from the nursing staff as she wasn’t a trauma!!!!!!

The nursing communication is a challenge…… and the relationships here!!!!!!!!!! but I do understand why......

Saturday night bara….. 116 patients, 27 resuscitations and 12 tubed, 9 to theatre……………….

Prehospital JHB……..!

Prehospital JHB……..! Response car and Heli

2 long days pre-hospital in the response car ER24 and fire EMS.

While blue lighting around the roads of JHB at 180 kmph with Jan an experienced paramedic while contacting control and back up negotiating  the JHB traffic and corners he casually drops in stories from 18 years on the JHB roads- GSWs, armed robberies in peoples homes and shops etc, mass shootings, hijackings, train crashes, plane crashes, chasing from heli’s, paediatric drownings, riots, multiple stabbings, MVA pile ups, watching patients burn to death in cars that explode as arrive on scene, house fires… these scenarios as recent as 4 nights ago…. disclosed so innocently with a raise of the eyebrows followed by a grin….its the norm here!!

JHB has approximately 50 murders a day. SA has 1,200 deaths on the road a month and 60 000 South African’s meet their end violently every year

We attended MVAs, sports injuries, bike injuries, 1 x DOA. 1 x  ICU transfer actually the trauma patient from the heli earlier. Car on fire. Another call 12 people injured strike by lightening- 1 child died, 2 critically ill!

I experienced many of the private hospitals in JHB- trauma and ICU… and heli trauma patients.

The pre hospital system in JHB consist of provincial government and private companies, although both private EMS attends all calls with medical aid or not. Emergency calls are sieved by the individual call centres, as each company has they own public call number.

Pre- hospital is my favourite! Another shift tomorrow!

Heli for long day shift too... learning even more about SA history and culture... why its is the way it is...... its becoming clearer!!!

J

Bara, teaching and trauma

Last 2/7 I've been at Bara Trauma Unit, Thursday 8am EM reg teaching: intrapleural blocks, traumatic aortic dissections, triage sieve and sort, sepsis mediators and pathways and Mx of malignant hyperthermia and sux scholine apneoa to name some of the subjects discussed.

My UKISAR team is off to Japan, 2nd earthquake in over 2 weeks- sorry I cant go but good luck!

The rest of the shifts have been clinical- MVAs, severe assaults requiring ventilation.

One patient was brought in naked on a stretcher from the wrong side of the hospital ie back entrance which was strange?!…. he had GCS 3, unilateral blown pupil, bradycardic and beaten black and blue with rod marks anterior and posterior- poor prognosis eh….. now the story is this man was caught thieving (like so many) in the nurses accommodation…. So the students nurses beat him severely …. People do not mess with the student nurses!!!

Yesterday was so busy with surgical patients 18 waiting to be seen all been there since early morning still 10-12 hours later without being clerked, all so sick too. Every patient is so ill as they come in when they are at the sickest point as they have no medical aid, it really is sad and therefore more difficult to treat…

As trauma was fairly quiet for a Friday evening so far?... the trauma doctors helped out with the surgical, I clerked some patients and started treatments etc. The emergency side was heaving as usual… patients everywhere as trauma side lying on trolleys and off… tied to trolleys…. Awful smell and all with probable underlying TB.

Meetings, private trauma units, data and MVAs.

Well the last 3 days I've been busy with meetings, I had the pleasure to meet secertary of the Trauma society and head of Net.Care... now this highly competent lady runs the world as Ive been told and runs trauma in SA. Very productive meeting augmenting my knowledge of S Africa's trauma and the lack of a comprehensive trauma system.... more in my final paper!

Been catching up with the Prof K... great man!! And having trauma data meetings... statistics or lack of them in SA.... more in the final paper!

Today I spent time at a private trauma unit Net.Care MilPark. Impressive establishment - 4 resus bays which can go to 7. 8 nurses on duty. Unit see’s 30-60 patients daily. Approx 60-80 P1 traumas a month.

90 bedded ICU, 30 ICU trauma beds. Excellent burns unit the only private one in Africa so they get referrals from all over. The unit has its own theatre and ICU, they receive patients with 80-90% burns, survival rates 70-80%! This trauma unit is one of two that are just being accredited in SA now for a level 1 trauma unit. The first in legislation, hopefully this will ge the first of many to assist the SA trauma issues.

Driving back on the highway, some of the robots aka traffic lights do not work at busy junctions so its first come first served, whoever gets there first! I just missed and swerved a dumper track turning left into a minibus both going at significant speed….. the minibus was crushed into the dumper track… approx 10-12 casualties who where trying to get out. All eventually managed to get out through shattered windows or the front smashed end, one woman was trapped for longer but then freed. No P1 injuries surprisingly! I called Jan paramedic who called his teams to attend, interestingly a policeman arrived on his motorbike looked at the scene then left on his bike blue lighting somewhere else!!  20 minutes later no paramedics but the tow trucks arrived within minutes!!

Okay….. now out with Jan excellent paramedic with 18 years experience in JHB in the response car the evening shift!! J

Saturday Night Bara Trauma Unit Johannesburg …….!!! HETIC not the word!

Saturday Night Bara Trauma Unit Johannesburg …….!!! HETIC not the word!

As the sunsets over Sowetto township I head to the hospital for the famous Saturday night shift- swerving the minibus taxis on the way as they aim for head on collisions and own the road!

The shift starts at 7pm- arriving in trauma resus 10 patients are already there, seemingly a busy day MVAs and shattered pelvis, GSW to heart, stab requiring surgical thorocotomy  - all to theatre and multiple stabs or assaults tubed in resus and waiting CT scans - scanner down again! And the ‘minors areas’ although not minors very busy, patients waiting everywhere.

What an experience- if I am honest through the night I lost count the amount of stabbings, GSW and MVAs - ejections, PVAs we resus’ed… lost count how many ICDs and CVPs where inserted!

Man comes in carried in a blanket by friends- stabbing pericardium … another open sucking chest wound/ pneumo..

Helicopter brings in a 22yr old female shotgun shooting…. Went out to the heli pad and retrieved the patients resus’ed.. lodox showed 17 BULLETS dotted over her abdomen- to theatre.

