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!