Welcome to Bara

Nés Sous la Même Étoile - IAM

I have so far spoken about my excitement and angst revolving around my South African project but after four updates, I have yet to speak about what I am here for: trauma at the Chris Hani Baragwanath Hospital.

After a week working at one of the busiest trauma units in the world, it would be easy to write pages and pages about a multitude of specific individual cases but that would be like unveiling a painting one color at a time. If you are to understanding me, to share what I am experiencing, I would rather take a more global approach. Apologies to the seeker of uncanny stories of blood and gore, you will find your fill when I come back.

Bara is a giant within the giant that Soweto is. At close to one and a half million inhabitants, this South Western Township of Johannesburg is quite enormous for a suburb. Townships, in the time of Apartheid, were the ghettos of delocalized blacks and Soweto was and still is the biggest in the country. It played quite an important role in the struggle to end Apartheid with many important leaders and political groups emerging from it and thus holds somewhat of an aura about it. At the southeastern end of it lies Bara, a three thousand plus bed hospital which dwarves major North American hospitals in comparison (boasting a meagre five hundred bed capacity on average). To the three thousand inpatients add themselves an army of orderlies, nurses, medical students, staffs, janitors, administrative workers, security guards, etc… It is a small city.

     (Mind you, the scale is slightly bigger on the bottom picture)

Canada is not plagued with trauma as South Africa is, and the concept of a trauma unit is almost foreign to me. A trauma service: yes. An entire unit devoted to trauma: not quite. While Soweto’s socioeconomic status has improved over the past two decades, crime and violence still conduct the soundtrack to many Sowetans’ life. Many of our patients are victims of unfortunate accidents but the majority of them have earned their hospital admission from the gratuitous aggression of another person. As I have heard many people say over the past week, there seems to be no respect for the value of a human being’s life and it is this sad truth that requires the existence of the unit that I work in. Stab wounds and gunshot wounds – relatively rare occurrences in Montreal – are the daily bread and butter of the trauma unit at Bara.  Burns, beatings, rape, and motor vehicle accidents are also common sights. I have spent the past two years in hospitals. I have seen suffering, I have seen death, but these have usually been the tragic consequences of an organic disease. At Bara, when confronted with the very real results of such a labour of hate, of a conscious decision to do harm, disbelief and sorrow seep through me and humanity weeps red with shame.

On duty, there is little time to stop and ponder about the philosophical signification of such human misery, just time to see the next patient and hopefully avoid the worst. The law of supply and demand makes it quite difficult to offer the human warmth that we as physicians, healers, would like to provide and that these people require after such terrible experiences. I was taught and adopted the practice that one who calls himself doctor should heal both mind and body for they are one of the same. A smile, a hand on the shoulder, or a compassionate look are our feeble attempts at comforting the shaken and traumatized spirits of these death-defying survivors.

Despite numbering more than four hundred different buildings, Bara mainly sees its trauma service in two separate areas: the resuscitation area and the ward. The resuscitation area is split between the “pit” where relatively stable patients are assessed and the eight bed trauma bay where the worst off receive emergency care. The ward houses roughly fifty patients and is where patients continue to receive treatment and hopefully recover from their injuries. Because the Intensive Care Unit at Bara is perennially full, our ward also acts as an ICU for some of our sickest patients requiring mechanical ventilation and constant monitoring.     

The helipad in front of the resuscitation area

The trauma ward on the right

Blood is omnipresent though not flying through the air and drying on the walls as some of you may wrongly think. Blood is on our hands, on our clothes, on the bed sheets, on the patients, and well... hopefully in them too. We do not have the luxury of phlebotomists or highly trained nurses: we do our own blood tests, we place our own intravenous lines. There are no needle drivers on the ward: hand stitching with three inch long suture needles is the norm. There are only two containers in which to dispose of our soiled sharps such as needles or scalpel blades (no actual scalpel handles are available). With an HIV prevalence exceeding 50% in our patient population, mistakes are strongly recommended against, but as Dawn Francis, the Witswatersrand University’s foreign student coordinator, put: “you won’t get better HIV management than here.”  I remember answering her with an uncomfortable smile. X-rays and CT scans are done on films – no playing with brightness and contrast at the click of a mouse – and read at ambient light. Increasing brightness means going outside... when it is daytime of course. Sterile gauze, sterile glove, and topical anesthetics are expensive and spared when possible. The sterile technique and the “no touch” technique are unofficially interchangeable.

Welcome to Bara.

But despite the lack of what our North American selves might call as standard, this trauma unit gets the job done. Granted, there might be a lack of elegance, but the job gets done. I wonder if in Canada we should consider ourselves wasteful or should we be pleased with being able to provide our patients with a higher general quality of care. I suspect the answer is a combination of both but the unfortunate reality is that we are too often unaware of either and even more unaware of the precious help other health care workers provide so that physicians may focus on medical matters.

I am thankfully surrounded by a multitude of staff (called consultants), junior residents (interns), and medical students both local and foreign. The international students, of which I have made many friends already, presently represent USA, Sweden, Germany, Switzerland, New Zealand, Australia, and Canada.

The medical lingo is slightly different but my two favorites so far are:

•           Calling nurses “sisters” or rather “seestas”. I am guessing this is a tradition which started at a time when nurses where religious nuns, or sisters. It is stupid I know, but I feel much closer calling someone sister than nurse which coming from certain staffs back home is almost spoken with a pejorative connotation. The only disadvantage I could think of would be in the context of a male nurse which I am told would still be referred to as a sister.

•           One of the surgeons on the team is referred to as “mister” and not doctor. In countries like Australia or South Africa, surgeons drop their title of “Doctor” because traditionally, surgeons were barbers being told where to cut by physicians. I thought this was rather demeaning but apparently surgeons have kept this tradition because when someone is referred to as “mister” in a medical setting, everyone then identifies them as surgeons and not medical doctors. “Another bit of surgical wankering is what that is” as beautifully put by an Australian student.

Cheers folks,

TF