Gunshot after gunshot

Unlike so many others, I didn't choose sun, sea, sand and ... well ...who knows what else(!) for my elective experience. Indeed, I couldn't have been further from tranquillity if I tried. My time was spent in a trauma centre in Johannesburg.

The overall attitude of most, when I announced my intended destination, was that I was on a suicide mission. The general consensus was that my decision to opt for the trauma capital of the world was best put down to a moment of insanity.

The reality, however, was that I knew the clinical experience and exposure would be second to none, and that I would be able to partake in a vast array of practical procedures that you just don't get to do over here. My aim was to hone in on the practical side of medicine and do as much as possible so that, when I returned, inserting a cannula wouldn't be such a daunting concept.

A dangerous city

For someone who spent six weeks in Johannesburg, I saw relatively little of it. It just wasn't safe to do so. Living merely 50m from the hospital, I wasn't allowed to walk the distance without an armed security guard, even during the day. The accommodation was surrounded by 10ft electrical fencing with guards spread around the perimeter.

One aspect of the city that was all too clear was the social segregation - black from white, rich from poor. A street in some areas was almost a physical divide between two entirely separate worlds; mansions on the right, metal shacks on the left. There seemed to be no in-between.

As for the racial segregation, although in some areas blacks and whites live in relative harmony, there are still "black malls" and "white malls". Getting to these places was an adventure in itself. Having hired a car with a couple of students I met out there, I would drive to a mall, following advice not to stop at any red lights (for car jacking is a favourite pastime and you're not safe even in a clapped-out Mazda), and be searched by guards on arrival before proceeding through security gates.

Gunshot, stabbings and beatings

Johannesburg General Hospital is well equipped with modern technology but, like here, bed shortages are an issue. Unlike here, this problem is overcome by treating patients on the floor.

My time was spent in Trauma Unit 163. It was like a war zone - we saw gunshot after gunshot after gunshot, interspersed with stabbings, beatings, PVAs (pedestrian-vehicle accidents) and MVAs (motor vehicle accidents). For those patients presenting with a swollen joint, there was no such thing as a sprain: if it warranted them turning up at hospital, it was broken.

The reason for the lack of presentation of minor injuries I feel was best put down to the fact that, unlike our healthcare system, theirs isn't free. There are payment bands, depending upon wages earned, but even the unemployed are required to pay the equivalent of £5 to be seen. This may not seem much to us, but £5 there could easily feed a family for a week.

There were no medical emergencies either; the hospital had a separate unit for that, as indeed it did for paediatric emergencies.
 
Due to the large number of resuscitations that take place in the trauma unit - on average 10-15 a day - the unit has its own protocols, which, although closely following the ATLS guidelines in the UK, are designed to follow the staffing structure of the department. As the doctors are so experienced, the whole department runs only with two medical officers (F2 equivalent) at any one time. Compare that to the team that turns up for a single resuscitation when the trauma bleep is activated in the UK!
 
The system used for categorising patients was P1-4, as follows:
 P1: those requiring immediate resuscitation
P2: those who may need resuscitation, e.g. expanding haematoma as a result of a stab wound to the neck
 P3: walking wounded
P4: dead on arrival

Indeed, not all patients were priority 1, and in between resuscitations I was able to clerk in patients, present them to the doctors and practise more minor skills such as suturing, applying plaster casts and reducing dislocations. These form the bread and butter of the department and once proficient I was encouraged to teach other medical students and paramedics these skills.

See one, do one, teach one

The environment in the trauma department was ideal for learning. In between resuscitations, the doctors would talk me through and demonstrate practical procedures. Their mentality was such that once I knew the theory behind a procedure, the possible complications caused by such a procedure, and how to treat any such complications, then the "see one, do one, teach one" maxim took over. It wasn't long before I'd seen and done enough to become a fully participating member of the team.