Tracheal- broncho injury….

Then 17yr old stabbed in the abdomen….. bowel evisceration… her whole bowel/intestines hanging out her abdomen….- to theatre

5 patients went to theatre that night.. 3 still waiting.

I spent the night doing or assisting with invasive procedures and investigations… all full resus’s. At the beginning of a shift the nurses draw up all the drugs- morphine, sedation and anaesthetic drugs so they are ready to use. The nurses know there roles but communication can be the challenge! I worked with a experienced trauma unit manager from the private sector who was volunteering for the night…she knew her stuff and  very proactive.

One of the surgical professors was on shift all night, in between theatre he was in resus advising, teaching the registrars and interims. The teaching and support is readily there and such a high standard by experienced skilled clinicians.

I did lose count the amount of resus patients but the resus admin book stated 20 in the morning. In the middle of the night more patients attending with stabbings and GSW who lay in the ‘minors’ area, at 5.30 we had run out of space in resus the bays were doubled up to 16 but we had 18 patients so they couldn’t be monitored. There are no curtains in resus so every patient can see each other, the procedures and exposure.

At 6.45 the outside area had a sea of patients on a trolley if there was one or on the floor- with GSW and stabbings, MVAs.

Some of the patients particularly resus patients are not cooperative, they are violent and therefore difficult to treat. I do understand how this volume and presentation wears the healthcare professionals down, most patients have added infectious diseases/HIV- no wonder there is burn out, the risk is heightened in these situations.

One of the other professors arrived with the day team for the 7am shift, the unit was heaving. Jburg Gen had apparently closed – we had to close for the morning at least until the plethora of patients been cleared and managed, although a call came through with GSW… which of course was accepted.

So the trauma ward round commenced, every patient was discussed- then onto the trauma wards and then ICU. Each patient is discussed and managed, the professors set high standards this is heavily implemented or one will be told to ensure good care. The treatment is excellent, this cannot be faulted- centre of excellence. All the teams work hard, the professors, regs and interims work long hours 24hrs plus and more if work is incomplete.

Such a remarkable experience, very hard to even describe what happens weekly for them, this the norm here- violence and active physical consequences- another Saturday night shift here at Bara JHB the staff deal with….

I enjoyed every second of it- after all this is what I love doing. I finally finished at 9.30 after all the rounds… I felt satisfied, elated I can be part of this and help- and welcomed by the Bara staff. By far the best shift and clinical time I have had so far ever!! J

Hardship- Psychology of trauma

Psychology of trauma

As emergency medical providers we are not always aware of the extent and gravity of the psychological consequences of crime, interpersonal violence, accidents, disasters or domestic violence.

We do not know what patients experience pre-hospital- what led them to the serious assault for an example or rape/domestic violence…. who did it, why, how was is carried out, can they return home? Will they live….

Let alone while post operatively laying in a bed trying to recover from this certain traumatic incident physically and mentally- how will they live, where- homeless, increased poverty, inability to work., disability.

40% of the population are unemployed, only 5% of people pay taxes

The critical traumatic incident is usually experienced as:

·        A breakdown of coherence, meaning, predictability, and understanding of how the world is

·        An intense loss of control over environment and destiny

·        An intense experience of powerlessness and helplessness

·         An experience of extreme vulnerability and insecurity

These statements resonant with me when I see and treat these patients, or review them on the ward round- post GSW, stabbing or severe beatings……  its not just what one see’s

Trauma and Academic teaching

Trauma and Academic teaching

Arriving in the trauma unit yesterday early morning 3 patients just declared deceased… one 16 yrs old in a petrol bomb fire… all 95-98% full thickness burns full resus was put in place but the injuries to futile.

Onto DREAM teaching- the registrar teaching sessions. Critical analysis of C spine and head injuries articles in paediatrics- sensitivity and specificity false negatives/true positives/predicated values! Case presentations and ECG’s. Excellent teaching and facilitating by Prof K and EM consultant RD, highly regarded reg training programmes at Wits Uni.

Then the afternoon was again fairly quiet, the trauma students nurses got shown around as they were starting the course (all qualified nurses), I did quick session on ABGs and hyper/hypokaelmia.  They all showed good  knowledge.

Today I attended ATLS for doctors SA style, again very good. The surgical skills where on full pigs. They covered some PHTLS in the sessions too. Very good ATLS instructors, seemingly they hold the same challenges as us- difficult to get faculty members to run the programmes and are hugely oversubscribed.

Thicker skin- Bara trauma unit

So day 2,  yet again I made my way on the roads to Sowetto and got lost again in the Township!

Once arrived into Resus trauma:

23yrd old PVA v motorbike. GCS 2/10 intubated, severe facial fractures and epistaxis with posterior packing foley catheter and anterior packing,  # pelvis. Head injury- SAH, DAI, no brain stem reflexes. 18 hours later it was decided turn the vent off and for T piece as neuro surgical final review..  basically TLC. As he was initially an unknown male the family couldn’t be contacted…. they finally arrived 23 hours later 17.00hrs… they were so distraught. Possible organ donation.

Other resus patients trauma assault- gross facial swelling, tubed. Another unknown male. Various other trauma patients- minor area busy with patients we would put into resus.

The trauma resus are managed well by the team- Primary A-E, secondary survey, C spine immobilised, airway stabilsed +/- tube/vent, IV/I, fast scan, ABG, catheter, NG, tetanus, IVAB, analgesia.... next patient

Trauma round in the afternoon to the ward and ICU- the ward is full of sick trauma patients post surgery or intervention, all MVAs and assaults…. These are severe assaults from the community or individuals. The community might of shunned the patient for a wrong doing then they beat them, the police arrive and stop the killing… sometimes if they make it. I have only seen the ones that make it. The violence is serious and high…..

One white man (only the 2^rd I have seen in either off the hospitals)… GSW into Right orbital area the bullet lodge into C2…. The bullet not to be removed- memorial piece of shrapnel!! Now week later worsening condition and confusion… to monitor.

