Monday, January 29, 2018

A Clinical Elective in Acute Trauma Resuscitation and Management in Cape Town, South Africa: Part II

Bryant C. Shannon, MD
Harvard Affiliated Emergency Medicine Residency Program
PGY2 Resident

A Clinical Elective in Acute Trauma Resuscitation and Management in Cape Town, South Africa.

Part II

As I wrap up my time in South Africa, I reflect on the very brief four weeks spent here. It was an incredible and trying experience, working and learning in such a beautiful city inundated with terrible violence. I left most of my 14-hour overnight shifts completely exhausted and utterly impressed with my South African co-residents. On a typical Saturday night, we were constantly moving, attempting to provide appropriate care to the constant stream of victims of severe traumatic injury with limited sources and far less support than back in Boston. I would get tips for improvement from the local residents with chest tube placements in exchange for a second set of eyes on an xray or ultrasound.

On one particular weekend night, the South African residents were forced to adapt to the sheer number of patients by writing down the injury burden, assessment, and plan on a sticky note that was then taped to each stretcher, starting the formal medical charting after their shift ended. It wasn’t until the resuscitation unit ran out of ventilators, but after there were no more stretchers that the government hospital was finally able to get permission to go on diversion. Diversion is a status given to tertiary referral centers when they cannot accept transfers given their own resource constraints.

In the thick of the chaos, nurses somehow were able to find or improvise physician-requested supplies that were out of stock in the supply room. Residents performed brain death exams and called families about organ donation while still in the Red Zone, as critical care beds were rarely available, and new patients in extremis continue to arrive. I witnessed my first ED Thoracotomy during this shift, performed by a second year resident and supervised by a fourth year resident. It was during this procedure that a fellow resident reminded me that nearly 20% of the general population is HIV positive, a likely underestimate for the trauma population. “Its kind of a right of passage to go on antiretroviral treatment after an occupational exposure at least a few times while here.” Despite the multitude of intoxicated and sometimes unruly trauma patients, I was able to avoid this ‘right of passage.’

I left Groote Schuur Hospital with a renewed level of appreciation for all of the ancillary staff in the Boston emergency departments. Its not until you’re forced to take on some of their responsibilities do you realize how unfamiliar you are with these roles. In this short clinical elective, I was not close to being able to digest the multiple of socioeconomic and historical factors at play. During a resuscitation, I was stopped by a nurse from using trauma shears to quickly remove the patient’s clothing. She rightfully knew that the patient would live to discharge and would have no other clothes to go home with if I cut them. I observed and participated in many less common emergency procedures. The South African junior residents’ resilience and ability to problem solve quickly to take care of very ill patients without attending and consultant availability overnight was intense and courageous. I look forward to improving my clinical acumen over the next few years of my residency so that next time I work in a similar environment abroad I am more valuable.

Ventilator Equipment in the Resuscitation Unit

Traumas triaged to the left, medical emergencies to the right

Procedure and casting room

A Clinical Elective in Acute Trauma Resuscitation and Management in Cape Town, South Africa: Part I

Bryant C. Shannon, MD
Harvard Affiliated Emergency Medicine Residency Program
PGY2 Resident

A Clinical Elective in Acute Trauma Resuscitation and Management in Cape Town, South Africa.

Part I:

I arrived in Cape Town a week ago and hit the ground running. Four weeks is going to fly by. I have traveled extensively throughout the African continent before, but one thing that already stands out about this experience is the vast socioeconomic disparities within the city. Cape Town is the second largest city in South Africa with a diverse population of roughly 3 million people and a striking landscape of large mountains rising against the backdrop of the Atlantic Ocean. My clinical elective takes place at Groote Schuur Hospital (GSH), the public teaching hospital for the University of Cape Town, which is well known for being the location of the first heart transplant in the world. The patient population mainly comes from the nearby ‘Townships,’ which are low socioeconomic neighborhoods just outside of the ‘City Bowl.’ Townships are primarily black African settlements that are a remnant of the forceful relocation of the black population under Apartheid. Overcrowding, poor infrastructure, and significant poverty-driven violence plague these settlements. In start contrast, and a 10-15 min drive, central Cape Town or ‘City Bowl’ is a dense urban environment abutting a large international port with green parks, quaint cafes, and high-end real estate.

