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.