Stories From the Field:

SOUTH AFRICA

Acute Trauma Resuscitation and Management in Cape Town, South Africa

Dr. Bryan Shannon traveled to South Africa supported by an MGH Global Health Travel Award. Dr. Shannon is a resident in the Harvard Affiliated Emergency Medicine Residency Program at Mass General.

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. I have traveled extensively throughout the African continent before, but one thing that 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 took place at Groote Schuur Hospital (GSH), the public teaching hospital for the University of Cape Town and the site of the first heart transplant in the world. The patient population mainly comes from the nearby ‘Townships,’ neighborhoods just outside of the ‘City Bowl.’ Townships are a remnant of the forceful relocation of the black population under Apartheid and suffer from overcrowding, poor infrastructure, and significant poverty-driven violence. In stark contrast, and only a 15-minute drive away, 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, and attending trauma physicians who round on the patients twice a day. Many medical trainees from Europe, Canada, and other countries in Africa routinely rotate through Groote Schuur because of the Unit’s reputation as a leader in penetrating trauma management and research.

My initial shifts had 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. Like in Boston, paramedics roll patients into the red zone, transfer the patient onto a stretcher, and give their report. Given the sheer volume, new patients being actively resuscitated are often cared for by a team of a single junior resident and nurse. The role of the resident 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 in Cape Town with a 24-hour CT scanner and radiologist, 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 X-ray as their initial assessment - a quick way to assess for thoracic injuries, fracture, or bullets. Additional imaging orders require approval by the on-call radiologist and no additional CT scans will be approved until a head CT can rule out non-viable head injuries. This is in stark contrast to my experience in Boston where we ‘pan scan’ most traumas.

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 advice on my chest tube placements from the local residents in exchange for my second set of eyes on an X-ray or ultrasound.

On one particularly busy 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 taped to each stretcher, starting the formal medical charting after their shifts ended. Only after there were no more stretchers available was the hospital finally able to get permission to go on diversion, a status granted to tertiary referral centers when they cannot accept additional transfers because of severe resource constraints.

I left Groote Schuur Hospital with a renewed level of appreciation for all of the ancillary staff in the Boston emergency departments. Only after you take on some of their responsibilities do you realize how unfamiliar you are with these roles. In this short clinical elective, I only began to understand 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. 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 I am more valuable.