Last Saturday was December 1st;
a time that normally marks the coming of Christmas and the holiday season. A
wake up call for people to seriously think about the presents they will buy,
the family dinners to organize, final exams for some, or putting on winter
tires for others. Shopping centers all across the world have already dawned
their glittering holiday attire and Johannesburg is no exception. What marked
this December 1st for me apart from the lack of snow and the summer
temperatures was the unfortunate coincidental meeting of a weekend with the end
of the month.
Weekends are usually busier for the
trauma unit. No work: people go out, people drink, people fight, and people end
up with a knife blade or a bullet where it should not be. This happens fifty
one times per year and does not surprise anyone at Bara. The reality here is
obviously different and these are the kinds of horrors we have to deal with.
Some weekends are different though, even for Bara, and last weekend was just
that. The end of the month is when people here get paid. Combine a weekend with
a pay day and you have a perfect storm with a payload so hard to cope with that
even a three thousand bed megahospital like Bara had to divert ambulances
coming in with critical patients to other hospitals for several hours.
As I previously mentioned in another
post, I would rather describe an experience than specific cases. I feel like
this transcendence is more appropriate in order to share my “world”. Here is
what I went through on my twenty six hour shift on December 1st.
Morning rounds (going over each new
ward admission from overnight) start at seven. I asked the call team how their
night had been: “Not too bad considering it’s pay day weekend: a couple stab
chests, stab necks, only one gunshot wound, no deaths… pretty quiet. Lots of lacerations though.”
Once the rounds and the ward work
were over, the previous day’s team went home to sleep and I headed over to the
resuscitation area. On my short walk
there, I could not help but draw a parallel with my experience in Inuit
communities in the Arctic exactly a year ago. It was a Saturday night in a tiny
little village called Salluit: a drunk teenage girl had been assaulted by her
drunk teenage cousin with a piece of broken glass. I was a fairly green medical
student back then and after having stitched the girl’s eyebrow, I turned to one
of the nurses in disbelief looking for some answer that might make me regain my
use of speech. “This is what happens on weekends here”. Now with an extra year
of clinical experience under my belt, I still had an uneasy feeling about what
I was going to see: that creepy calm before the storm.
It was not as chaotic as I thought
it would be in the end. Or perhaps, I did not react as chaotically as I thought
I would. I had prepared myself mentally and emotionally to the dreadful things
I was going to see in South Africa and it was a matter of applying this frame
of mind. It is a difficult balancing act; that of careful, competent, calculating
callousness with caring concerned compassion. A robot makes a terrible doctor, but so would
a drama queen. One has to be both unphased by the human drama unfolding before
him and caring enough to have patients feel “safe” in your hands. Yes, it is a
difficult balancing act, but oh so important; like looking straight into
someone’s eyes while he exsanguinates and telling him “We’ll take care of you,
Baba (term for adult males). We’ll do our best”. With this, the patient may
feel reassured. With this, his heart rate may slow down, decreasing the rate at
which he is losing blood. It may buy you a few more minutes, the time it takes
to run to the blood bank, snatch a few units and run back. Everything matters. No, I did not react as chaotically as I
thought I would.
Time is an additional vital sign
here. The raggedy shredded bodies accumulate waiting to see a doctor hours and
hours after initially getting injured. If a patient is still alive hours after
getting assaulted, time crudely confirmed the patient’s stability. Many wait so
long while their blood thickly cakes on their faces and clothes because the emergency response teams are oversaturated or because they were unconscious either from head trauma or from
simply being drunk – a lot of them drunker than I have ever been despite my
best attempts during my rugby days.
Medicine is practised differently
here, partly because of the sheer volume of patients that require treatment and
partly because of the physical capacity for such treatments. In Montreal,
lacerations are superficial cuts that require a few stitches. The lacerations
at Bara are fleshy trenches requiring multi-layered stitches (once the bleeding
has stopped of course), and further investigations to identify possible
arterial or bony damages. In the best of
worlds, these would be addressed in an operating theater but since ours are overflowing
with more critical patients on such nights, we repair them in the pit (the
ambulatory trauma department). This often includes hands and faces which are
the sacrosanct domains of plastic surgery back home. The concept of an emergency
is also different. I learned in shock that a lacerated facial nerve is not the
latter.
This brings me to preach about my
values on practising medicine in foreign countries. This trauma elective is
a fantastic learning experience but I did not come here to play doctor and
practice procedures that I am not qualified to do. I sought additional training
at personal cost to prepare for this. These people are not Guinea pigs and they
should not be subjected to a lower standard of medical care. Primum non nocere.
One obviously has to bend the rules when it is physically impossible to comply
with them, like trying to do a sterile procedure with no sterile gloves, but
they are nevertheless a standard to continuously aspire to. In the converse situation, you are
nothing less than an asshole and a failure as a professional.
I remained calm throughout my shift but I was
angry. So very angry. A disguised anger behind the double mask I just
described, but I was nevertheless boiling inside. I had described the trauma
victims of armed aggression in a previous post as having been subjected to a labor of hate. But part of the complex
truth behind the trauma epidemic in Soweto is not solely explained by hate.
Hate alone could not cause so much destruction. It is indifference which I painfully
learned to blame. Some people just do not care and the frighteningly primitive responses
to a vast array of life challenges seem to funnel down to the bark of a gun,
the flash of a blade, or worse… A “tire necklace” or a “Goodyear special” is
when a poor soul is restrained with a gas-filled tire around his chest and arms
and is then lit on fire. People also get dragged under cars in a premeditated
way. The weight of human life does not factor in the equation and it violates
my belief system so harshly that I was filled with anger. A calm silent anger
behind the focus of my work, but intense and burning deep.
And it goes on. You may have just
witnessed the worst thing in your life but there is no time to process, to
breathe, as there are other patients to see. One minute you are performing
chest compressions on a person with a stabbed heart, his warm crimson life
pouring out of his wound and onto your hands, inside your gloves with each
compression, the next minute, you are inserting a chest drain into someone
else.
By day break, the new team arrived
to relieve us. While I remained vigilant throughout the night, I had difficulty
staying awake during morning ward rounds. The type of fatigue that sees you
rewrite orders five times because they are illegible, and no my notoriously bad
handwriting had nothing to do with it. I got home safely and crashed in my
surprisingly inviting tiny single bed.
This was
quite a test – physically, mentally, emotionally, and professionally – but one
which I am glad to have passed according to my personal standards. Medical
students fight endlessly with doubt on their unsteady road to learn the
incredibly complex and vast art of medicine. Earlier this week, the smile of a
patient I first assessed on December 1st reassured me and confirmed that
my time and efforts will make me a competent emergency physician. He had four
holes in his heart.
The road is
long, the cost is high, but I was built for this.
The
woods are lovely, dark and deep,
But
I have promises to keep,
And
miles to go before I sleep,
And
miles to go before I sleep.
-
Robert Frost
Yours
truly,
TF
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