From July to September 2018, I undertook a six week elective in the trauma and emergency medicine departments at Tygerberg Hospital, South Africa. This tertiary hospital is situated about 20 minutes drive from central Cape Town. Opened in 1976, it is the largest hospital in the Western Cape with 1899 beds and is state-funded by the National Department of Health. It serves as a teaching hospital for students from Stellenbosch University’s Health Science Faculty and manages a population of over 3 million people (South Africa has a total population of around 55 million).
In terms of hospital resources, my visit to Cape Town coincided with the end of a severe drought which had lasted almost three years. There had been concern that in the months running up to the start of my elective the city’s water supply would dry up, an event referred to as ‘Day Zero’. At this point water taps would cease to function and Capetonians would have been forced to collect water from local municipality spots throughout the city. Hospitals themselves wouldn’t have their water supply revoked, however a spike in admissions was still predicted due to the acute effects of the supply ban in the community. Fortunately sufficient rain throughout July and the rapid construction of desalination plants had removed this acute threat, however water was still used sparingly in the hospital. There was a scarcity of other resources too due to chronic underfunding from the Department of Health which limited access to investigations such as blood tests and imaging. A positive consequence of such shortages was that doctors were diligent at relying on signs and symptoms to form diagnoses.
Departments and Ambulance Work:
Unlike hospitals in the UK, Tygerberg Hospital has separate emergency and trauma departments. The emergency department handles similar cases to Accident and Emergency departments in the UK. The vast majority of cases presenting to the trauma department were shootings and stabbings of young males from the multitude of townships surrounding the hospital. Many of these patients were involved in the Number’s Gangs:a collection of rival gangs which is prevalent in Cape Town prisons. Former inmates often remain associated with their respective gangs even after release where they are known to impose tyrannical control over township communities. I had the opportunity to see first hand the violence in these townships whilst joining the ambulance crew who often had to venture into the townships under police escort. On some occasions, the police refused to escort ambulances into the most dangerous townships, so-called ‘red zones’. In these situations, the patient would have to rely on self-admission to hospital which would have worse prognoses. Aside from ambulance shifts, I had the option each day to work either in the trauma or emergency departments. The trauma department was generally busier during weekend night shifts and busiest on a payday weekend, with alcohol-fuelled violence causing a surge in trauma admissions.
A typical shift:
Shifts would last up to 12 hours, although it was not uncommon to be working with doctors on 24 hour shifts. A typical shift in the trauma department would involve shadowing a junior doctor or clerking my own patients as part of triage, performing a variety of clinical skills including venepuncture, arterial blood gases and catheterisation. I had learnt the foundations of sutering from courses with the Cutting Edge Surgical Society and I was very keen to develop these skills in the trauma unit. Following teaching at the skills lab at Tygerberg and ward teaching from the junior doctors, I was able to suture some of the patients that were admitted with sharp trauma, for example knife attacks. With the clinical skills I was performing, I received constructive feedback which I believe improved my clinical performance. After a few shifts I was inserting chest drains for haemothoraxes secondary to sharp chest traumas, and performing lumbar punctures (all under close supervision!). As with my experience in the UK, it was incredibly useful for my learning to follow patients from their admission to discharge and understand the reasoning behind each clinical decision in the patient’s management plan.
Unlike the trauma department, I would normally attend day shifts at the emergency department, mainly so I could attend the morning ward round which may have involved up to 15 medical professionals from different specialities. The ward round would take around three hours and involve reviewing up to 70 patients. Despite the number of patients, the consultant leading the ward round would consistently provide teaching to the medical students. My key observations from the emergency department were: firstly, the late presentation of so many patients – this could be put down to multiple factors including poor health education meaning patients are far less aware of urgent symptoms, socio-economic factors affecting their ability to transport themselves to hospital and the lack of screening programmes to enable early disease identification; and secondly the prevalence of HIV and TB.
Public health concerns: HIV and TB
Nineteen percent of South Africans are believed to have HIV, making it the country with the largest population of HIV patients. However antiretroviral drugs, health education programmes and increased condom usage (amongst other factors) have contributed to a reduced incidence of HIV by up to 44% from 2010-2016.This comes after a period of ‘AIDS denialism’ when Thabo Mbeki, the president of South Africa from 1999-2008 publicly denied that AIDS was caused by the HIV virus. This belief delayed public health authorities into commencing anti-retroviral (ARV) programmes. HIV remains a significant public health concern, however, and was accountable for a substantial number of immune-related hospital admissions that I witnessed. Furthermore, stigma towards HIV remains high which has reduced ARV compliance.
Aside from HIV, TB is a very common comorbidity with a co-infection rate of about 60%. Screening programmes have become more prevalent and public health authorities now believe that TB and HIV should be given the same attention. Previously undiagnosed late-stage TB was a common presenting complaint in the emergency department at Tygerberg. Whilst distressing to witness, it was beneficial to develop my chest x-ray interpretation skills and respiratory examinations during the management of these patients.
Conclusion and reflection:
I thoroughly enjoyed my elective in South Africa: I felt that my clinical skills improved and I became more confident in carrying them out competently and safely. I was also glad that I saw a wide range of admissions to the emergency department. Moving forward I would like to focus on the clinical skills and knowledge that I have obtained from my elective and put this into practice during my placements this year. I also feel more comfortable performing the types of jobs that will be expected if me as a foundation year doctor.