                                                                                                  

Back to trauma and helped tubed a patient with polytrauma that had been transferred. The trauma surgeons and medical officers carry out the airway and tubing, including difficult airways then refer.

The surgical intervention and skills are impressive, the doctors run the units and work so hard..

Getting to know who’s who- who to work with and how to communicate or ask for things to be done… dialogue… hello… pause…. How are you… pause.. wait for an answer … then ask for want you need really nicely!!  

What an experience… we are so lucky for what we have in the 1^st world

Day 1 Working at Baragawanath 1st March 11

Day 1 Working at Baragawanth

Yeap this is the more Africa, I had a soft landing in Cape Town!

The day started at 5am, negotiating the roads to get to Bara which lays in the heart of Sowetto township in which I got very lost and had to compete with the minibus taxis on the uneven roads.

Finally after arriving I made it in for 6.15 am with the sun rising on the township, the trauma unit round began at 6.45am this consisted of the Prof leading it with approximately 24 attendees ranging from registrars, interims- surgeons and emergency medicine, medical students and nurses! The Prof D runs the trauma unit and is an excellent surgeon and takes pleasure in asking lots of questions and putting individuals on the spot! This is a famous teaching hospital so students come to learn and gain the experience. The traditional doctor system is here.

Patients in trauma resus where MVAs, assaults, penetrating and blunt trauma, patients were intubated and waiting CT scans, reviews or the wards. We all then trailed through the hospital’s old army barracks with corrugated iron and open corridors covering some ground to the trauma ward. This ward had over 48 beds full, one side trauma high dependency where some  patients were ventilated and the other lower dependency with exercise bikes for patients with ICD. Full of young patients average age 20-25, geriatric medicine is rare here. We had the full ward round and discussed all the patients, conditions mainly severe assaults, MVAs/PVAs post surgery and polytrauma,. All sick trauma patients… with suffering and hardship.

After on to 8.10am academic teaching on NET Neuro Endrocine tumours. Then up to the surgical handover room to discuss the days patients, surgery and roles for the shift. I then meet all the professors and got my famous bara scrubs, then visited ICU holding 20 beds, 8 for trauma, comprehensive ICU and well equipped- trauma surgical patients post GSW, MVA’s or mob beatings. The visit continued to the burns unit funded by Johnson & Johnson with 20 beds, theatre and ICU. One little boy in a side room wrapped from head to foot in bandages… crying. In the winter the unit is full because of burns from fires made to keep people warm, the summer is always quieter.

Eventually we made our way back to the trauma unit where I got stuck into resus. The nurses seem to have slightly different skills depending on the hospital but the core competencies are generic as deemed by the SANC. The doctors work 12 or 24 hour shifts. The trauma unit was built 2 yrs ago so the resus is new and well equipped, new vents and telemetry monitoring.

Trauma resus patients attended:

MVA’s including paediatrics

PVA’s with loss sensation L1/L2 and below! Wife ran him over.

Stabbing to T2- no sensation lower than that!

6 year old PVA, HIV +ve grossly displaced femur fracture 100% bony opposition. This little girl only looked about 3yrs old. :-(  The children look so much younger because of the poor development.

The trauma resus are efficient – if patient appears stable lodox first before off the ambulance trolley then primary/secondary survey, unstable lodox after patient stabilised. Efasts is at hand as part of the survey. Once stabilised resus trauma patients tend to wait for CT and CT results, the review and ward -some 24hrs.

Patients wait in the minors area to be seen by the surgeons, ortho or other specialties- patients waiting desperately.

Feels harder, life is even tougher here, the pain and suffering and poverty is everywhere- harsh…….. this is reflected with all the individuals and healthcare professionals too.

Today was the hardest for me nonetheless I need a thicker skin although it does not take away my compassion, morals and ethics as a nurse and why I do this job………. my skin will be thicker tomorrow otherwise one would not cope, this is how it is.

Johannesburg... 2nd leg the harder leg! Bara Trauma Unit!!!!

27th Feb 2011:
Finally left CT and got the flight to J'Burg. Interestingly I noted we were flying low less than 40,000 ft from my aeromedical days and knowledge, I asked the air steward and we are actually 37,000 ft due to the heavy cargo. This meant you had perfect visibility of the geography and tomography, the land was flatter and a richer green compared to CT. No mountains or beach here, the altitude is higher too.

So finally arrived in JHB and the gorgeous Evan picked me up who’s looking after me! J JHB is a huge city with a successful powerful financial district. Its feels like a city here, faster, edger and the people…. I am nearer the real Africa which it certainly feels and reflects in my observations. Very different to the affluent beauty of CT.

Today after getting another hirer car this time with AC! I made my way across JHB to Wits University navigating the roads around deviating road blocks due to MVA’s. I at last got to met Professor Efraim Kramer Head of Division of Emergency Medicine, Medical lead FIFA and Lead SA Search and Rescue SAISR, very respected talented gentleman so kind, knowledgeable and welcoming to me in coming to S Africa. After tagging along to his meeting we chatted about my trip and objectives, accommodating my needs and desires. The university was very impressive and one of the worlds best, students come from all around the world to study here.
Then after making some calls for me and important correspondence he took me to Chris Hani Bara trauma unit….. you kind of had to believe it to see it but here’s some facts….

Chris Hani Baragwanath Hospital, with its 2'964 beds, is the largest acute hospital in the world. It is situated to the south west of Johannesburg, on the southern border of Soweto. The Hospital grounds cover an area of 173 acres, consisting of 429 buildings with a total floor area of 233'785.19m2.

It is the only public hospital serving approximately 3.5 million people in Soweto and it provides half of all the hospital services in Southern Gauteng. Being a specialist hospital, referrals for specialist treatment are received from all over the country, as well as surrounding African States.

Bara is one of 40 provincial hospitals in the Gauteng Province, which is financed and run by the Gauteng provincial health authorities.

The hospital has a staff establishment of nearly 5'000, of which 600 are doctors and 2'000 are nurses. The greater part of the teaching and clinical research for the Faculty of Health Sciences of the University of the Witwatersrand takes place at this hospital.

