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My Elective - Blog 2

By James Lee

My Elective - Blog 2

Day 1 of elective has proven to be a logistical nightmare, with the resolution being a hospital switch to Chris Hani Baragawanath Academic Hospital: another government run hospital but in Soweto, a township in the south of Johannesburg. The main difference between this hospital and most in Johannesburg is the sheer volume of patients. To call my first shift a baptism by fire would be an insult to fire.

This hospital has seen a stream of extremely capable elective students, meaning that the expectations of you even from day 1 are extremely high. The unit consists of a 14-bed resus department and 12 bays in "the pit". There is then a trauma ward with over 40 beds plus outliers, within the barracks of surgical wards, spread across the site.

Colloquially known as Bara, the hospital is a tertiary referral centre, meaning patients must be seen by a local clinic before their arrival at the trauma department. This means that often the patient will only present for medical assistance 2-3 days after injury, sometimes even a week later. Practising good public health and informing these patients that they should have presented earlier only feels like lecturing, so a prompt assessment is all that can be offered. Without the golden ticket in the form of a referral letter, patients are turned away at the front door.

A common pattern of injury in patients here were crush injuries, not common in my short time in A+E at home. This said, mechanism of injury is not actually a crush, but "community assault": a vague term used usually to describe some sort of "mob justice". It is rare that there is a pre-alert for patients attending the unit, so each new patient is a surprise. These patients present days after injury, with injuries resulting in high blood potassium, urinary ketones and deranged U+Es: the onset of rhabdomyolysis. 

A commonly seen injury is known as "tram-tracking". Daily, I would find these injuries covering the back, arms and head of patients who have been hit repeatedly by large sticks. Where overall coverage approaches 20%, the presentation mimics a crush injury, affecting multiple organ systems if treatment is not prompt and efficient. This is definitely not something I had come across in the day-to-day of the emergency department at home and had only seen this when working in the first aid tent at the Brighton Marathon. Here, interns can rely on well-honed pattern recognition and standard operating procedures to work these patients up and prepare them for an admission.

I realised very early on that the clinical skills and pattern recognition of the most junior doctors here at Bara were much stronger than ours as nearly-qualified doctors on elective from our host countries. These interns had also not been on the job very long, which is promising as I hope that I might be just as competent in a few short weeks.

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