Down in the pit

A bit of background.  The surgical pit consists of examination rooms w a clear space in the middle that holds 3 desks:  leftmost is trauma, center is surgery, right is orthopedics.  Walk-in patients get triaged at the nurses' desk to one of the three desks.  Right next to the pit is resus, which seems to fall solely under trauma's purview, so we're the only ones who receive patients directly from paramedics.  Once we stabilize a patient, we can then refer to surgery or ortho or burns or peds.  We also have two theaters dedicated solely to trauma surgery, which seems to run around the clock.  Obviously, there's the gunshot/stab emergency laparotomies and thoracotomies that we do, but for some reason, we also do wound debridement, skin grafting, and I've seen one bowel obstruction.  

On calls are 24h and run from 7am to 7am.  My first one was last Saturday, which happened to be the perfect storm of ppl doing stupid shit to hospitalize each other.  Not only was it payday, it was also a Darby between the two rival local soccer teams playing in Soweto stadium, and some rowdy political party's first year anniversary, for which they would throw a rowdy party.  Lots of drunkenness, which led to lots of stabbing, RTAs, burns, gunshots.  the stretchers in resus were wall to wall all night long.  You couldn't walk from the foot of a patient to their head without scooting at least 2 beds sideways, like clotheshangers on a discount rack.  More stretchers were placed helter skelter at the feet of the lined-up beds.  It was a war zone.  Things were even worse in the pit (except better bc those patients weren't immediately dying), with people lying, sitting, standing in whatever space they could find.  Patients literally lying on the floor!    We filled the entire pit.  We ran out of blood and X-ray forms at our desk and had to borrow from the fat pads at the other desks  We ran out of lidocaine.  We ran out of small and medium gloves, giving sets for drips, etc etc.  trash and sharps were strewn on the floor and kicked to a corner.   It was the best night I've ever had in a hospital.  And really, it beat most nights out too.  I learned to put in a chest drain, took a few ABGs under pressure, put in a wide bore line under pressure, dressed a burn, sutured and sutured and sutured--all stab wounds.  

That first night, we actually ended up staying till 11am bc josh was stuck assisting in a thoracotomy for an iatrogenic rupture of the internal thoracic artery during a chest drain insertion (not mine, a narrow miss, actually.  I had asked to put that one in, but bc the intern was under time pressure, she said she'd just go ahead and do it.  When she pierced the pleura, a gush of red blood came out.  I actually said "whoa" but she took it as a sign that she was in the right space for the hemothorax.  I'd never seen a hemo before, so I just went w it.  About ten min later, the patient starts getting really sweaty and   We had to resus him.  But bc the bleed was flowing directly into the drain, 1) there was no hydrostatic pressure increase to help staunch the bleeding  2) the bleed didn't show up on the fast scan.  The drain filled up quick though. He lost 1.5 L in no time at all.  He was a young guy, so he managed to compensate quite well initially, so his vitals stayed normal for quite a while.  Kudos to the intern for recognizing the crash just by him sweating.  I would've taken it as a ketamine overdose (we use it to sedate the patients and pretty much keep giving it until they tolerate the drain insertion (it's super painful)).  I also had to stay to sort out some pep stuff (more on that later).  By the time we got to the car, I was exhausted.  And of course, the car wouldn't start bc the battery was dead.  Matt reckons it's bc he left the lights on overnight.  It's a smallish car so we tried to push start it.  Then we tried to jump start it.  Then we tried to push start it again.  No dice.  Finally, the boys called the hire company to change the battery, and I called Chris (a driver I met earlier) to get of me the heck out of there.  Stopped to pick up some food, and Got home around 2pm.  Pulled Up to find the Germans sitting in our driveway.  I didn't realize that they were moving in today and was completely disheartened that my plan to eat an entire pizza in my bedroom while skyping Jon had been scarpered.  Ate in the living room while trying to be sociable.  Didn't get to bed till 3pm, slept till 10pm, skyped Jon for a bit, then slept again till morning, when I began my second 24h on call.  

Second one was just as busy for me--as in, I did the same amount of work, but we actually managed to clear the pit and resus by the time 7am rolled around.  Sutured loads of knees.  Two from car accidents where the driver bashed his knee on the dash and one from a tree falling on him.  Also learned to do a fast scan and cleared a patient w it on my lonesome (sort of, don't worry, the reg was looking over my shoulder at the screen while I did it).  Bc josh and Matt weren't on that night and bc I had had to give the Germans my key, I couldn't leave until they came in and gave me their key.  Of course, it's the one morning that they're late.  So late that the guy who had offered to drive me home leaves, and i have to get josh to drive me back again.  Cannot catch a break w getting home from on calls on time.  Anyways, managed to sleep a bit more, and am about to start my 3rd on call in a row.  Wish me luck.  