Bara is also a training school for nurses with a training college, affiliated with Wits University, on the premises.

2,000 patients check in a day and over half are HIV +ve            

Getting a better idea of it…. Not intimidating at all!!

On the way we talked and I had the very important safety talk- diseases, AIDS and crime. 90% patients are HIV or full blown AIDS- universal precautions and AVD at the ready.

I got to meet the Trauma Lead Prof and the Lead manager Dr. Anderson who runs the unit. Resus room…. 10 beds but space to double up to 20! GSH had 6 which could double up to about 9.

It was decided between the profs I would work as medical student that way I can do more, anything as Prof K suggested ICDs, thorocostomies! Just need to get involved and ask to do it. If I work with the doctors I will be more proactive, this is great as I can get a overall view of the trauma unit running, clinical skills and be part of and observe the trauma team process. So just need to get some Bara scrubs and start at 6.45 tomorrow – early start 545 from home! 7pm start of the shift, trauma handover, ward handover and who knows! This really is Africa….

Rest of the week clinical work, DREAM registrar teaching Thursday and ATLS SA style Friday!

 The hard work REALLY begins now…… jeez…trepidation …I have been privileged to be welcomed by SA top clinical leaders … until tomorrow….. here goes!

Off to Jburg

Well off to Jburg tomorrow and a new adventure begins, just as I have got use to the Cape, the areas, roads and places to go, work and the gym.

CT is so beautiful- Ive been very fortunate thanks to some special friends in staying in the Southern suburbs higher end of stunning the houses here are spectacular  - especially the views of Table Mountain. The weather has been delightful 30-34 degrees with the occasional winds which expel from no where then die just as quickly. This area is so green, leafy and warming just through the colours and textures. The people reflect this warmth, the Capetonians are so laid back and chilled. Ive made some great friends too.

I went to my first SA rugby match- Stormers v Lions... great game and atmosphere from all walks of life!

Right now... next door are having want sounds to be the best party EVER.... now if only I could get over the electric fences to gate crash!! dam... :-)

I don't quite feel ready to leave here yet... but I will be back towards the end of my trip.

So here's to the second stage, a larger scale I have been warned!

Last Day GSH

Well last shift at GSH....

The GSW from last night -shortly after we left his swelling increased ,sats dropped and his airway obstructed therefore needing a needle circoid then surgical airway, he was sedated as very agitated throughout even before his sats dropped. He finally went to ICU awaiting cardiothorax review 10.15 am he arrived the evening before at 17.30hrs.

The young 20 yr old MVA boy finally passed away at 6.15am in resus- family distraught, very sad.

There are so many community assaults mainly from the townships although it does not matter the colour of your skin or where you live, Ive heard so many horror stories- hi jacking, assaults- left for dead. People go missing, loved ones try to find them but they end up in hospital as unknown male or female with such bad injuries usually head injuries and unconscious. Today another young man came in looking for his cousin he was beaten so badly and died from a community assault- we informed him.. He was so shocked and had to go to the mortuary to ID his cousin.

Again more community assaults- patients left with severe permanent brain injuries.

Today was fairly quiet apart from the above - lots of cleaning and restocking going on.

So last day... more sweets and thank you card to all! I have had such a great time and have learnt a lot, all the staff- nurses, doctors, even porters and security have been welcoming. The care I have been involved in has been excellent-clinical skills, patient management and team working even under what might seem a challenging environment.

Seemingly I have made a positive impact on them too.. with my clinical skills, approach, personality and communication. They have learnt from me and I have learnt from them! International collaborative clinical working- the perfect results achieved so pleased! Will kind of miss them all, what an enriching experience.

Just as I have now got use to GSH and the Cape.... off to Jburg for a new adventure and antics... what lies ahead?

The journey continues... :-)

Gun Shot wounds -GSW

Today started with obtaining some good trauma data form GSH- very impressive (for my paper)!

Then I went to the weekly trauma teaching with the doctors, which was about organ transplant  issues and referrals. Then a presentation on diaphragmatic injuries- all very good.

Then back to trauma resus-

One patient who had such severe community assault and sustained such a gross head injury with his brains coming out of his head arrested- RIP. Beaten to death.

Another- stab to the RUQ and large liver laceration hb 4.7 and haemodynamically stable quite the joker in fact lovely guy- awaiting surgical review.

Male with again severe community assault- open skull fracture and limb fractures. Crush protocol in place, regular monitoring CVP and fluids.

In 2010 GSH saw 9022 trauma patients- 1242 resuscitations and only 129 deaths. 572 GSW , 3343 assaults and 1601 MVA, 3440 other. Reflecting the good clinical management at GSH. Although can I be as bold to say these patients are robust... they are all young with this on there side... is this a culture heritage too though!!??

Some of the nurses on the diploma for trauma, critical, emergency course came down, they had done their first intubation, the course requires 5. In an emergency  without the presence of a doctor they are able to tube, this is particularly useful for rural hospitals where doctors are not on site.

As I have noted I am working in the best hospital in the province, rural parts of Africa do not have the privileged of a secondary centre.

For a short period resus just had 3 patients so fairly quiet- then 2 trauma resus arrived within minutes:

20 year old male PVA- pedestrian- isolated head injury GCS 3, fixed dilated pupils, intubated,  hypovolemic shock- ? cause the reason. Filled with fluids, non responder so we gave blood… responder for a while then started to deteriorate. Lodox- only fracture clavicle, abdomen soft. No bleeding from the head… ??? Awaiting CT.
Very sad as the family came in, grandfather a doctor… the medical condition was given to him doctor to doctor…. he knows the prognosis. He was just about to turn 21.

Trauma team run effortlessly- primary ABCDE,  secondary survey he was even sutured all in less than an hour. One doctor, 2 interims and 3 nurses. At off all the trauma resus teams I've seen- no-one gets stressed, presses the panic button or speaks out of tone, all done with an air of ease.

