Time in rural South Africa as a UK trainee. St Emlyn’s.

Stemlyns rural South Africa

Imagine if you will, a hypotensive alcoholic with active haematemesis and melaena, something they taught us in medical school, earning its own place in OSCEs and even a page in the cheese and onion.1 In fact, you think as you look at the patient being wheeled in, it’s a mirror image of the last patient you saw back in the UK. Plan; Involve the ED consultant early, 2 big IV lines, massive transfusion protocol, terlipressin, ITU support and straight up to theatre for an emergency OGD. If yes, then well done, excellent job.

But let’s crank things up a notch. How about, you’re the only doctor here, we can only get a pink in, there’s three units of blood for the whole hospital (and you just sent an ectopic to theatre), no terlipressin or ITU, and the nearest endoscopy suite is two hours down the road… Oh and let’s throw in a blood gas.

A note on St.Emlyn’s clinic cases here.

It was these sort of practical conundrums that made me realise how far away I was from the rainy shores of the NHS and its comforts that we take for granted. I, like many other junior doctors, had opted to step off the training ladder after F2 and venture elsewhere to broaden my personal and professional horizons (although some would call it running away).

Whatever you call it of course, there can be no denying that it is an increasingly popular trend. The strain on the NHS, winter crises becoming summer crises, and the junior doctor contract debacle have all taken their toll. A recent BMA survey revealed that more than half of junior doctors are taking time out of training, and that emergency medicine trainees report the lowest enthusiasm for working in the NHS.2

Our consultants tell us tales of hop, skipping and sampling between multiple specialties before eventually settling on the one they enjoyed the most. However, we are ever more being pushed to get to consultancy in the least possible time, and training feels increasingly squeezed in exchange for more time at the coal face.

The rise of the F3 generation has been embraced by some places, with a number of specially designed Trust grade posts popping up, best demonstrated by the Bangor Mountain Medicine project2. However, many end up heading (fleeing) abroad, with 75% going to Australia or New Zealand3.

But for those who want to try a different type of medicine, South Africa is often the destination of choice3,4. You may be familiar with Rob Lloyd’s description of his incredible and often harrowing time in Khayelitsha Emergency Department in Cape Town 5. Short postgraduate electives in cities like this are usually voluntary,  but there are longer term paid positions available. These tend to be in rural areas, where the posts are unable to be filled by South African doctors. On average, Africa Health Placements have helped over 100 British doctors take up a job there every year.6

So why should a junior doctor brave the long (18 months to get a job offer and a visa), winding (I was surprised I had any hair left by the time we arrived) and expensive (several thousand pounds in various costs) road to work in South Africa?

For myself and my partner, it was the once in a lifetime chance to experience something truly different. The learning was more vertical than curved, but we were amazed by the gross pathology that comes with HIV, TB, poverty and vicious indiscriminate trauma. Gladly, we don’t see many truly sick young people in the UK, so having so many under our care was both nerve wracking and extremely rewarding when they got better.

With these presentations, came opportunities for multiple procedures; complex suturing, chest drains, lumbar punctures, ascitic drains, central lines, incising and draining abscesses (often ones that would be done in theatre at home), sedation, intubations and umbilical lines. Even basics like doing PV exams (often withheld from male students and ED doctors alike at home) became a good learning opportunity.

Of course, the mantra “see one, do one, teach one” is very literal there, and it is easy to find yourself  in the deep end beyond your competence. The premise of “first do no harm” can be exceedingly difficult to balance when considering a risky procedure, with which you have little or no experience, but the patient really needs and there is no one else available. It hones decision making skills and keeping calm under pressure, but it is important to realise it does not mirror what you may do when back in the NHS, lest you end up on the Dunning-Kruger mountaintop.