Johannesburg, first impressions

It seems a lifetime ago that Jon left me at joburg airport after what I think we are counting as our honeymoon (more on that later).  Here, in joburg, on my elective at the Chris hani baragwanath hospital in Soweto, my world has focused down to the hospital, the house we have rented in mondeor, and the gym.  This microcosm provides enough stimulation to keep me wholly engaged.  I'm like a newborn babe, content to try to make sense of my immediate surrounds before trying to wander wider.  

the hospital is like a tent city.  It's huge and always bathed in sunlight during the day (something no one who has lived in England for any amount of time takes for granted), which goes miles towards dispelling the mordor-like, Goliath slum image I had built up in my mind.  an admonitory tale describes a female doctor getting raped in the hospital while walking at night from obs and gyne to blood bank.  I had always imagined someone getting dragged by her hair to some dank cellar broom closet in a deserted hospital.  Actually, the hospital is never deserted, and obs and gyne and blood bank are on opposite sides of the hospital and requires walking outside for long stretches (a cardinal rule of survival in joburg is that no one should EVER be alone outside after dark).   I'm not saying it's ok that she was raped, I'm just saying that precautions can be taken to prevent it happening to me (so stop worrying, Jon).  Funny that the lesson ppl seem to have picked up is that girls shouldn't walk to blood bank by themselves at night as opposed to girls shouldn't walk outside by themselves at night.  Blood bank is really close to trauma (makes sense, eh?), but I'm usually forbidden from going to collect blood when I'm on call.  Seems weirdly superstitious, but I guess when personal safety is so down to luck, we try to make sense of things any way that we can.  The other day, a man in the hospital parking lot got shot in the wrist while making a bread delivery.  Broad daylight.  He was sitting in his car, some guy tried to carjack him, he drove off and got shot, fracturing both radius and ulna.  He was surprisingly nonchalant about it.  After he got set, splinted, and sutured, he absconded to go finish his bread delivery.  Pure luck (or lack thereof).  

The elective itself is fulfilling my need for adventure.  Every day I learn something new, and it's usually how to DO something new, not just a new medical fact (bc tbh, there are tons of new medical facts that I could learn and forget in every blink of every eye back in England).  The first week, I spent mostly on the ward, practicing cannulation and blood letting w unfamiliar equipment, getting to know people, tacitly absorbing all those details of a new place and its logistics that are long-term useless but short-term necessary and incredibly exhausting to figure out.   Did manage to do my first femoral stab, which was surprisingly easy.  Don't know why it's not done more commonly in the uk...British distaste for the groin, perhaps?

Things do feel more gilligan's island here, and by that I mean a little makeshift, but cool in that self-reliance way.  For example, they don't flush cannulae lines here.  They just attach a bag of saline, then lower it below the arm:  if blood flows up the line then you know the line is intravascular.  Or before extubating burns victims, they deflate the cuff and measure the exhaled co2.  If co2 is low, that means air is escaping around the cuff, so there's no soft tissue edema and the patient is ready for extubation. Clever, eh?  

And dunno if it's bc I'm in trauma, where everything is literally life or death, or whether it's because im in joburg, but the way they treat patients is...interesting.  Not good or bad necessarily...ok who am I kidding?  It's bad (but also often hilarious).  The balance of power is definitely shifted towards doctors.  Every night, I see the registrar slapping patients on the head: "hey man! hold still!  I'm trying to save your life here!  You're really starting to get on my nerves!" WHACK upside the head.  In her defence, the patients are generally drunk/high with multiple stab wounds, falling bp, etc etc and she's trying to get a central line in for ionotropes or something while they're flailing about and screaming their fool heads off.  Tbh, when she does it, I cheer internally.  Surely, every doctor has had that time when they just wanted to slap a truculent patient.  If the slaps don't quieten them down, the threshold for sedating patients is low,  and a surprisingly high number of them get rapid sequence induced and intubated just to keep them docile.  Dunno what the ethics on that is.  This morning, a lady w a pelvis fracture was lying in an L shape across hers and another patient's trolleys.  A reg dragged her bodily back onto her own trolley like a sack of potatoes while she screamed in pain (and she'd just been handed over, so the reg definitely knew about the fractures).

The way they deal w consent is likewise shifty.  I asked an intern whether she'd already gotten consent for a chest drain, and she looked at me like "why in heaven would I want to do that?"  A hefty dose of ketamine later, the guy no longer has capacity anyways.  In the wards, the only way patients express lack of consent is by being uncooperative.  One guy w a partially obstructed bowel kept pulling out his Ng tube.  I think they explained it to him once or twice that he needed the tube, but then by the third and fourth time, it was "hey, my man, I've already explained this to you multiple times. If you don't want us to treat you, then you can sign this sheet of paper and we'll discharge you, and you can go home and die by yourself.  And don't come back when it starts getting bad again either!  And the death WILL be painful!"  Luckily, it was only a scare tactic (they didn't let the guy go home after all, even though he offered to sign the form), but it's a scare tactic that gets pulled out w surprising frequency and facility.  Another man didn't want to let us take bloods.  He was immediately declared "confused".  "Hey baba, why are you acting this way?  You're confused!"  At least they still have to get written consent for surgery.

Bc the healthcare here is still v paternalistic, patients are grateful for the care they get, even though the care is free (cf UK patients' attitudes).  I've made grown men cry w pain while suturing them, but afterwards, they all thank me in this charming, sincere way.  It's amazing.  We went grocery shopping in our scrubs after work the other day, and ppl stopped us to say what good care they got at Bara after their accident.  it felt good.  Like i'd finally become a useful member of society.  Maybe this contributes to the lack of consent...bc doctors know best, and afterwards, patients are thankful, regardless of their feelings at the time.  Well, they're either thankful or dead.