Elective in Trauma Resus and Pre Hospital Care
Emergency Medicine Abroad
Matt Ellington, Year 5 Medical Student, University of Birmingham
As a senior medical student with a long standing and fairly unsuccessful interest in trauma and pre hospital care, I was delighted to be oﬀered the chance of spending 5 weeks doing just that in one of the world’s most dangerous cities: Johannesburg. The Chris Hani Baragwanath Academic Hospital is the world’s second largest hospital and is home to the busiest trauma unit in the world. In just one shift they average as much penetrating trauma as the UK’s busiest centre does in a month.
Despite having attended Pre Hospital Trauma Life Support (PHTLS) and Advanced Trauma Life Support (ATLS) courses as an observer, as well as completing the Undergraduate Pre Hospital Trauma Course in Birmingham; I had always struggled to gain clinical experience. Embarrassingly, my most relevant actualroadside practical experience was couch side, with ‘helicopter heroes’, ‘emergency bikers’ and other day time favourites. I’d had a few observer shifts with the local ambulance service and a pre-hospital charity that had provided very limited exposure to some pre hospital medicine, but overall my knowledge was very much theory based and experience-lacking. It was therefore with great excitement, and type 7’s on the Bristol chart that I headed to South Africa to embark on the trip of a lifetime.
South Africa, and in particular Soweto, sees more trauma than anywhere else in the world. The trauma comes as a mix of blunt trauma (courtesy of some of the worst taxi drivers on the planet), penetrating trauma (guns, knives, broken bottles or anything else to hand) and a seasonal specialty of thermal trauma (winter – kerosene heater injuries, boiling water, oil or chemicals). All of these and more arrived, relentlessly around the clock, totalling around 150 patients per day. Some patients even arrived twice, having been patched up and discharged; one of my favourite patients was re-stabbed within 4 hours! It wasn’t until our second day at the hospital that we were rostered into our ﬁrst 24 hour on call shift. Jumping in at the deep end, my ﬁrst patient, a lady of the gallstones demographic, had been set alight by her ex-boyfriend who had locked the door on his way out. We calculated her to have 60% burns including inhalational injuries. After stabilisation with an endotracheal tube and 16 litres of ﬂuid prescriptions we moved onto the next patient. And the next, and the next. As gun shot after gun shot, car accidents and more than 20 stab wounds came in, I slowly came to grips with the ABCDE systematic approach. Some particularly gory cases stick out in my mind for various reasons. The resuscitative thoracotomy, and a young man successfully treated with mannitol and a decompressive craniotomy stand out as utter marvels of life saving modern medicine. The pregnant (32/40) lady who died of a pulmonary embolus stands out as poor postoperative care due, in part, to staggering patient numbers and a lack of resources in the developing world, resulting in two lives lost. The stabbed abdomen with bowel evisceration and the 60% burns mentioned above, who both went on to pass away during their admission, shocked me with how little humans can respect the life of another.
Pre hospital care
The 8-minute target in which an ambulance in the UK is meant to arrive can seem like an eternity when you are alone with a sick patient and need expert medical help. South African ambulances lag some way behind their British counterparts. The most basic level of paramedic qualiﬁcation, who staﬀ about three quarters of the ambulances, simply have basic life support training. There are very few paramedics trained to the Advanced Life Support level that is so commonplace in the UK. I was lucky enough to have the opportunity to spend a week with the air ambulance covering Johannesburg. However, the logistics of this were strange; the government could not aﬀord to run the service, instead it was run by an insurance company, who funded it through monthly premiums paid by middle and upper class South Africans who could aﬀord private medical insurance. These are exactly the demographics who were unlikely to be shot, stabbed or sustain drunken injuries. This being the case, the service was predictably under-used. Frustratingly, many of the uninsured trauma patients who met the activation criteria for the helimed team were not authorised by the government medical oﬃcer, presumably due to cost. We did however, attend a number of scenes (which were mainly blunt trauma) and also complete a number of inter-hospital intensive care transfers. I thoroughly enjoyed the challenge of taking lifesaving medicine out of a nice, warm, well lit resus suite and onto the roadside, exposed to the elements and dangers, the absence of which we take utterly for granted in modern hospital practice. The adrenaline rush of stepping out of a helicopter into a trauma scene never dwindled, however it was the lifesaving work done by the team on board that will stick with me forever.
I would unreservedly recommend this elective in trauma to any medical students or junior doctor considering a career in surgery, emergency medicine, anaesthesia or pre hospital medicine. The volume of trauma cannot be seen anywhere else in the world and the expectation for medical students to perform supervised procedures gives unrivalled experience whilst preserving patient safety. The principles, experiences and knowledge gained on this trip will stick with me throughout my career and I hope make all the diﬀerence to tomorrows trauma victims.
Ellington M, British Undergraduate Emergency Journal. 2012, 1.15