At the same time a male GSW, he heard 4 shots.. 3 went into him.
Number 1- entrance into right side of his mandible- exit left side submandibular area… now this same bullet went into his chest and through into his back.. entrance, exit, entrance… then you could feel the bullet in the back!!
Number 2 – right distal forearm palmar side 2cm proximal to the wound  you could see the bullet…. So we took it out. Old style bullet apparently… very large too!
Number 3- entrance and exit wound to right tibia. His comuniuted  mandible fracture GSW site had facial swelling increasing, on arrival bleeding but not profusely…. Then profusely. Despite attempts at a NG tube which he would not tolerate.. he stayed haemodynamically stable. For CT., max fax and surgeons.

The daily 6pm ward round... then hand over to the 7pm night shift...

South Africa's clinical leads

22^nd Feb 11

Today I went up to Karl Bremer Hospital to the EMS offices as I am privileged to have a meeting with Professor Lee Wallis President EMSSA and Head of Emergency Medicine UCT & SU  to discuss trauma and emergency care in SA, developing agendas and strategy.

Prof  Wallis was very informative and talented clinician who has led the recent EM innovations for the SA world cup. I was very impressed to read his articles, and publications. The EMSSA handbook details highly academic emergency medicine courses, core definitions, Emergency Nursing and Medicine and management- document to be proud of. 

He also put me in touch with other trauma leads and data collection- huge thanks to the EMSSA and ENSSA Lee, Petra and Jean- these experienced skilled nurses and doctor working collaboratively led the speciality and I have been fortunate enough to met them and gain knowledge.

I have been so lucky to meet and gain knowledge from the top trauma, surgical and medical leads in Cape Town and J Burg- so accommodating. The skills and expertise are highly regarded. Cant thank them all enough.

NE earthquake – my team UKISAR are deploying without me… oh well I’m in S Africian trauma!

Stab to the mouth...

Back in the trauma resus room.....

Today there was only 1 doctor again for the entire unit and a excellent doctor too, this is not ideal and recognised but 2 doctors have just resigned.

The days patients mainly consisted of severe community assaults from metal rods or stones causing gross head injuries- SAH, DAI. Again these patients are ventilated in the resus room. Haemo/pneumothorices due to stabbing of the chests, fractured ribs/sternums. Multiple stabs to the head, back and legs with acute abdomen- emergency lap was performed. Interestingly so many young men have huge thoracostomy scars from stabbings.

The emergency/trauma doctor (medical officers) stabilises the patients first then call the specialties, they could have multiple patients in resus too – so its hard work and can be very demanding. Unlike our system- the specialties come first in a trauma call then we eliminate but we are better placed to be able to do that.

Mid afternoon man came in due to being stabbed into the floor of his mouth, facial lacerations and swelling to the left side of his neck. Now I’ve been looking after many patients here who are thankful and I have felt very safe with... this man you instantly knew was not a pleasant chap. He in fact was the gang leader of the largest gang in Cape Town, he clearly disliked women and turned his head when I approached like the other nurses. He appeared dangerous and everyone felt it.... security hang around (head of security is my new best friend NBF soon to be on FB!) as the gangs can kick off especially when the head gang lead is injured.

Clinically this man was unstable  ... lost 1L blood out of his mouth and counting, HB 4.6- despite 650 mls colloids and 3 units O Neg blood and the swelling was getting worse. His airway was patent but dropped sats when lying him flat to 87%... and pouring with blood (very unemotional to his clinical state). All adjacents where put in place.. NG, catheter, IVs, fluids etc. The bleeding needed to be stopped and before his airway was comprised, the specialties are impressive at GS government hospital so we rushed him (me and the 1 doc) for angio and embolisation in the vascular radiology theatre room where he was ET tubed by the anaesthetic consultant otherwise he would of needed a surgical airway and the procedure performed.

Highly impressive the team in the room and equipment, up through his inguinal artery up to the linguinal artery and the facial artery to stop the severe bleeding and glued! After he went to the high care ward tubed -he was saved, if that facility had not been available I doubt he would of survived so well . The other nurses felt the same when nursing him- we saved him but how many people has he harmed and killed…. but that’s what we have to do- non judgemental.

So many of the patients I have seen are stabbed in the neck or face- they injure to kill.

The resources are poor ie no head blocks, no portable suction or slings… but then this 1^st class imaging and surgery!

Earlier part of the day I observed the nurse educators with the new post grad nurses on the emergency, trauma and critical care course go through the resus patients and how you should assess primary surveys.
The nurses do have a code of conduct with the SANC and the practise does seem limited to ours, although the emergency nurses do catheterise its not really in there scope apparently. Also they do not suture and plaster- the doctors do this.

I had a lovely conversation with one of the nurses today, she has been nursing for over 20 years in emergency and trauma, she loves her job and what she does- she is very good. Really enlightening-  they apparently have really enjoyed having me and I have just got stuck in with them in the team. They have been a pleasure to work with, overall the nurses are skilled, caring and I have the up most respect for what they do.

Another good day in trauma resus…..

Days off in Cape Town

Days off in Cape Town are pretty special-

I’ve been to the Winelands, stroking cheetahs, having traditional African meals in tree houses, Camps Bay beach (lots of beautiful people!), Kirstenbosch botantical gardens.. and amazing sun sets from the beach or table mountain... night life is great too good bars and restaurants, stunning food particularly fish... I’ve meet some special people too! :-)

Cape Town is full of warm and friendly folk, striking difference.

And back at Bishopscourt.... woo hoo! :-)... thanks N&D!

Metro EMS prehospital

Awesome day with the paramedics... 7am-7pm shift.

The crew were excellent- clinically and patient care. Good fun too...!

The type of patients we saw were mainly medical- DKA, chest pain, MI, diabetic coma, collapse, gastro. Quiet day by all accounts.

One stabbing- which I high fived as it came over the radio!! However it was not a major stabbing- but about 9 SA police and detectives were there. Oh and one patient dead on arrival at scene- DOA.

We spent time transferring patients once stabilised from day units and home to hospitals- mainly GSH where I am working, the emergency side was so busy and over run today as usual. Patients on trolleys lay everywhere, sharing monitors, no curtains or privacy. The trolley mattresses where like paper and so old. Really not good conditions, the staff overrun and bed manager but accepting and will try to accommodate despite these poor resources. As I know the staff now they are especially friendly- even hugs and warm exchanges. The resources and conditions are poor to us, but nearly all of the staff do there very best and are welcoming under the stress.

