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Khayelitsha

The last decade, crime rates have increased in Cape Town, while in the bigger South African cities, including Johannesburg and Durban, a downward trend can be seen. In Cape Town, 69 inhabitants per 100,000 were murdered in 2017, a significant and astonishing increase when compared with 2010, when it was 42 per 100,000. [1] Violence takes place mostly in the townships and the informal settlements east of the city centre. The biggest township in Cape Town is Khayelitsha. In 2011, this fast-growing township had approximately 400,000 inhabitants. Khayelitsha is also known for its large proportion of unemployment (38%), and the majority of the people live in shacks, with 74% of households existing on a monthly income of less than $220. [2] Khayelitsha is considered a dangerous township because of the activity of gangs, murders, robberies, and the use of alcohol and drugs such as ‘tik’ (amphetamines) and ‘whoonga’ (cheap heroine which is smoked).[3] Approximately 16% of traumatic injury is caused by gang-related violence. [4]

Khayelitsha has one district hospital that was founded in 2012. The hospital is equipped with a 24-hour level-3 emergency service. Almost 40% of the patients in the resuscitation room have trauma-related problems. [5] Trauma occurs mostly during the nights in the weekends and especially when it is ‘pay day’, the day that salary is handed over and people start drinking alcohol, using drugs and stealing. The busiest shifts in the year take place during the weekend before Christmas, when the number of patients arriving can increase to 50 cases in one night, the majority of which consist of penetrating trauma of the thoracic region. This includes many stab wounds as well as gunshot wounds. [6,7] I was personally a lot more exposed to out-of-hospital cardiac arrests in children and infants than in my own hospital, including a very striking case of a victim with a lacerated trachea.

Dutch emergency physician

I spent the final phase of my residency in South Africa. For me as a Dutch Emergency physician (EP) in training, an internship in Khayelitsha District Hospital in Cape Town was valuable for gaining skills in resuscitative procedures because of the extensive exposure to traumatic injury, in particular the treatment of penetrating traumatic injuries (i.e. thoracocentesis, intercostal drainage of a pneumothorax or hematothorax, pericardiocentesis, airway management, paediatric trauma, traumatic arrest and ultrasound in trauma). However, the practice in Khayelitsha is different from Dutch practices. I learned three major lessons at this hospital.

Shared responsibility?

The first one is about responsibility. An important difference between the practice in the Netherlands and in South Africa is the degree of independence of a doctor working in the Emergency Room (ER). In the Netherlands, the decision to perform a major intervention will be discussed in larger teams with representatives and supervisors from different acute specialties such as anaesthesiology, intensive care medicine and surgery. Responsibility is shared with supervisors, who are medical specialists. The Dutch EP is accustomed to sharing responsibility, and this is often documented in protocols.

In South Africa these decisions are made by the individual doctor working in the resuscitation room, and this requires thorough knowledge, skills and competence. An EP or senior resident in emergency medicine available at the ER for direct supervision. These are involved only in complex cases, and they expect the doctor working in the resuscitation room to solve the majority of the cases by himself. They give a foreign doctor the responsibility to treat a patient completely independently. This means that you provide the indication to start a procedure, know the contraindications, understand the preparation and deal with complications, even if a patient is in haemorrhagic or obstructive shock.

During my visit, the number of patients in serious shock was high. This was an unexpected challenge that I never thought about before starting this internship. To be responsible for the initial treatment of a life-threatening injury takes more than the capability and competency of performing a lifesaving procedure. It is quite an experience to be faced with the most severely injured patients from stab wounds, shootings and burn wounds in large numbers within short time spans. It is mentally challenging. Treating one patient while two other patients are rushed into the resuscitation room with comparable injuries requires a coping strategy. You need someone at home to share your experience after a hectic shift. And maybe you should share the experience again later.

For me it also helped to realize that the causes of the patients’ problems can be sought in the greater social problem that exists in the townships of Cape Town. It is part of daily life. On a medical level, it was also challenging. I remember a patient in the resuscitation room who was visibly distressed and excessively sweating after a stab wound of the chest. The patient had a precordial sucking chest wound located on the sternum without signs of decreased breathing sounds in the left or right lung. Vital parameters remained stable without signs of haemorrhagic shock. After point-of-care ultrasound a hemopericardium was excluded. An immediate decision on management of the patient was required. Is it acceptable to perform imaging of the chest with the accompanying delays, or does immediate intercostal drainage need to be performed at the injured site or on both sites?

Who gets the blood?

The second lesson is about dealing with scarce resources. The number of emergency blood units is limited. Intraosseous needles are present in small numbers. Syringes can suddenly be used up. EPs have to deal with out-of-stock running medication and medical equipment. An unlimited supply cannot be taken for granted, and health care workers need to be thrifty with the amount of equipment and medication. There are six units of blood ready for use while in some situations more blood is needed for traumatic injuries. Limited resources put limits on medical treatment.

