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