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.

Everywhere you go, a Chinatown you will find

Just as I was starting to feel a little homesick missing Chinese New Year, my landlord’s friend invited me out to little Chinatown right here in Joburg! Complete with street meats, taro milk tea, 粽子 and a variety of fireworks-induced health hazards (not sure how safe it is to launch fireworks directly below power lines).

At first, it felt like any good old grimy Chinatown. But looking closer, I noticed how, for instance, the lion dance team was half black, or that there were more Jews at my dinner table than Asians. In this South African community there is a genuine culture of open-mindedness that brings together people from all backgrounds to celebrate each ethnicity's heritage. Being in the midst of that was even cooler than celebrating at home. 

Meeting the cast of the Lion King

A few med students and I returned today from a two day self-drive safari.

The savannah is majestic. 300+ km² of preserved nature and wildlife. It was a pleasure to see an ecosystem of animals in their natural element, not spirits broken behind bars. Looking out on God’s creation, it is hard not to feel a sense of wonder.

I absolutely recommend self-driving over a packaged tour - more flexibility to spend your time as you see fit. Two days in the park was sufficient to see everything. Satara, in particular, had excellent facilities and lodging.

Picture slideshow:

Memories of Apartheid

Visiting the apartheid museum today, I caught a glimpse into South Africa's moment in history. It was fascinating to see Mandela's roots. Before the articulate, matured product of his twilight years, he was a radical, fiery young man who went the distance for his beliefs.

Other parts of the museum, however, were heartbreaking. Video footage of 1994 Soweto conjured an exact reflection of 2013 Soweto; not much has changed. Sure, some parts have improved, and Bara's volume is less than it used to be (hard to imagine that), but not much else can be shown for the last twenty years. Driving to Bara, there is a large billboard that reads “Soweto, you've come far but you've got a long way to go.” This rings true.

I sense that black South Africans have forgotten the price of opportunity. A young educated white couple (MBAs) explained to me a “backlash of entitlement” among the blacks, a reasonable response to so many years of being deprived. Policies like the BBBE have aggressively redistributed jobs and income, creating bitterness among young educated whites (as well as some educated blacks who decry the crutch). But these handouts have not been accompanied by sustainable economic or educational opportunities. Said differently, the government has given plenty of fish but not taught many to fish.

At Chaf Posi yesterday, I noticed an unusual sight: a large group of young blacks amidst the usual sea of whites (the only place you will find whites en masse in Soweto). I started chatting with them, sharing some of my thoughts. They were lucky ones – they had good paying jobs and could afford to go out. I remarked how they seemed to be a privileged minority, and what his generation – young, educated and empowered blacks – were doing about the state of the nation. “Yeah it is bad, but we are not really doing anything. We just come out and party.” It was disheartening.

For some reason, his words reminded me of the apathy sometims seen in 3^rd generation (Asian-American) immigrants. Having never known the struggles of the generations before them, they often are less ambitious, less successful. They have forgotten the price paid by those who paved the way for them.

African Cup of Nations!

Attended my first ever soccer match – in Johannesburg of all places. A local friend was able to score us six tickets for $10 apiece to the African Cup of Nations, held in the new stadium built for the World Cup just a couple years ago. Sadly Bafana Bafana was eliminated the week prior, but that didn't stop us (and many South Africans!) from sporting yellow. We loaded up on braii beforehand and then hopped on a minibus to the game! Great memories!

All nations under God

When we were in grade school, we would salute the flag every morning with hands over hearts proclaiming “one nation under God.”

Worshiping with a Johannesburg church today, I glimpsed a global kingdom of God that encompasses believers from all nations. The heart of the church is bigger than its local congregation. It is an identity and authority before all others.

How humbling and inspiring to join with them as one body of believers:

Eating well in South Africa

I want to document more than just my clinical impressions during my month here, as that is only one part of my overall experience. Today we'll talk about food.

Fresh fruit, daily and cheap.

Nutrition is easy here, fortunately. As is the case with most countries outside of America, fruits and vegetables are affordable and fresh. I go to the supermarket twice a week and pick up fresh produce. 

As with home, I usually prefer to cook rather than takeout since I know exactly what I am putting into my body. 