The third important lesson to learn is related to the first and second lesson: critical decision making with these limited resources in mind. The idea is that wasting a limited supply on a hopeless case with little chance for survival negatively impacts other patients with better chances. In such situations, the individual EP plays a prominent role in deciding to stop treatment, causing the patient to die. These decisions also differ from Dutch practice. In the Netherlands, treatment is never stopped due to limited equipment, and blood products and vital resources must be available. The process for stopping treatment if there is little chance of success is also more elaborate. As a Dutch doctor, it was difficult to see drastic decisions being taken in such a short period of time, especially if it involved a young patient. And it was precisely the age group around 18 years old that were brought in after stabbing.

Room for innovation

But my experience in South Africa also opened up opportunities for smart ideas and innovation. Instead of using expensive blood products such as fresh frozen plasma, freeze-dried plasma is used in South Africa. This limits the use of blood units so they can be used for subsequent cases. [8] In Khayelitsha, the views on trauma and massive blood loss are very modern. No crystalloid fluids like normal saline are given to the patient. Instead, tranexamic acid (TXA), emergency blood, and plasma are supplied. During a traumatic arrest there will be no thoracic compressions, but the acronym ‘HOTT’ (i.e. hypovolemia, oxygenation, tension pneumothorax and cardiac tamponade) is used. Hypovolemia due to blood loss is treated with mass blood transfusion. Oxygenation is treated preferably with bag mask ventilation. Tension pneumothorax requires direct relief or intercostal drainage. And cardiac tamponade is treated by a resuscitative thoracotomy. [9]

During mass blood transfusion, we used a maximum of two units of emergency blood, and more units of freeze-dried plasma could be supplied until an acceptable state of perfusion was reached. After a haemothorax, blood that was collected by an intercostal drain was returned to the patient immediately. The chest tube drainage system contained an intravenous access point. This makes autotransfusion possible. And with the help of a glove and the longest and thickest intravenous needle, you can prepare a one-way valve thoracocentesis device to relieve a tension pneumothorax. In case of a sucking chest wound that was caused by a big laceration in the thoracic wall, we applied a plastic sheet which was cut to the size of the wound. The plastic sheet used was from the package of an adhesive plaster. After that, we applied the adhesive bandage on three sides so that during inspiration no free air was sucked into the intrathoracic space.

Conclusion

In conclusion, it seems that the most important learning goal is not the skill itself but the bigger picture. Practicing a resuscitative skill in South Africa also involves understanding the clinical context, daring to make a decision by yourself, and taking responsibility for this decision. The transition from the Dutch situation to the South African is a big one, but in view of the large number of critically injured patients, the contribution made by foreign doctors is very important. In the first half of the internship, I needed more support and supervision, but after treating more patients I became more independent. In cases where I felt the need to consult a senior clinician/EP, there was always the possibility to do so. After a few weeks, I was able to work on my own with help from the nursing staff, who were very suitable and well educated for the job at hand.

References

  1. Crime statistics 2017/2018 South African Police servic-es. Available at: https://www.saps.gov.za/services/long_version_presentation_april_to_march_2017_2018.pdf
  2. Strategic Development Information and GIS Department. City of Cape Town; 2011 Cen-sus – Khayelitsha Health District. 2013.
  3. 3May PA, Blankenship J, Marais AS, et al. Approach-ing the prevalence of the full spectrum of foetal alcohol syndrome in a South African population-based study. Alcohol Clin Exp Res. 2013;37(5):818-30.
  4. Meijering VM, Edu S, Navsaria P, et al. Spectrum of intentional injuries in the juvenile population treated at a level one trauma centre: a South African perspective. S Afr J Surg 2017;55(2):61-62.
  5. Hunter LD, Lahri S, van Hoving DJ. Case mix of patients managed in the resuscitation area of a district-level public hospital in Cape Town. Afr J Emerg Med. 2017;7(1):19-23.
  6. Schuurman N, Cinnamon J, Walker BB, et al. Intentional injury and violence in Cape Town, South Africa: an epidemiological analysis of trauma admis-sions data. Glob Health Action 2015;8:27016.
  7. http://www.stemlynsblog.org/englishman-south-africa-robert-lloyd-st-emlyns/. [Accessed: 7 Jan 2019.]
  8. Van PY, Holcomb JB, Schreiber MA. Novel con-cepts for damage control resuscitation in trauma. Curr Opin Crit Care 2017;23(6):498-502.
  9. Smith JE, Rickard A, Wise D. Traumatic ar-rest. J R Soc Med. 2015;108(1):11-6.