Groote Schuur Hospital splits their medical and traumatic emergencies between two distinct units, sometimes ‘turfing’ patients from one to the other. Any patient with a traumatic injury is brought to the Trauma Unit, where they are triaged into zones by severity. The red zone or “Resuscitation” is the highest acuity, while green is the lowest. The Trauma Unit is staffed by surgical and emergency residents, nurses, nursing assistants, as well as trauma attendings who round on the patients twice a day. Many medical trainees from Europe, Canada, and other parts of Africa routinely rotate given the Unit’s reputation as a leader in penetrating trauma management and research.

My initial shifts were fraught with the usual frustrations that come with starting on a new service as you learn workflow, culture, and a new electronic medical record. I was surprised that patients with stab or gun shot wounds were often triaged to ‘Yellow,’ the intermediate zone, where patients were placed on a stretcher but not typically on a monitor. The staff at GSH see so much penetrating trauma that patients are not brought to the ‘Red’ zone unless, among other things, they are hypotensive, in respiratory distress, or severely altered. Similar to Boston, paramedics roll patients into the red zone, transfer the patient onto a stretcher, and give report. Given the shear volume, new patients being actively resuscitated are often cared for by the dual team of a single junior resident and a nurse. The resident role is to follow ATLS, while simultaneously securing IV access, obtaining vitals, and drawing labs. A senior surgical resident or ‘cutting reg’ is called to the resuscitation if the junior feels the patient imminently needs to go to the operating room.

As one of the only hospitals with a 24 hour CT scanner and radiologist in Cape Town, GSH receives many outside transfers for imaging overnight. Patient volume tends to surge on the weekend nights as substance abuse and gang-related trauma compounds the usual visits. In the Resuscitation Unit, they utilize a full body, low dose radiation xray (LODOX) as their initial assessment for most patients. It is quick way to assess for some thoracic injuries, fracture, bullets, etc. Unfortunately, FAST exams were often not possible given unreliable ultrasound machines. Additional imaging orders require a conversation for approval by the on call radiologist. In severe trauma, no additional CT scans will be approved until a head CT has been done and read that rules out non-viable head injuries. This is in stark contrast to my own institution where we ‘pan scan’ most traumas, partly due to resource availability and partly due to our medical-legal environment.

Beautiful and historic, Groote Schuur Hospital, from the outside
Low-dose full body xray machine in the resuscitation unit

Criteria for triage to the Resuscitation Unit

Monday, December 18, 2017

An Internal Medicine Rotation in Mirebalais, Haiti: Some Reflections from Two Weeks in Haiti

Anastasia Vishnevetsky
Resident in the Partners Neurology Program, preliminary year in internal medicine at Brigham and Women’s

An Internal Medicine Rotation in Mirebalais, Haiti: Some Reflections from Two Weeks in Haiti

It’s been now almost two weeks that I have been in Mirebalais, so here are a few reflections from my time:

1. On daily life as a resident: 
A first year resident in internal medicine at Mirebalais, starts their day around 6:30, with prerounding and seeing approximately 8-10 patients. At 8:00AM, most residents go to the resident’s lounge for a quick breakfast. At 8:30, they have ‘morning report,’ which is a formal presentation of all the new admissions from the previous nights with the internal medicine attending physicians and all of the residents. There’s usually some informal teaching and discussion at morning report as well, which is completed around 10AM. After morning report, residents will break off to the different wards (women’s ward, men’s ward, or isolation ward for patients who are being ruled out for TB) for ‘small rounds,’ which are bedside rounds with the senior resident and sometimes the attending as well. This continues until noon, with the residency gathering again at 12PM on Tuesdays, Wednesdays, and Thursdays for an interesting case presentation on one of the wards. Everyday, except Friday, there is a teaching conference around 1pm, and around 2pm the residents go for lunch. The interns are on a Q5 day call schedule, staying for long call until around 2AM every 5th day.
The intern day here is quite different from Boston. There’s significantly less paperwork and fewer labs to follow up, consults to call, or orders to put in - a natural consequence of fewer medications available, limited lab test availability, and few specialty services. The days are just as long however, with group case presentations taking up almost half the day.  The interns have shared housing on the campus of the hospital and work 6 days out of the week.