After a long night, my favorite comfort food is a giant omelette – followed by a three hour nap :) 

Braii (bbq) with fellow med students on a relaxing afternoon.

Eating out has likewise been delightful. Braii – barbecue – is a South African favorite, and now a favorite of mine as well. We have now been to Chaf Posi twice already, enjoying delicious (and cheap!) barbecue among great company. Other restaurants – Moyo, The Foundry – have been up to par with any restaurant back home. My notion that I might lose weight in Africa has been clearly dispelled.

“There is no hurry in Africa.”

Time is a precious commodity in the hospital. As a future emergency medicine physician, my specialization will be in time. Trauma departments throughout the US understand that time is the enemy.

It can be frustrating to work in a time-intensive field  in a culture that values time differently. “There is no rush in Africa” is the overriding mantra here.

Solution: Never go fast.

I never saw “sisters” (nurses) respond to an emergent request with anything resembling emergency. That is not to say they were not pleasant and likable  Some were welcome company on long night calls. Expectations, however, are simply much lower for nurses here than the states. Level of medical knowledge is far, far behind. Mistakes are common, charting abysmal, and it is not unusual for a nurse to directly ignore a physician's order she disagrees with because of cultural superstitions. And as I mentioned earlier, IV access and blood draws are the physician's responsibility. 

This laid-back culture also permeates to the ancillary services. Transporters huddle in the break room while patients hobble through the hallways. I will refrain from comment on Bara's radiology department. The blood bank stood out as the sole dependable entity.

I can definitively say that I have tremendous newfound appreciation for our ancillary and nursing staff back home.

How long should it take to train a doctor?

Aside from the way healthcare is practiced, I have also been drawing observations on how doctors are educatd here and comparing its merits to our system.

As with most of the world, SA graduates its doctors through a direct 6-year undergrad/med program. They start after high school and complete at age 24. Following graduation, they begin two years of general internship rotating through all major disciplines, followed by one year of rural community service. At this point, they enter a specific field (i.e. internal medicine, surgery, pediatrics) either as a simple house officer or as a registrar, which is their residency equivalent toward becoming a consultant (an attending).

Compared to America, there is no “time savings” – SA physicians become attendings at the same age we do. Certainly they do emerge from their longer clinical course with a broader proficiency in all medical disciplines; I have been very impressed with the competency of SA interns and registrars/residents. That being said, if they ultimately specialize anyway, this raises the question of whether this generalist skillset warrants the three additional years of cheap labor before they begin their residency.

 More importantly, the opportunity cost of an early, narrow education is hefty. I am a well-satisfied product of the delayed choice system in the US. I was not prepared to make the commitment to pursue medicine even at age 22; how could I possibly make that at 17? I greatly valued my general curriculum in college and having a business career before coming to medicine. These experiences enriched my ability to relate to patients from all walks of life, which I have found equally as important in doctoring as applying as science, and also made me confident in this long career path. Conversely from my own route, the undergraduate degree also offers a secure fall-back option for the many who choose to leave the pre-med route for various reasons, leaving them great flexibility to pursue career choices outside of the life sciences.

Choice is intrinsic to American culture; it is in our national roots. Jefferson founded this country on the principle of the self-made man, carving out his own plot in life. I believe our undgergrad --> graduate setup enables American doctors to make the most informed choices while minimizing regret.

Being Asian in South Africa

Before arriving, I imagined Bara's predominantly black population might take issue with or at least notice that I look different. Curiously, nobody has commented. Initially I believed this was due to them just being thankful to receive any care at all. Non-EMS intakes can wait upwards of 3 hours to be seen, regardless if they come in with traumatic eye, brain, or orthopedic injuries. Nonetheless, for the Soweto poor, this is their only option.

However, today I had another thought. I suspect the only racial difference these under-served blacks draw is black vs. not black. There is no Asian, just as there is no Australian, British, Indian, etc. There is only what they know and see everyday, and then everyone else in the hospital who is different from them – different in race, social, and economic station. There is only us vs. them.

I was curious how providers felt about this discrepancy. I asked one of the white interns how he felt. He didn't really seem to notice it. Then I asked one of (few) black interns how she felt about the issue. She didn't seem to really care. I suppose doctors draw that same divide – the patients are not like us.