Very interesting going into different homes and different states of poverty.

Ive discovered drivers in SA do NOT move for blue light ambulances at all!

Overall great experience- as I really like prehospital. Again made great contacts to keep in touch with.

I was hoping to get hard core edgy trauma but I can go out again and I will spend time with the EMS on Jburg .

Private Emergency/Trauma unit

16th Feb:

Spent the day at a Private Emergency/Trauma unit. Very nice hospital like our top private hospitals with full specialties- ICU, paeds, medical, surgical, orthos, plastic's and clinics. Very clean and so highly equipped - with every bit of equipment you could think of and excellent care for private patients. 3 doctors on duty and 3 nurses, seeing approx 1100 patients a month. With phlembotamists and full x-ray, CT and US reporting immediately.

It was a fairly quiet day and I saw mainly primary care/walk in type patients- no traumas today!

This is 1st class health care. SA has 1st and 3rd class- another paradox!

Interestingly- although I am aware SA does not have our traditional ENP roles. RNs at triage can not send patients to x-ray or give out analgesia under PGDs. As this is well established in the UK and I have set up in my ED, I can assist with these educational programmes with the nurse manager and nurse educator... international nurse networking and collaborative skills.

More trauma... the tongue

Today at work in GSH trauma unit was again the daily plethora of traumas...

as I just came in a motorcyclist MVA arrived. Completely smashed up face, numerous facial fractures, huge facial /head swelling....his tongue was in a plastic bag...... the impact was so hard he bit 80% of his tongue off. His upper dentures where deeply imbedded into the upper gums as the lower dentures severly embedded in the lower gums. The facial fractures where extremely bad but the paramedics managed to tube but he needed a trachy. Also had pneumo/limb fractures and severe head injury... he went to theatre pretty quickly after we stabilised him.

Other traumas MVA, stabbings, pelvis fractures with bladder ruptures, more severe assaults with head injuries, diffuse axonal head injuries, SDH, +/- le fort fractures. Many very young patients involved in MVAs- again severe head injuries. All these pateints having GCS below 8 so intubated and ventilated in the resus room where the emergency trauma room doctors (medical officers) and nurses look after these patients for 24 hrs plus before they move to wards or HDU. Some patients dont even need sedation due to the injuries, otherwise midazolam is sometimes used.

The team again works extremely well in resus traumas- the nurses automatically insert catheter, NG, ventilator, immobilise, monitoring, set up for ICD, CVP, femoral stabbs and IV lines/fluids, emergency O +ve blood... like clock work. Continue to monitor... then lodox the patient. Although the equipment and resources are low and old- they make do.

The practices here are very doctor orientated as its the traditional doctor- nurse model unlike most EDs in England with nurses leading and nurse practitioners. The nurses do the nursing and that's how the doctors see the nurses.... the old traditional individual professional roles and conflicts??

I realise even more how lucky we are to be able to practise as advanced nurse practitioners, advanced nursing roles and enhanced nursing profession... we are also very lucky to have access to uni courses and in house and mandatory training. We do have an advanced proactive system and governance.

I even saw a doctor that I worked with back in Worthing ED! Small world!

I really like working in this government hospital, the team, the patients and really making a difference... :-)

meetings, metro, jazz

Yesterday morning I got into my sweat box of a car and went to meet Jean Augustyn at the Milnerton Mediclinc private trauma unit, Jean is a nurse educator for mediclinc and has also been invaluable in helping me, she is highly skilled and gave me so much information about SA nursing education both in the private and public sector- more of that in my final paper! I had a brief look around the private unit which I am working in this week, far cry from the government hospital. We went out to lunch where I picked Jean's brain, she is also the secretary of the ENSSA.

Earlier that morning I tried to find the Metro ambulance station in Pinelands driving in the wrong areas of SA... to no avail and sweating in my sweat box! However with some help I finally made it before the office closed... I went to sign papers so I can work with the paramedics for prehospital experience- I have been warned to be super careful as they go into gangland areas. Basically the papers I signed was a disclaimer stating I am responsible for my life and any loss of that life or injury is not the metro's responsibility... my own and I am going at my own risk. I said to the paramedic do you not want proof of who I am and registration... he answered ' no... even a terrorist can come out with us'. Awesome- I see you Thursday 7am then for a 12hrs shift!

That evening it was Becca's birthday a doctor out here working in HIV clinic which I work with at the Whitt so great shes out here- lovely gal! We went out to a Jazz bar- fab evening and people.

Table Mountain and Inequality

Awesome day with Becca and Dom climbing the top of Table Mountain... yep climbed up and cable car down. Stunning Cape Town, breathless views, peaks of the table and beyond. Such a beautiful poignant place, its hot hot hot. Then catch up with N & D- fab!

So much to see and do in this complex cultural city... it is breathtaking. Of course the Cape is one of the richest places of SA,  amidst the beauty poverty stricken shanty towns and town ships surround the area where a different world exists- gangs, violence, crime and poor sanitation. Inequality is the highest in the world here... some choose to ignore this, some are frustrated. I will do the little I can in helping those with less.

This week lies ahead working in a private trauma clinic, prehospital experience with the paramedics gangland area and townships.. then back in GS government hospital. More paradigms... preparing for J'burg- every time I mention Bara hospital J'burg the response is a shocking 'ooh' apparently twenty times worse than the government hospital I'm currently in!  :-0

Back on it & traumatic cardiac arrests

Back on it this am and amazing workout at the gym- vibe and kettle bells, loving my workouts here but missing the vibe crew!

Off to work for the twilight shift, I am working out how the teams work and there is another good team on the weekend- Saturday night too. Another comment is that the hospital I am working is a very good government run and resourced much more than the others- this is the best in the province even though I have observed resources are low- this is as good as it gets for that but the medicine is excellent regardless. How will I find the differences in private unit?


Well another amazing day! My observations and knowledge grow every day.

