Do you recommend this rotation to other students?

If you found this blog as a medical student, this is probably the key question for you.

My answer: yes.

Professionally: Yes, if you set your expectations accordingly. You will work hard on your call days (q4), and thankfully so, because that is when you will see and do the most. I developed proficiency in IV access, blood draws, and ABGs despite coming into the month with no previous experience. In terms of procedures, I placed 7 chest tubes, two central lines (one IJ, one subclavian), one intubation, and sutured more complex lacerations than I usually do at home. You likely will not learn cutting edge ATLS here, but if your goals for the month are mainly technical (as mine were), you will not be disappointed. And if you have any interest in surgery, you will frequently first-assist and on high acuity and complexity cases.

Personally: South Africa is a beautiful country and I only wish I had more time to explore all it has to offer. There is a richness to the country and the people. Like I said previously, you are stepping into history in the making. At any given time there is a robust international medical student community here and plenty of social opportunities to jump into. There is something here for everyone. Financially, I spent approximately $4500 all inclusive for the month, which includes airfare, lodging, car rental, side trips, and the steep registration costs; I would budget between $3500-5000. Safety is a valid concern but if you are prudent you will be fine (I did not experience any crime or health exposures).

Please feel free to email me with any questions. My month at Baragwanath on Trauma Surgery exceeded both my professional and personal goals. I recommend this rotation wholeheartedly. Good luck to you and enjoy your experience!

Out of Africa

This has been an incredible month not soon forgotten.

In many ways, it felt similar to my summer spent living in China. It is very different passing through a place as a tourist than actually setting down some roots: having an address, a phone number, a favorite grocery store, a barber, local backroad shortcuts to work – being around long enough to develop an appreciation for what lies beneath the surface. To, at least in a small way, make this city my own.

This month was a perfect confluence of blessings: awesome fellow students from Kansas, outgoing international students from Australia and Germany, a summer escape from wintry Boston, amazing opportunities to explore the country (African national cup! Kruger safari! Cape Town!). It was also a tremendous privilege to step into a country that is making its own history. But the single most important ingredient for success has been community: sharing in new memories alongside others.

As I write this final entry from the airport, I am filled with a sweet sadness. This month has been riddled with unexpected experiences that left me thankful each day for the opportunity to be here. I have glimpsed into a new healthcare system, a new classist struggle, and a new culture still evolving but proud in its heritage. And, most of all, I am utterly delighted to call new strangers friends. God is gracious. How beautiful it is that we continually shape and become shaped by the lives we intersect.

What’s next for South Africa?

Although my time here has been short, I have seen and heard enough to formulate an opinion on what I think are the two biggest challenges for Johannesburg as it moves into its third post-apartheid decade.

Political leadership

I will quote the words of another who speaks with more authority than me. In Cape Town I went on a tour of Robben Island, a prison for political prisoners (including Nelson Mandela). The tour was lead by a former 6-year prisoner himself, one who had participated in the Soweto uprisings in the late 1980s. After the neatly packaged tour, I asked him a a pointed question: "How do you feel about the current political situation in South Africa?" He took a minute for his thoughts and replied as such: "I did not think I would live to see corruption in my own party in my lifetime. We fought to get rid of corruption, not perfect it. It is important for leadership to remember who they are and that they can change lives."

Education

The average black male’s education terminates at age 13 (likely even earlier for females). For true economic empowerment, the closing of the wage gap must parallel a closing in the education gap in order to protect skilled labor. For future harmony between whites and blacks, a level playing field in schools is necessary to prevent arguments of favoritism in either direction. For political elections to become more than high-school popularity contests, an educated vote is necessary to raise up leaders who bring platforms of substance, not short-sighted bribes and sensationalism.

Escape to Cape Town

Sampling local vendor foods - like Costco for foodies.

Following the end of my rotation, I spent four days in Cape Town before heading home. Only a short two-hour flight from Joburg, the cities have vastly different personalities. Johannesburg most reminds me of Balitmore – a checkerboard layout with sioled diversity and pockets of seediness. Cape Town is more like California, the natural beauty of the Bay Area with the laid-back feel of Los Angeles.

Philharmonic @ Kirstenbosch Gardens.
Putting Tanglewood to shame!

This is what vacation should feel like: beach hopping on the drive down the Cape of Good Hope, grazing local artisan foods at Neighborgoods market, enjoying the philharmonic at the most beautiful outdoor amphitheater I’ve ever seen, hiking Lion’s Head mountain through sunset into the full moon, and eating a variety of game meats seen on our safari. And Hillsong Church even has a plant here!

The self-selecting community that lives here must be amongst the happiest in the world.

A relaxing finish to a wonderful month!

View from Lion's Head mountaintop

What has shocked me the most

As I wrap up my month at Baragwanath, what has shocked me the most about the violence here is not the volume but the culture of acceptance.

I wish I could say this were a joke.

Let me showcase what I mean with an example: A few nights ago I stitched up a gentleman’s lip, wondering if I could possibly get second-hand drunk from his delightful breath. As I took him back to the pit, he pointed out a fella with a massive forehead laceration. “See that guy? He did this to me." Then, in disbelief, I watched them clap each other on the back and share a good laugh. Not only were there no hard feelings, it almost seemed like good sport. Just another Friday night ending at Bara. 

I am still baffled when patients with penetrating wounds lay quietly in the resus bay, telling their stories with a calmness bordering on nonchalance, as if they were grizzled veterans. Well, perhaps they are.

What has been exceptionally appalling is the tide of domestic violence. Women here are not economically empowered, there is no public female leadership, and the legal system is in shambles. Men abuse women without fear. A young couple came in one day. The man complained loudly of pain in his knee; his wife had scratched him during an argument. In return, he had beaten her head in with a brick. In contrast to his theatrical display, she waited without words. I have now sutured some 20+ men and women here. Without fail, the men always yell and squirm while the women bear the needle silently, pain tolerance built up through years of voiceless suffering.