While you generally get a preference in what specialty you will cover, you are put where the hospital needs you most. This means often covering areas that you are unfamiliar and less comfortable with. I worked in the outpatient department seeing a mixture of emergency and primary care, meaning I could go from adjusting hypertensive medications to dealing with a stabbed chest back to PV bleeding and finally diagnosing cryptococcal meningitis before the morning had finished. But at different points in my year, I was responsible for the nursery, paediatrics and surgical wards. Other hospitals expected doctors to cover obstetric theatre cases on call, meaning either doing caesarians or the anaesthetic, which we felt lucky to avoid. This variety of daily practice can be on a scale from invigorating to terrifying, but is certainly a beneficial experience for those wanting to go into EM.

Lack of diagnostics made clinical examination and history key to management. On any given day you wouldn’t know what you might be lacking when you arrived; drugs, fluids, blood, oxygen, X-ray, lab tests, USS, blood gases, phones, water or electricity. Even the nurses sometimes seemed to all disappear simultaneously. The only thing in abundance were the patients. I once saw 70 (mostly pretty minor) patients in a day.

This lack of resources led to ingenious problem solving at every turn. Got a pleural effusion but your only option is a 32 French with no Seldinger drain? Substitute with an orange cannula, plumbed into a giving set and then a catheter bag. No NIV or ventilator? Put them on nasal prongs and a non-rebreath mask both at 15L/min. No manometer for your LP? Mark the centimetres on a giving set, attach to the needle and hold vertically. No nasal atomiser? Find a cannula and some oxygen tubing?7

The rural hospitals are usually under staffed and relatively over run (hence why foreigners can be employed). This can lead to a lack of senior support and extra help when you need it the most. Again this is a double edged sword; it can be enterprising to take decisions about patient care that you wouldn’t at home, but when the decisions are stacking up, the odds increasing and the resources limiting, they weigh heavy.

As often the only doctor in the department, I would have to decide who was seen next, who should wait, who gets a prized stretcher, who gets the valuable unit of blood, who should I invest more time into, who is asked l come back next week, and most importantly, when can I sneak away for lunch without being lynched. These were in addition to the clinical questions of deciding what was wrong or indeed how to treat patients. It sometimes felt like a terribly designed crash course in being a middle grade and a consultant rolled into one.

For all of the extra effort, we saw a much higher proportion of genuinely sick people than we did at home, and actually felt like we made much more of a difference every day. I came to realise that the educational value for me personally was not the pathology and procedures, but rather the extra “grown up” responsibilities, and the recognition that doing the basics well saved lives on a daily basis. Knowing the renal dosing of antiretrovirals probably won’t come in handy too much back home, but knowing what a septic infant looks like and when to give it a fluid bolus, certainly will.

There were of course downsides to working in a middle income country. I saw more children die in my time there than I hope to see in the rest of my career. Terrifying moments seemed to pop up with alarming frequency, the pinnacle being inserting a chest drain (only my third ever) into a peri-arrest seven week old baby at two o’clock in the morning. Or possibly having to perform a ventricular tap on another with hydrocephalus. There may be debates about the pros and cons of the EU working time directive, but we missed it when doing our 30 hour on call shift every week.

We often found that many of the basics of the hospital could be improved upon, and this led to quality improvement projects that, for a change, actually did just that. A lot of patients were left hypoxic on the ward. The answer? Buy some saturations monitors and teach the nurses how to give oxygen. Triage was running poorly and we were missing target times to see patients (sound familiar?) So we redesigned the triage forms and ran workshops with the nurses. There were of lots of poorly controlled diabetics, so a multidisciplinary clinic was set up to coordinate their care better. All of these were sustainable and have continued after we left.

We also passed on knowledge that we might otherwise take for granted to our fellow doctors and nursing staff, and vice versa, through teaching programmes. While we had a lot to learn about infectious diseases, we probably had more experience dealing with non-communicable diseases in an ageing population. Several of us presented our work at international conferences or got a publication. In short, a lot of opportunities to bolster both the hospital and our application portfolios.

I should also mention that South Africa is an incredible country to live in. We enjoyed amazing beaches, fantastic safaris, world class diving, hiked in the beautiful Drakensbergs Mountains and had great Braiis with new lifelong friends. (Did I mention that I am writing this blog from a hammock in the middle of the Kalahari?)

