The HCA International Foundation Travelling Scholarship 2009 report: Surgical Fellow, The Trauma Unit, Groote Schuur Hospital, Cape Town, South Africa, J Cleo Oliver MBChB MSc MRCS (Eng)
Introduction
Devils peak looming over Groote Schuur hospital, Cape Town
I would like to thank the trustees for the award of the HCA traveling fellowship which covered some of the expenses for my rotation to the Groote Schuur Trauma unit. This provided me with a phenomenal experience of the initial management of patients with major trauma, and the surgical care of these patients.
Preparation
The organization for this trip started over 2 years in advance when I traveled to Cape Town to teach on their ATLS course, and make contact with the head of the department of surgery.
Arranging medical registration and a work permit involved endless paperwork and red tape, and I am very grateful for the support and encouragement of my Parents through this process, and to Mrs Y Kannemeyer, secretary at the department of surgery for useful tips at negotiating the Health Professions Council of South Africa.
Daily Life
I am grateful to my parents who arranged my accommodation for the duration of my stay in a safe complex in a central suburb filled mostly with foreigners. Despite having previously arranged accommodation, my first week was still a little overwhelming when I had to arrange a bank account and buy a car in a strange city with few contacts, but as is the South African reputation, everyone I met quickly became a close friend and I was carefully guided through the complexities of this city which at first glance is very developed but has many quirks that are only found in the developing world.
Trauma in South Africa and The Groote Schuur Trauma Unit
Unfortunately despite great improvements over the last few years, South Africa still has the highest global levels of penetrating and blunt trauma, as well as low velocity gun crime. Within the Western Cape, this trauma is mainly restricted to the townships of the cape flats where the Coloureds and the Africans were relocated during the Apartheid regime. The penetrating crime is coordinated by gangs which exist both in the townships and the prisons. Gangsters can be identified by distinctive black tattoos on the arms and torso. The gangsters have a long history and their skills in inflicting injuries are often very precise.
The quality of emergency care for the non fee paying patient in the Western Cape is exceptional and even many doctors would choose the government hospitals over private hospitals in the emergency setting.
The trauma unit at Groote Schuur was lead by Prof Andrew Nicol with his associate Prof Pradeep Navsaria and 2 more consultants and a senior fellow, who rotated every 6 months. All the staff have a tough reputation as teachers but are supportive and well published and recognized around the world. All trauma patients bypass the emergency department of Groote Schuur hospital and are assessed by the trauma staff. The admissions area (known as the “Front Room”) is divided into a minors area, Trolley bays, and Resus with space officially for 6 Ventillated patients, although on a busy weekend at the end of the month this was usually filled to way beyond capacity. Registrars in all surgical subspecialities training through the University of the Western Cape must spend at least 3 months working on shifts in the Front room. I spent my first 3 months here. Learning skills such as leading the trauma team, endotracheal intubation and the surgical airway, Central venous access and venous cut down – all skills I’d taught on dummies in the UK during the ATLS course. But here was the first time that I’d been able to do this for real.
The front room nurses decorating the department on a rare quiet night shift
I found this period very traumatic. Every patient has their own tale of woe. The only way to effectively treat a trauma victim is to prevent the trauma, and coming from a society who has effectively reduced the levels of trauma to a minimum with effective implementation of strict public health policies, my role patching up the victims only for them to return the next week, month, year seamed a futile effort. For the first time I really saw that if I wanted to make a real difference I would quit medicine and move into politics.
Fortunately after three months I moved to “The back” where I became the “Cutting Registrar”. We worked a 1 in 3 on call however each shift on call there were 2 registrars, the first on call would review all the patients to decided which needed operating, the 2nd would only be woken to operate, giving maximum surgical exposure. When we weren’t on call there was very little clinical commitment after the daily consultant teaching ward round from 8.30 to 9.30am of all the patients which may or had needed general surgical operations. Research was encouraged during our time not on call.
Surgical Experience
There was no elective surgery as such within the trauma unit, but during the day there was a dedicated trauma theatre where I was involved with the management of stable vascular injuries including the repair of several traumatic a-v fistulas. Frequently relook laparotomies were required for the patients who had undergone damage control laparotomy overnight. Skin grafts and closure of stomas were also perfomed.
Overnight, the commonest procedure was the trauma laparotomy, or arterial repair for ongoing bleeding or a threatened limb – however this was greatly reduced by the use of the foley catheter, a simple innovation from Groote Schuur, now used extensively across South Africa, especially after penetrating neck trauma.
I also gained experience of the front room thoracotomy, performing 3 myself and assisting in 2 further procedures. Overall my logbook for this 6 months includes 123 procedures, including 41 trauma laparotomies and 19 peripheral arterial explorations.
Other Experiences
In my final 2 ˝ months in South Africa, I moved to George, a small Afrikaans town, 5 hours drive from Cape Town. Here I had an amazing opportunity to experience full “General Surgery” under the close supervision of 3 very experienced consultants. Due to the long travel time to Cape Town, the General surgeons also covered emergency neurosurgical trauma and Burns, so I became experienced at drilling a burhole when indicated on the CT scan, and performing escharotomies, as well as extensive wound management. During this short period my logbook includes 150 procedures.
Out of hospital experience
I used the time living in the country of the Biggest Ultra marathon to extend my running experience. During the year I was able to successfully train for and compete in the 33rd 2 Oceans 56km Ultra Marathon and the 85th Comrades 89km race.
After the 2 oceans marathon with one of the Gold medal winners
And of course no-one could have missed the World Cup 2010. The South Africans created an unbeatable occasion as they took to the streets for the opening ceremony. I hope that London can match the celebrations in 2012
Teaching
In the UK I have been regularly involved with teaching the ATLS and Basic Surgical skills courses, so I became involved with these in South Africa, I also used this as an excuse to travel around South Africa. It was fascinating to see the much greater depth of knowledge of the South African doctors on this course, mostly helped by their experience of the subject matter, but also, because they paid for the course from their own pockets, they took care to read the book!
Research
There was a strong track record for research so I got involved in two retrospective research projects regarding the management of Iliac Vessel trauma, and the use of a temporary shunt in vascular trauma.
Teaching Courses
The Definitive Surgical Trauma Care course is a course aimed at senior surgeons involved in the operative care of trauma patients. It was first established by Prof Ken Boffard, of the Johannesburg trauma centre, and has spread around the world, including to the Royal College of Surgeons of England in the UK. However due to the British restrictions on animal experimentation the UK course does not involve operating on live anaesthetised pigs. I completed this course in Durban, again allowing me a little further travel around South Africa and the opportunity to learn about the practice of a different group of trauma surgeons.
Conclusion
Would I recommend this experience?:- To undertake this experience you need to have a thick skin both physically and emotionally. However the experience I gained is unrepeatable and has provided me with huge confidence both as a general surgeon and in terms of managing the multiply injured patient.
I have learned that trauma is a disease process which is very different from Cancer or cardiovascular disease which afflicts young patients. Its management requires prompt decision making which can be missed by surgeons not experienced in the care of these types of patients. I hope that the commitment to extend the trauma centre care beyond London that was promised by the former government is not forgotten.
Meetings
2010 Surgical Research Society, East London
Pending Articles
- Retrospective review of the management of iliac vessel trauma.
- Retrospective review of the use of the temporary shunt in vascular trauma.