This year we took our family Easter holiday in Southern Africa. Twelve amazing nights in Namibia followed by 3 in Cape Town and then (rather unexpectedly owing to a broken aircraft) 2 nights in Johannesburg. Holidays are clearly family time and we are usually very disciplined about this, but whilst in Cape Town I was invited out by the #BadEM1 team for an insight into South African emergency medicine.
Kat Evans and Craig Wylie showed my around Mitchells Plain hospitals and then we met up with Jo Park-Ross at the V&A for a meal and a chat. I was incredibly grateful for their time, energy and hospitality in showing me round. Kat and Craig were not planning to be at work and Jo was coming off a night shift so thanks ++, you really didn’t have to and I’m very pleased that you did.
If you want to know what working in a township hospital is like when busy then take time to read Robert Lloyd’s blog on his experiences at Khayelitsha hospital. It’s one of our most read blog posts and with good reason, outlining the shock and psychological challenges of a UK trained physician getting their first exposure to South African medicine, seriously, if you’ve not read that post then do so now, it’s incredibly candid and informative.
So here we go. In no particular order these are my recollections of a very brief but fascinating insight into the truly outstanding work our South Africa friends deliver.
Where & when
Mitchells Plain is a township to the South East of Cape Town with roughly 400,000 residents, but the hospital has a receiving population of around 750,000 as a result of large neighbouring areas that link into the hospital. SA healthcare is a mix of private and public but in the townships the major provider is the district general hospital at Mitchells Plain. There are reasonably well defined geographical boundaries for access and so the hospital is linked to it’s population reasonably closely. It is not a designated trauma centre (that’s Groote Schurr in Cape Town) and it does not have an ITU on site. I visited on Good Friday on a quiet day. Driving in through the security gates on a beautiful day in Cape Town the hospital is beautifully set, recently built and loks like something from a movie, perhaps in America. There has clearly been a lot of investment in infrastructure here and despite the rather ominous gates that can lock down the hospital in the event of an onsite incident it looks like a great place to work. This does feel like a community hospital with some amazing artwork within the public areas designed and created by the local community.
The hospital is linked to Mitchell’s Plain Community Healthcare Centre which has a 24/7 emergency centre. We also visited the Heideveld Emergency Centre hub which is effectively a stand alone ED with no onsite specialities. Hold that thought as we’ll be back about that in a minute.
Clean, bright, secure.
First impressions are always important and to be honest I was first struck with how clean the clinical areas were. How well organised the equipment around bed spaces was and how well the staff appeared to look after the equipment. To be totally honest it looked cleaner and better organised than my department in Virchester. That might be because Mitchell Plain hospital is pretty new, but we all know that this cannot be the only reason. It’s down to culture and values and I was impressed. Security was clearly in evidence both in terms of personnel but also with high security gates onto the site and into the ED (it’s not unknown for patients to be assaulted and for attempted murder to take place in the hospital).
The 8am handover was led by one of the junior doctors and would be familiar to many Emergency Clinicians across the world with a few differences. I liked the juniors leading the handover, it worked well and I think was empowering, we do ask our senior trainees to do this, but perhaps we should encourage our juniors too. With a good structure it should work well. What was striking was the small number of doctors coming onto shift. Just one consultant (@kamilvallabh who was on call from home later, and who very kindly took us round the department and cases), one registrar and two doctors in their first 3 years of training. Considering the patient load, severity and complexity of patients in the department this made me stop and think about how lucky we are in the UK. Yes we have tough staffing and lots of gaps on rotas, but this was a reminder that much of the world would look at our rosters with envy.
I loved the fun fact of the day during handover, led by the middle grade on duty. It’s always fantastic to see education being built into any transactional process in the ED and this works well. We briefly discussed this paper on the impact of peppy comments on shift activity2.
Consultant numbers are pretty low as compared to the UK and thus they still work a more traditional on call system out of hours. Interestingly phone advice for trauma is pretty low as the junior team are so well experienced in treating them, it’s more common to get called about medical, paediatric and toxicological emergencies. For example decisions around ECGs and thrombolysis are more common than a thoracotomy (you would not get called for a thoracotomy). There is no PCI here, it’s thrombolysis with Streptokinase here, something I’ve not used for perhaps 20 years in the UK.