On our return to the NHS in August I will feel a new sense of awe and appreciation that I could not have fathomed without stepping outside of its borders. I would hope that all of us who have worked out here will come back more rested, experienced and motivated to get on with the next step in our training. How many people continuing non-stop through their training could honestly say that?

If I were to do this all again, my wish list would include a clearer application process and timetable, maybe someone in the deanery who was on my side, some extra training before I went, a group of like minded people also going, some more supervision whilst I was out there and perhaps even some kind of recognition of my efforts when I returned to my training programme.

But hang on, someone has already done that you cry!

Yes, GPs have been sending Global Health Fellows to South Africa for a little while now8.  Excitingly, I recently spotted the first of what I hope to be many EM Global Health Fellow posts advertised 9. Once again, I hear Bangor have something similar in the pipeline, and fantastically the new RCEM Global Health Committee hwill hopefully be helping more similar programmes develop. It isn’t clear at what stage in training would be best to go abroad, and I think this would be a good topic for them to discuss.

I cannot emphasise what a fantastic opportunity working abroad is, and I think it is something that the Emergency Medicine community in the UK should really try and help grow. The benefits are their for trainees, the NHS and of course the population they go to help. To any grumbling consultants, training programme directors or managers worried about sending your trainees away; they are going anyway, this will make them happier, better doctors and more likely to come back to you rather than staying on a beach in the antipodes.

So my take home points for those of you thinking about taking the leap:

  • Start your planning early (minimum of 18 months before you want to go)
  • Research thoroughly and talk to as many people as possible
  • Be open minded
  • Give something back (teaching/meaningful QIPs/sustainable positive change)
  • Enjoy it!

P.s. what happened to the patient with the variceal bleed?

We had some oxygen, a femoral line placed with landmark technique (no USS/IO), 1L fluid, 1 unit blood, 2 units freeze dried plasma, tranexamic acid, vitamin K, calcium gluconate, insulin/dextrose, sodium bicarbonate, antibiotics, and this was his repeat blood gas before we loaded him onto a helicopter.

And who wouldn’t want to work in South Africa when your critical care transfers could look like this? 🙂

vb

Chris Wearmouth

@ccwearmouth

References

1.
Oxford Handbook of Emergency Medicine. Amazon. https://www.amazon.co.uk/Handbook-Clinical-Medicine-Medical-Handbooks/dp/0199689903/ref=dp_ob_title_bk. Published 2018. Accessed 2018.
2.
Bangor Mountain Medicine. Bangor Hospital. http://www.mountainmedicine.co.uk/. Published 2018. Accessed 2018.
4.
Life as an EM trainee in South Africa. St Emlyn’s. http://stemlynspodcast.org/e/life-as-an-em-trainee-in-south-africa-postgraduate-electives-and-more/. Published 2018. Accessed 2018.
5.
Lloyd R. An Englishman in South Africa: Robert Lloyd at St.Emlyn’s – St.Emlyn’s. St.Emlyn’s. http://stemlynsblog.org/englishman-south-africa-robert-lloyd-st-emlyns/. Published 2016. Accessed 2018.
6.
Africa Health Placements. Africa Health Placements. http://ahp.org.za/. Published 2018. Accessed 2018.
7.
Evans          Kat, Stassen          Willem. Nasal atomisation without the device – 5th place – AfJEM resource innovation competition 2015 – #badEM. #badEM. https://badem.co.za/nasal-atomisation-without-the-device/. Published 2015. Accessed 2018.
8.
Global Health Fellowships (GHF) . GHF. https://gprecruitment.hee.nhs.uk/Recruitment/GHF. Published 2018. Accessed 2018.
9.
Global Health Fellowship OOPE. Health Education England. https://heeoe.hee.nhs.uk/node/3877. Published 2016. Accessed 2018.

Thanks so much for following. Viva la #FOAMed

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