The trauma unit also takes minor trauma (although that minor trauma would be major to us!) as some of the walk in traumas should be dealt with in the day hospitals ie simple pneumo's ICD insertion, but the unit gets all hence this makes it busier to manage the real major trauma.

Nonetheless overall the teams of doctors and nurses are very good and a high standard, they are particularly good at trauma resus and critical care of patients- quick, know their roles and treat effectively and the area is immediately cleaned by a cleaner. Strict regular obs from the nurses from then on.
The medicine, surgery and management is really impressive. The doctors are extremely proactive and do everything themselves -DIY! One excellent doctor I have been working with- today just took a tubed ventilated immobilised patient on his own to CT... I was amazed and off course insisted I go to help him!
The doctors work long hours, back to back 12 hrs and 24hrs... so different from our doctors in the UK no working time directive in SA! It is very doctor orientated- the doctors triage all the ambulances and are in charge much more- much different to us in the UK where the nurses run the ED.

Again the average wait is 24hrs to get to a ward this is because all specialties have to review the patient then get  the bed, there might be 4-5 specialties to review due to the dense polytrauma ie plastics, neuro, ortho, max-fax .... there is no 4 hr target for admission or discharge... there are no targets that's why patients wait and wait... also everyone is so busy.

Another difference in traumas is the Trauma/ED doctors and nurses deal with the patients then call the specialties- I have not seen an anaesthetist in site - ever! They deal with the airway and continue to while the patient is tubed- end of until the patient goes to ITU or HDU. Like wise for surgeons or cutting reg as they are called- they are contacted once the patient has been sorted unless surgery is needed immediately.

Another compiling factor for health care professionals is a huge percentage of patients are HIV +ve +/- TB adding to the stressors and risks.
I spent my day seeing patients with severe assaults, stabbings and MVA. Severe MVA- brain injuries and poly trauma. Again suturing up faces and scalps from diffuse injuries.

Last resus off the day- Pedestrian hit by car- infact he was completely run over, the tyre marks evident across both arms and legs. Open book pelvis, distended abdo full of blood, racoons eyes, huge scalp swelling, widespread chest surgical emphysema bilateral puemo/haemo- after arriving he went into cardiac arrest aka traumatic cardiac arrest. The definitive management for blunt cardiac arrest is bilateral ICD review then CPR.... he was futile no more interventions performed...

The clinical exposure is text book- conditions you tend to only read but I am experiencing first hand.... if clinicians what experiences come here!

All the nurses and doctors are so friendly and welcoming, I am part of the team and seem to be respected from all- porters, security, doctors and nurses- pleasure to work with all!!

Knife in the back

Today I arrived into the trauma resus room- on my far left lay a poor man prone with a huge knife stuck in his back into T10 with CSF leaking, he was still there at the end of my shift before being moved to the ward then surgery some 12 hours later. I have nice pictures!

Apparently I missed a good resus earlier, 20 week pregnant lady shot by her partner in the abdominal cavity just hitting the uterus entrance and exit wounds, HB 4.0 and haemorrhaging intra-abdominally- she died in theatre 5 hours later.

Other patients I encountered today more severe assaults with metal rods, open sucking pneumothorax due to stabbing and a haemo/pneumothorax due to stabbing pericardium- echo showed blood surrounding the pericardium as only 4.3mm for surgery in 2 days.

What amazes me is the physiology reserve of these patients- they are sick but maintain these vital signs for hours/days.

As there was only 1 doctor for the entire trauma unit and approx 30 patients waiting to be seen I spent most of the day helping the doc out, suturing patients up (severe lacerations that max fax would usually see from stabbings). The suture kits where poor and one sharps bin available in the next area. I just got on with what I know best and carried out my emergency nurse practitioners skills, assessing patients sending for x-rays, referring to plastics, treating etc.

These patients wait for hours, in fact I don't look at the hour of arrival I look at the date... they wait 12-24hrs for treatment to discharge. The ENP role seemingly is not a role available but its evident this would be vital in seeing and treating these patients. However this maybe difficult to introduce with the nursing and medical historical differences.

What strikes me the most is how thankful and humble these patients are, just for you giving them the time and assessing them sending for an x-ray, talking to them like you care. They don't moan or complain. Apparently if they leave before completion of treatment they will get a red card which means they cant be treated again. One patient I stitched up had be there 24hrs waiting for completion of his treatment, desperate to leave but couldn't. My heart does really feel for them all. Even the ones with bullets and knifes still in them don't complain.

The shift today was DIY... do it yourself as the doc said to me! Don't bother asking its quicker doing it yourself! I can certainly see a difference with particular nursing teams on and generations of nursing and therefore reflection of active skills. Today myself, one doc - and more nurses.

When the young night staff came on, I was back in resus trauma and another resus came in- suicide down 2 storey building. The nurses assessment trauma skills where excellent, quick efficient and pro active, one step a head and knew exactly what do it.

Erm yes-  a reflective day. Heart out for those patients today and how I could help them.... or how I would like to do more....

More tomorrow weekend frantics in the trauma room

Waterfront

Moved from the lovely N & D's to Claremont into a guest house this am. Then hooked up with Adam (friend of Paul's- cheers KS!) amazing day on the V&A waterfront, extremely cosmo and western. Afternoon cocktail then onto an amazing boat ride across the sea thanks to skipper Adam! Beautiful boat catching rays on the trampoline at the front and drinking champagne... good times! Met some mad fun American girls- proper nuts but good girls. Vibrant and vivacious Cape Town which has such pulse and so much to do!

Also learning how complex this country is full of history, pain and politics... its a paradox in every sense. White, Blacks, coloureds- the ANC - gravy train and BEE (black economic empowerment).

A book I must read "why Africa is poor" Greg Mills.

Looking foward to two days at work tomorrow... the unknown, craving the experience! :-)

Day off

Today was a day off! I went to meet Terri lovely friend from SA who took me up to Chapmans peak and the mountains of the Cape, so delightful and picturesque stunning weather then lunch in Chapmans peak hotel- biggest and most delicious squid I have ever eaten. Camps bay very nice, very cosmo. Huge diversity's of rich and poor here.