Writing notes at the hospital

The Arbonite river flowing through Mirebalais, about a 10 minute walk from the hospital. This is the river that was affected by the cholera epidemic brought by the UN in the aftermath of the 2010 earthquake. Signs demanding reparations from the UN can be seen throughout the city, and anti-cholera vaccination efforts are ongoing.

2. On practicing medicine in Haiti:
Life as a doctor in Haiti is hard even after training, and many of the residents have their eyes set on foreign medical exams after residency. The government provides little public funding for physician salaries, and most needy patients have neither insurance nor the capacity to pay out of pocket for health care. Equipment and lab testing is difficult to come by, and costs can be very high. Healthcare is often provided by foreign NGOs like Partners in Health, which provide free care, but there are a limited number of attending positions at these institutions.  One co-intern who has thought about trying to move to Spain after residency, laughed when I said Haiti needs doctors to stay in Haiti: “Easy for you to say.” Indeed, easy for me to say. He added that of course he would want to stay in Haiti and make a living here, but at some point ‘you have to think about where you want your kids to grow up and what kind of life you would want for them, and so if you have to leave, you leave.” It’s a sad thought, especially looking at some of the talented residents I’ve worked with here in Mirebalais. On admitting nights, I’ve worked with one of the best residents I’ve worked with all intern year, whether in Boston or Mirebalais. I joked that I came down to Haiti just to learn from this brilliant resident, but in all seriousness, I think it would have been worth it for him alone. I heard later that he is studying to take the USMLE.

3. On the importance of language:
The vast majority of patients and people in general in Haiti speak Haitian Creole amongst themselves. French is only used in official and administrative settings (including between doctors in the hospital or during presentations in the hospital). English is rarely used at all, though some doctors can speak it, and most residents can understand it to some degree. The language barrier creates an immediate division between expats and locals that is troublesome and makes it difficult to form deeper and more significant local relationships. For me, speaking French has allowed me to get closer with many of the residents and function as a resident in the hospital, but I still wish I could speak in something other than the former colonialist language. The requirement to speak French, which is spoken almost exclusively by the Haitian elite, in official settings and also to study in French in schools perpetuates the inequalities in Haitian society. Creole is incredibly similar to French in terms of vocabulary, but learning to understand spoken Creole from a base of French is much more difficult.  It was very worthwhile to learn some Creole before coming to Haiti, and I wish I had learned more.

My co-intern at Saut d’Eau, a famous Haitian waterfall with great importance in the Vodou tradition. We took the trip about 25 minutes outside of Mirebalais on our Sunday off.

4. A reading recommendation:
‘The Big Truck that Went By: How the World Came to Save Haiti and Left Behind a Disaster.” This book, which was recommended to me by another doctor who has repeatedly come to Haiti, was one of the best books that I’ve read in a long time. It is written by the AP journalist who was in Haiti at the time of the earthquake in 2010, and who later broke the cholera epidemic story. I’d particularly recommend it to anyone interested in global health or development, or to anyone interested in coming to Haiti and understanding the complex and often fraught relationship that Haiti has with foreign aid.

5. On Haiti:
Haiti is incredibly beautiful. I had heard that Haiti was mountainous and beautiful, but the landscapes here truly blow me away. The mountains, beautiful sunsets, which then roll into a perfect turquoise Caribbean Sea have to be seen to be believed. The fact that Haiti is not overflowing with tourists speaks to the infrastructure problems, as well as to the negative mythology that surrounds Haiti. I’m still a few weeks away from leaving, but I can tell I’m going to miss it!

The view from Saut D’Eau,