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

day 3 in the Cape.. Invictus

The car has arrived! So Barleycorn's daily mission has been to navigate the streets of Cape Town City, after a dummy or two spat out because the indicators are on a different side (therefore initiating the window screen wipers instead which is potentially serious as others drivers would expect prior warning before turning off!) I got the hang off it and cruised across the city and motor ways! yeah- phew to be honest and after a few trial and errors I worked out the traffic lights aka robots. So pat on the back for the ole gal... she can do it :-)

While cruising with trepidation across the South Africans highways green plots like football pitches lay in the middle of the intersections where 40 or more black africans playing football surrounded by shanty towns full of tin huts.

After my successful road trip I headed to the the gym again, driving myself! Another awesome workout I certainly feel healthier since being here! :-)

Well tomorrow is really where the testing begins, I have to make my way up to Tygberg Hospitial about hour and half drive early to meet the senior lecturer to register then back to Groote Schuur to start in the trauma unit at 1pm..... jeez

Reading the SA rough guide this afternoon- Cape Town townships... high proportion of Cape Towns 2000 annual murders take place there... that works out 5.5 A DAY!  (mum don't read that bit and I won't be going there!)

Ah well as the good man Mandela himself quotes from W.E Henley's Victorian poem Invictus: 'I am the master of my fate, I am the captain of my soul'...

day two

So far so good!

The house I am staying in is amazing thanks to the wonderful hospitality of the lovely Naomi and David.. the property is situated high up adjacent from Table Mountain - the view is breath taking every time I look! The house (in two parts) has robust high gates and a drive way up. My room with en suite is bigger than my flat and I can do laps in the power shower! :-) I slept like a princess with an occasional sounding of nearby high security house alarms going off.. and the falling off a acorns hitting the roof!

Today after much chilling in the sun thinking about my study!? I picked my SA mobile up... got air time.. now good to go! Another successful res-ult. I then went to the Virgin active gym Claremont.. well although expensive to join temporarily this is by far the nicest gyms I have ever been to! Woow- the layout, equipment and indoor cycling studio holding 45 bikes and panoramic view of Table Mountain OMG- would like to teach here! Among e-spinners and awesome pool, juice bar and all the equipment one could want to train with I was in heaven! CT you know how to run a gym!

Post work out with Mountain vibrancy :-) coffee and the evening in CT at a gorgeous restaurant with N& D, amazing atmosphere wine and fish.And now the clouds have encompassed Table Mountain like a table cloth..

Loving it far to much so far... although the hard work has not began! Right car tomorrow.. all a learning curve! :-0

Day 1 in the Cape

Well arrived in one piece, always good!

Successful pick up from my friend Naomi who is kindly letting me stay for the first week. We drive through Cape Town into the Suburbs to Bishopcourt, the houses are incredible with views to match. And yeap I can almost touch Table Mountain, the scenery, greenery, blazing sun and the pure oxygen.... I feel better already!

After laying in the garden with a right view of one of the edges of Table Mountain dodging acorns falling from an old old tree banging then popping as they hit the ground, we finally went into town where I made my first bartering attempt in getting my phone unlocked, kinda successful although probably ripped off! Then went into a GP type surgery, before the consultation room housed a metal detector for firearms and weapons- I am in SA after all, interestingly the whites sat on one sofa while the blacks on the other?!

Once back home my next mission were to find my current locations and the various hospitals I would be visiting and working- result the sat nav works! Lets hope the user puts in the right addresses! Second result internet works! :-) Now chill before the real hard work begins!!

The Cape is beautiful, vibrant and haemorrhaging with diverse cultures and history... I have so much to learn...until tomorrow