I am now bombing round the Cape much like the Capetonians!

Last day at staying at Naomi's and Dave's they have been so kind in letting me stay, feel safe and at home here.

They are off on their own adventures- driving back to London from Cape Town, and is covering 15,000 miles to raise £15,000 pounds- wow!

The Long Drive

www.thelongdrive.net

David Gittelson and Naomi Ruben are driving from Cape Town to London to raise money for a charity- Lawrences Roundabout Well appeal - www.lawrencesroundaboutwellappeal.org. You can donate on their justgiving page:http://www.justgiving.com/NaomiAndDave- please give!

 

Amazing adventure- good luck and thank you!

 

Tomorrow- boat ride I believe?... Loving the Cape and all it encompasses...

5th day... GSW, MVA & assualts

Today was filled with a plethora of patients with GSW (gun shot wounds), MVA (motor vehicle accidents) and severe assaults… to name a few

Examples; GSW to Jaw (gross comunited fracture of the mandible) with bullet going into neck C2 shattering the bones and causing false aneurysm of the artery requiring embolisation via cath lab then removal of bullet in surgery

Numerous pelvis fractures on patients- 2 being pregnant secondary to MVA

GSW to the tibia causing gross comunited fracture

Stabbing to the tongue and into the mouth

Patients were still there from 24 hrs ago waiting for beds. Today I had time to reflect more on the care, some aspects of nursing care is very good, it seems acute initial assessment is excellent ie trauma team and roles but some aspects less so on longer care of patients. Although I expect some aspects of compassion is a cultural mix and difference.

The nurses have excellent education by all accounts but are under paid and over worked with low numbers on duty and pressures from the nursing management. Low morale and burn out is a classic combination for SA nursing. But there is good and not so good practice everywhere in the world.

Huge influence is resources, equipment is old and they have little of it. An apron with no blood on it will stay on all day. On the wards and in emergency some patients if necessary are tied to beds as they will harm themselves.
Although GSH is known to be the best  government hospital in the province and has an abundance of resources compared to others. CT scans, diagnostics, advanced surgery, cardiac surgery specialties are impressive. Some of the equipment might be old ie CVP monitoring, thomas splints, cardiac monitors... but it works.

I guess I will see an huge difference in a private unit compared to a government run- the government puts in 11% of the funding but 80% of the population attends as there is a huge deficient of poverty in the country.

Paradoxically the medicine they practice is clinically based with only necessary  diagnostics as they do not have access to a whole hosts of blood tests for example. (We tend to over investigate which is not indicated unless it would change management)

They practice with fewer resources but use the most out of that, more emphasis is also on imaging even watch and wait. The crush injury  protocol is an interesting example (no LFTS or CKs as they will be raised- just U&Es, urinalysis and fluids/CVP)- pure medicine and treatment with no unnecessary bloods excellent clinical medicine, back to basics in the nursing too. Also the surgery and speciality is excellent.

Again the staff from the nurses and doctors have been so welcoming and helpful I feel so part of the team and really enjoying working at GSH- big thanks to them all. So another great day and experiences, I have learnt so much  – so much more to come…. J

Now thats what I call trauma!

The first day anywhere is like the first day of school- not sure whether the kids will like you and who will nick your sandwiches, doctor's friend works in Groote Schuur Hospital (GSH) and while he changed into his theatre scrubs some porter had nicked his trousers which he had to wrestle with to get back- love Africa!

So made my way on the busy rush hour roads of Cape Town to Tygberg Hospital negotiating the motor ways, as I have no AC I tend to turn to up like Princess Perspiration as the intense driving speeds heightens my level of sweating… nice!

Finally found the Hospital and University large old grand buildings where I met Senior Lecturer of Critical Care Janet Bell who has been invaluable in organising this trip. The University was amazing, robust academic institution with the best skills lab, moulage rooms, sim suite even a laryngoscope sim suite. Janet was hugely passionate about nursing in SA and what makes a good nurse- she was enlightening and refreshing and I learnt a lot about SA academic nursing. However this University of Stellenbosch- is one of the best academic institutions in SA so this comparison does not necessary reflect a true picture across SA, students are very lucky to attend here.

Then after lunch back on the highways jeez the Capetonians drive fast weaving out of lanes, I prefer to cruise at this stage being a virgin on the SA roads!
In a inch of my life I arrived at GSH and here I met Matron Patton, small powerful lady who runs the trauma and emergency unit at GSH, so friendly she introduced me to everyone and called all the head nurses and professors. I was showed around the unit which holds Trauma and Emergency on either side,

Emergency has resus, HDU and MAU, gynae unit, full psychiatric unit, DSU, infectious disease unit and triage. On the trauma unit side resus with Lodox a full body x-ray machine, CT room , theatre, trauma area. Patients with chest drains ICD sit in chairs then onto exercise bikes to get them out quicker! And huge helipad with a view of Cape Town stretching the harbour and beyond.

Nurses on shift… 9 in each of Emergency and Trauma.. 9!!! Say no more to nurses  reading this!

I got pretty much stuck into trauma resus- synopsis only here!:

First patient:
Gun Shot Wound GSW from gang shootings to the right chest -entrance wound T6 exit T8, haemothorax and pneumothorax, acute abdomen probably liver laceration. ICD inserted by paramedics.

Second patient:
GSW gang shootings to the head entrance and exit wound, GCS 5, racoon eyes, blood from nose then eventually after an hour of being with us… brain was oozing out of the nose and blood pouring from both wounds in the head. He was herniating- hypertensive and brady. So decided to do apnoea tests and depending on ABGs for harvesting his organs… only if the relatives arrived for consent otherwise just to die.

Third:
14 yr old girl GSW to the neck- caught in 2 gangs gun fire.

The nursing and medical teams primary surveys were slick and the team worked well. Some of the equipment was not great, but the skills outstanding. No more medical jargon or the details here but I had an amazing first day, loved every minute of it. The staff were all so friendly and welcoming which I had not really expected from what I was warned. Huge high! Now that’s what I have come to learn! Looking forward to tomorrow’s shift. :-0