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My Elective - Blog 3

By Alice Gwyn-Jones

My Elective - Blog 3

Getting shot right in

There was no time to figure out your way around, find out where the equipment is kept when arriving in Tygerberg's emergency department. With the trauma unit and the emergency medical department being separated, I was told the best time to go to the trauma unit was the evenings.

Arriving fresh faced and full of enthusiasm for an evening shift on the trauma unit, I entered through the barred gate, I was told it was there "to keep people from coming in to finish the job". With 30% of the patients here for road traffic accidents and the other 70% for assaults, mainly of the stabbing or gunshot variety.

I wasn't expecting to see the amount of patients cramped into the four bays and the aisle of chairs, I presumed was a relatives waiting area. How wrong I was, these chairs were actually for the patients, all snuggled up together chest drain next to chest drain. Having not been in the department five minutes, I was immediately roped into assisting with a chest drain insertion, on a patient with multiple stab wounds leading to a pneumothorax, this patient was 12 years old! It was certainly an eye opener into the gang culture here in Cape Town.

My first weekend in Cape Town was pay day weekend, "everyone goes out gets drunk and stabs each other" was my warning to my Sunday night shift. With paramedic crews still bringing in patients from the streets and from other hospitals that lacked the tertiary care, to say the department was busy was an understatement, there was even 4 patients on trolleys outside the barred gate.

EMS crew brought in a male in his 20s with a stab wound to the chest, chest drain already in situ, but with a blood pressure of 80/40 he wasn't a top priority for the doctors! It was up to another elective student and myself to try and stabilise this patient, getting fluids and plasma set up and taking bloods.

Noticing a raised JVP and a blood pressure that wasn't improving, this was way out of our remit. With good grounds for doctors attention, they carried out an ultrasound, a small pericardial effusion. Grabbing another doctor as the previous one had to rush off to intubate a different patient, the doctor commented that he'd preform a cardiocentesis… blind!!

I hope he was joking. But no time to check though as I spotted a patient that wasn't in resus just in between desks. With my "SICK" instinct kicking off, I checked his notes and asked one of the nurses to do some obs. 22 year old male with a gunshot wound to the abdomen, with a retained bullet. With a crashing blood pressure, increased respiratory distress, he was septic.

Obtaining a blood gas and getting another cannula in after realising the two bags of fluids on his drip stand were connected to the same pink cannula, obviously adjusted too much as this was more of an eye roll moment than a "WHAT??!!". Luckily like magic a surgeon appeared telling me he's taking the patient to theatre and can I assist… um YES!

All scrubbed in we realised the gunshot wound was the least of his worries, with extensive post peritoneal fasciitis, 100% mortality rate I was told. Hours of searching for damage, removing a section of colon and putting off investigating the huge haematoma until the stressed anaesthetics had enough blood and blood products up and had control of the airway, after reintubated due to the amount the patient had aspirated.

With the consultant called in for back up, the bowel that was left was still not looking well perfused, eventually putting this down to his saturations of 50% despite intubated on 100% oxygen, it was time to pack the abdomen and placing some NG tubes as drainage devices. The patient was now ready for his bed on ITU.

Unfortunately, his bed was no longer available and the patient was left clogging theatres, leaving the 5 patients who were constantly being discussed over who gets priority of the next theatre slot waiting. The priority was being given based on who they thought would die first, out of three patients with gunshot wounds, one that was conning and one with a stab wound to the heart. Now just to hope the patient we operated on survives 48 hours for more definitive surgery. Such a beautiful city with such darkness under the surface.

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