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