Some differences were sobering. We don’t routinely discuss the number and type of deaths overnight as we don’t get that many, here it’s usual and expected. Similarly the conversations around the number and severity of trauma injuries and deaths is frightening. We also discussed the large number of mental health patients in the department, roughly 30 of them if I remember rightly, in fact they were pretty much everywhere and certainly within the area we were taking the handover.
— Kamil Vallabh (@KamilVallabh) April 14, 2017
Mental Health patients
As mentioned at handover I saw vast numbers of mental health patients in the ED. This was a result of the difficulty of getting access to psych beds (same as here) but also the sheer load of mental health problems in the townships as a result of drug use. This is predominantly Crystal Meth (known locally as tic) induced psychosis presenting to the ED in a whole variety of ways. This places a huge burden on the ED as (same as Virchester) access to in patient psych services is limited and to be honest, most of these patients recover as the drugs wear off. it was noticable that it was…..calm….., much calmer in the ED here with 30+ psych patients as compared to my own ED with just a handful. The reason was pretty simple, the docs here sedate patients as they await more formal assessment. Patients get benzos/VitH whilst awaiting assessment, they also get a damn good sleep (which is therapeutic) and build a more gentle relationship with the security guards. As an aside, it’s worth giving ourselves a moment to reflect on just how much care security teams give to ED psych patients across the planet. They clearly spend more time with the patients than we do and I don’t think we acknowledge that enough. On reflection it’s interesting that I noticed this when visiting here, perhaps I have normalised it back home and I need to change that blind spot – the bottom line is that we could not do our job without the security team.
Psych patients frequently spend a long time (days) in the ED and so there are rooms with mattresses on the floor where they sleep. It’s basic but clean and appears to be working well. Interestingly all the psych patients are put into uniforms with ‘MPH’ for Mitchell’s Plain Hospital written across the back of them for all to see. i must admit that I initially misread this as MHP (Mental Health Patient) but that probably reflects my own biases. The patients and staff seemed unfazed by this labelling, so is this normalisation that would probably be rather unusual in the UK. It’s unclear, but compared to some EDs I’ve been in within the UK where access to psych support is challenging this appeared to work (better).
Limitation of Treatment
The #FOAMed world has really led on challenging us to think hard about limitations of treatment in the ED and the critical care unit. I’ve listened to colleagues from around the world and have frequently been struck by how the threshold for intervention is influenced by a complex mix of culture, pathology, tradition and resources. Sitting in Virchester it’s easy to think that you understand this, but it’s theoretical. Here it’s real. Mitchell’s Plain does not have an on site ITU and thus access to level 3 care is really limited and requires a transfer out to another hospital, where critical care beds are similarly resource limited. Easy to say, easy to document and as an abstract concept it’s fine and understandable. The reality is much harder. Whilst visiting a young lady in her 40s arrived in a critically unwell condition. Really unwell. Like a terrible acidosis with pH of 7 unwell and a lactate of 14. In Virchester this would be an all out, high level resuscitation case with the mobilisation of people, kit and a clear move to critical care. In SA that’s not possible for all, and for those patients with active HIV and TB there is no possibility of access to higher level care. This lady would get fluids and antibiotics but in reality her chance of survival without critical care would be close to zero. For me, a clinician based in a major UK teaching hospital the idea of this level of treatment limitation, actually seeing it happen in the reality of an emergency department was realy tough and yet our colleagues here in South Africa, and across most of the planet do this every day. For me, this moment of reality check brought home to me just how lucky we are in the UK.
Trauma, trauma, trauma
Robert’s post on his experiences at Khayelitsha hospital talked about the enormous trauma burden in the townships. These district general hospitals in the townships are seeing more penetrating trauma than any UK major trauma centre. Much more. Stabbings andd shootings are a daily occurence in the townships and thus the department is full of patients recovering from the violence. Penetrating injuries to the chest are incredibly common, unlike the UK these patients are evaluated with chest X-ray and USS rather than contrast CT, with many being managed within the ED. A simple haemopneumothorax will get a chest drain and an admission to the ICD ward. Yes, there is an ED ward (not an in patient facility) that simply manages patients with traumatic chest drains.
Patients are kept in chairs (no beds) and are encouraged to exercise on spin bikes at the end of the ward to improve lung function, physio and recovery. Perhaps unsurprisingly the ward was all young men with single or even bilateral chest drains in situ. It was surreal really. All these patients would be on the HDU back in Virchester, in a cosy bed, with teams of doctors, nurses and physios to look after them.