And the children – I do fear they get the worst of it. So many children hit by crazy Soweto minibus drivers. So many burns coming in with legs looking like a calico kitten. Where is the parents' indignation? Where is the outcry? Just a room full of mothers and their kids, one silent because they they know better, one silent because they don’t.

Sometimes, however, the violence is necessary. The policing authority here would be laughable if it weren't true. So a mob justice phenomenon has arisen where the people govern themselves. A young gentlemen came in with widespread bruises all over his body. He had hit a baby with his car and tried to drive off. The mob had pulled him out of the car and served a healthy dose of vigilante justice.

Patricia, my barber/hairdresser, thinks that the “culture starts in the home.” Fewer than 1 in 100 black South African young folks are married. Many children grow up in single parent households. They follow the example set for them. One of Patricia’s friends is an orphaned girl who is beat by her uncle and aunt for every little thing done wrong. They also beat her baby sometimes too. If this is all she has ever known, how can she even aspire to want better?

Bara, and every county hospital worldwide, serves to treat the symptoms of deeper societal issues at hand. And the doctors here are heroes, toiling tirelessly to make even the smallest of differences. But without addressing the root causes, it is a losing battle.

Driving – a gradual victory in confidence

Before coming here, I was significantly concerned about driving in South Africa for two reasons:

  - Driving on the left side of the road

  - Driving a manual transmission

Right-hand drive.

What I expected to be the greatest stressor has actually become my greatest satisfaction. Though challenging at first, I have come to enjoy driving a standard far more than an automatic. It is a more engaging driving experience, a deeper integration between will and vehicle. As I developed confidence, nervousness gave way to a deep contentment, even thrill.

Joburg traffic, right up there with the worst:
http://googlesightseeing.com/2012/05/top-5-worst-traffic-cities-in-the-world/

Thank you, little Nissan Micra, for being such a forgiving teacher. Now if only my right hand will pick up everything my left hand has learned...

Play-by-play recount of a 24hr call

I haven’t posted about Bara in a while, but I assure you the nights are still wild. Here’s a play-by-play of yesterday’s crazy call:

0700: One (of two) interns out sick and no replacement until 5pm. All 8 beds in resus bay full. It's going to be a LONG day.

0705: Stab wound #1 of the day rolls in. Eviscerated bowel injury with loops adorning the stretcher. Up goes two large-bore IVs, bloods, blood gas, Foley, and he's off to the operating theater.

0815: Chest xray confirms a pneumothorax I called on ultrasound for a stabbed chest!

The bird lands.

0900: Our lone ultrasound unit breaks. No more E-FAST exams. So much for ATLS protocol for the remainder of today's thorax/abdominal injuries.

0930: Helicopter arrives with multiple MVA motorbike vs. taxibus.

1200: First-assisting in the operating theater on a stabbed abdomen with pleural violation.

Radiology waiting area already packed by 10am.

1400: Back-to-back surgeries with another exploratory laporatomy.

1700: Covering intern is here! Yay, hopefully will decompress some of the workload.

1815: Covering intern gets splash exposure and is out of commission.

1830: Stabbed heart that rolled in earlier today with ? pericardial effusion develops tombstoning ST elevations. We're off to the operating theater.

Throwing stitches on a beating heart (not my hands!)

1930: Complications during surgery. Liters of cardiac output literally pour into the thoracic cavity. Ever seen a heart physically beat in ventricular fibrillation?

2030: Have not eaten food since 6am this morning. Sneak a quick trip to KFC in Soweto while I wait for the blood blank to crossmatch some emergency units for four unstable patients in the resus bay. Now I know why I was warned to stay out of Soweto after sunset. Ever seen a KFC with barred windows?

2100: One bite into the chicken wing and I'm called back into the OR. Stabbed neck with vascular compromise.

0030: Out of the OR, the resus bay is backed up four stretchers into the hallway. Like a assembly line, I pull ABGs in succession, with a chest tube at the end of the rainbow.

0045: Just got irradiated again by xray tech two beds down as I’m putting in the chest tube. Again no warning. This is probably the 20th time this month. My poor unborn children.

0130: I wheel a vented patient to radiology for a CT angiogram with the following instructions: “The patient is starting to wake up and buck the vent. Here is 2x20ml of morphine, push as much as you need. Sorry we don't know where the ambu-bag is.”

0145: Waiting in radiology while receptionist sleeps and radiologist is nowhere to be found. BP cuff doesn't work, swinging wildly by 30 points – the usual. Did manage to grab one of two pulse oximeters we have. Vital signs – I’ll take what I can get.

0230: Back in the resus bay, I get an axe kick to the head from a drunk patient. Surprisingly flexible for his size. He gets intubated.

0300: The patient I wheeled off to CT earlier is on a downward spiral. He is made comfort measures only.

0330: Second wind arrives! :)

0430: Second wind gone :(

The morning light beckoning.

0500: Are we up to stab wound #12 now? Who knows? There were a few gunshot wounds mixed in there. Resus bay is jampacked spilling out into the hallway but thankfully everyone is stable.

0530: A medical house officer starts asking me about hyponatremia on a blood gas for a polytrauma patient.....some things are the same everywhere.

0600: I am in full-on zombie mode. The intern, who is about to collapse from exhaustion, asks me to suture a complex head lac. I turn her down as I make it a point to not suture anything after 6am for safety reasons – especially since we often use hand Colt needles here instead of needle drivers. Reinforcements are coming in one hour so I’m just staying the course, tidying up paperwork and readying presentations.

0700: I’m a survivor.