At first my involvement was that of C-spine control, a role normally assumed by sister 1 and which basically involved the maintenance of C-spine throughout the resuscitation until it could be cleared either clinically or radiologically. The novelty of this position soon wore of and I was upgraded to that of Doctor 2.

This role included obtaining a manual bp, inserting two large-gauge cannulae into the cubital fossae, administering the appropriate inducing agents for intubation and then taking arterial gases. With the exception of the manual bp, these were procedures I had never done before and despite a couple of arterial gases taken from the femoral vein (!) they were procedures with which I soon became confident.

Resuscitations were at times extremely stressful and the pressure to get immediate venous access at times immense, not helped by the shouting of registrars who occasionally took time out from theatre to supervise things.
 
And the practical procedures didn't stop there. In week two they escalated to encompass elective chest drains and central-line insertions. Initially, the concept of inserting a huge needle blind into someone's chest in the hope of hitting the subclavian vein yet missing all arteries, nerves and lungs filled me with sheer horror, but these too were procedures with which I soon became comfortable and I was allowed to do them in a resuscitation setting. Having said that, I'd still sweat out the 10 minutes until the CXR returned to see if I'd caused a pneumothorax.

As with UK hospitals, the medical officers each week attend teaching with a consultant trauma surgeon. All resuscitations are filmed and the teaching usually involved critical analysis of any that didn't go to plan. It also took on a more practical side and we were given the opportunity to learn a diversity of techniques ranging from simple sutures to cricothyrocotomies.
 
I never expected the latter to come in handy, but it did, when one evening, a patient turned up in a taxi having been shot through the neck. It was impossible to maintain an airway by any other means. A surgical airway was the only option, and having learnt this only the day before, the registrar offered it to me. I did it, and couldn't believe that three weeks earlier I would have been terrified to take blood from a patient in Outpatients
 
There were also ample opportunities to go to theatre. In Johannesburg, they practise so-called damage-control surgery, whereby the operation is used merely to stabilise the patient enough to enable them to recover physiologically. A definitive operation is then carried out at a later date. I was able to see a wide range of techniques used, including laparotomy, sternotomy, craniotomy, dissection and amputation.

Unless the operation was particularly difficult, I was able to assist the surgeon and was taught and practised many basic surgical skills. In my final week, after hours of practising surgical stitches, I was able to perform part of a small-bowel anastomosis under the scrutinising eye of the consultant.

A pistol at my head

The opportunity was also available for me to work with the paramedics and doctors in the rapid-response car and on the trauma helicopter service. The latter I loved, and spent many more laid-back shifts being flown around the country either to MVAs unreachable by car or doing hospital transfers.

The rapid-response car I limited to one evening only. While I found rushing off to the most dangerous areas of Johannesburg in the middle of the night exhilarating at first, when I nearly became a statistic in the weekly mortality and morbidity meeting the novelty quickly wore off. On returning from a call, we came across a body by the side of the road with four men surrounding it. Having been sent off to assess the situation I found myself in the terrifying predicament of having a pistol pointed at my head.

It turned out that we had just interrupted the men who had shot the victim, rather than come across people who had been trying to help. It is not an experience I ever wish to repeat, though according to the paramedic I was never in too much danger for "they rarely actually shoot you". Well, I guess that's all right then!

Finally, after too many 13-hour night shifts and five weeks with only three days off, I hopped on a plane and headed to the sandy beaches of Cape Town for what I feel was some well earned, and much-needed, rest and recuperation. My whole elective experience was utterly amazing, and while I suppose my medical knowledge of general conditions hasn't changed, my practical capabilities have expanded extraordinarily. I obtained phenomenal clinical experience.

It was a shock returning to Leicester after the excitement of 163, and although I'm not able yet to put my skills into practice, who knows, I might be in the right place at the right time when someone presents with a pneumothorax!

I certainly plan to return to the department as a doctor when I have qualified. I don't regret a single minute of my elective and have returned relatively unscathed, and, to the surprise of my friends, free from bullet holes ... JUST!

This guidance was correct at publication 24/04/2009. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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