Check this incredible video of how the docs and nurses of Mitchell Plain are making a difference. Watch this and reflect on how amazing these clinicians are. Raisa and her colleagues are amazing: They really do magic.
Thoracotomies are common events and would typically be managed by the junior staff who are clearly more competent and experienced at them than I am. Again I was struck by how clean, well organised and streamlined the resus set up was. There is clearly much to take home on making things work.
With a very young population it’s no surprise that paediatrics forms a large part of the workload. Much of the work is recognisable to us in the UK with respiratory and gastrointestinal disease, but there is also the trauma, the burns and a fair workload of obstetric/neonatal emergencies presenting to the ED. A separate paeds area deals with these, again well organised and close to resus (though most kids are dealt with in the paeds area rather than the main resus).
A stand alone ED
After Mitchells Plain we drove out to a stand alone ED in the heart of the township. This is not something I would recommend unless you really know what you’re doing. Of course I had no idea what I was doing, but I was with Craig and Kat so felt safe…. up until the point when Kat said ‘Do Not go down here….’ to Craig as we drove around some of the flats. We were fine. The stand alone ED is apparently a legacy of institutional change but again was an insight into the challenges of EM practice here. In the heart of the township this facility has a resus, assessment areas and a co-located ward for medical and surgical patients.
The severity of patients here rivalled those in the main hospital and again we saw trauma patients with ICDs in situ completing their entire treatment process within this facility. Staffed by junior docs and with no onsite consultants for much of the time this unit sees more trauma than many UK major trauma centres. it felt risky from a safety point of view (Ijust to get there) but also clinically with such junior clinicians treating severely injured and ill patients with far less on site support than we would be used to back in the UK. We talked about those challenges as it’s no surprise that not everything goes well all the time. Mistakes are made (as they are everywhere) but the way error is handled is reflective of what can reasonably be achieved and not what might be possible in a perfect world. I saw a little of this in the discussions with a junior doctor about the management of a patient who died in the ED. The feedback was open, fair, honest and kind. I did not get the feeling of blame that would almost certainly be apparent in our system where incident forms and interspeciality rivalries push us away from a learning culture towards a defensive one. I did not get that feeling here.
I did not go out with the ambulance crews but the conversations with Craig revealed an incredibly challenging and difficult world where violence both witnessed and received is common. There is a real difference between the state ambulance service and the private firms like ER24. The standards and scope of practice amongst the paramedics is incredible and I’ve no doubt that they would put me to shame in trauma resuscitations. It’s tough though. I heard many stories of burnout amongst prehospital and hospital providers working under the constant stress of an incredible clinical workload. It made me reflect on how the phrase #ratherbeinRESUS is used in the UK. Sure, we all like being involved in the big cases and there is no doubt that in some areas we don’t have the right balance, but it’s also clear that it’s damaging to spend your whole life dealing with violence and tragedy. We need to be mindful of this and so it was reassuring to hear how the @bad__EM team are working hard to promote understanding and action around mental health. The video below gives some insight into the realities of #toomuchRESUS
Final thoughts on voyeurism, names and reality.
A few weeks after visiting South Africa and meeting the truly inspiring team from @__badEM I am still processing the briefest of visits. In principle I am always mindful of people like me dropping in to other countries health systems to pass comment, or to get a taste of what it’s like in a less well resourced system. There is always the risk of a degree of medical voyeurism here, it’s fascinating to visit and perhaps arrogant to compare and contrast when we can simply get on a plane and go back to the better resourced world of the NHS. That’s not what I wanted to do and I hope that this blog did not come across as this.
Perhaps the experience was encapsulated around a discussion we had about the @bad__EM name. The team told me that they had received some criticism for the name as it suggests that EM in Africa is bad. Of course you will know that bad stands for Brave African Discussions and that, for me, is the overriding summary of the experience. The patients, the staff, our fellow emergency physicians, paramedics and nurses are brave. The environments they work in are tough and that’s obvious. What’s not immediately obvious is the bravery required to make the decisions that working in Africa require. Brave African Discussions seems to fit well with what the @bad__EM team is achieving and I am left with such a high level of respect for what they achieve.
I left with an even higher feeling of respect for our SA colleagues. I’ll be back in October for the EMSSA conference in Sun City to talk about decision making and the challenges of an increasing incidence of diseases of affluence amongst some parts of the population. I can’t wait.
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