Baragwanath, a war zone

All 8 beds in resuscitation bay at capacity on a Sat morning.

Chris Hani Baragwanath Hospital (Bara) is an academic hospital but its trauma receiving area more closely resembles a war zone. It is effectively Soweto's county hospital, publicly funded and under-resourced  Named after a revolutionary freedom leader who was assassinated  the legacy of violence continues. There is as much penetrating trauma in a single night here as an entire month back home. 

Variety of penetrating and blunt trauma waiting in the "pit".

Friday night call was -wild-. Fridays are paydays, lubricating the culture of violence with dirt cheap liquor. The flow of ambulance stretchers into the resuscitation bay was constant. Blunt beatings, knife stabs, and gunshots were in no short supply. Many patients even walked in with a variety of penetrating wounds to the face, thorax, and abdomen. The intake “pit” area was bursting at the seams, lined with stretchers waiting to be resuscitated. 

"Storage"

The overarching mantra at Bara is “get it done with what you can.” This arises from a combination of short time and few resources. Forgetting what I've grown accustomed to in the United States, I learned to become effective in a different system. Where I used to call plastic surgery to suture faces, I now use a giant 3-0 Colt needle. Sterile technique is a commodity  not necessity. Femoral ABGs, Foley catheters, starting IV lines – proficiency develops quickly. By the end of the night, I had performed 3 chest tubes, 1 intubation, and an IJ central line without ultrasound.

A typical inpatient ward: short-staffed and under-resourced.

And this was a usual Friday night. Rinse and repeat weekend over weekend. Procedures and protocols move patients through like a meat grinder. By the end of my 28 hour shift, I was eager to go home. I felt physically exhausted and emotionally frustrated. Patients deserved better than what I gave them. I had no time to treat them more humanely, no resources to offer higher standards of care. Even though I had worked tirelessly, I just felt bad that in the morning I could not remember a single patient detail beyond their injury and plan.

Driving home, Skylar Grey's Coming Home was on my mind: 

A city of juxtapositions

Arrived safely on my 14hr direct flight from JFK. After one day of recovery sleep, I set out to explore the city with a friend who has lived here for five years.

Johannesburg is the international business epicenter of South Africa, perhaps all of Africa. And yet, greenery is so abundant here that concrete warehouses make the exception, not the norm. The heart of the city is not removed from the heart of the country.

We grabbed lunch at Arts on Main, an outdoor vendor market in a gentrifying district much like what you might find in Brooklyn. 

 Joburg is an incredibly diverse metropolis but remains an incredibly segregated society. Even at this socialite gathering, there is a palpable racial tension. In a post-apartheid era, blacks and whites now live side by side, shop at the same markets, eat at the same restaurants – yet everybody obeys the lines in the sand. In a way, I am reminded of Chicago: collegiality without community.

At one point I recall turning around from my rooftop haven and seeing below me unfurl a cascade of shanty housing stretching to the horizon. This was also the real Johannesburg, come to life from cinema the post-apocalyptic Dredd city, the District 9 slums of Soweto. I am sorry to say the movies did not have to stretch the imagination much.

Like any great city, Joburg has neighborhoods ranging from suburbs to ghettos. However, unlike many other cities, as the pie gets bigger not everyone shares in thes spoils. In places like Soweto, which Baragwanath hospital serves, it seems like poverty is perpetual. This month will be a privileged glimpse into how first-world and third-world neighborhoods coexist.

Why Johannesburg?

Johannesburg, South Africa is the only city in the world to raise two Nobel Peace Prize winners: Desmond Tutu and Nelson Mandela. In stark contrast, it remains the second most violent city in the world, with a crime rate more than ten times greater than the most dangerous cities in the United States. Chris Hani Baragwanath Hospital is the third largest hospital in the world and has more than 125 trauma activations daily, most of them penetrating trauma. The Trauma Surgery program is renowned; residents and medical students rotate here year-round from around the world. Yet, the hospital is severely understaffed and under-resourced. Many patients wait in hallways and die before they reach the operating table. Thus, visiting staff are invaluable to both faculty and patients. Because there is no shortage of work to be done, even medical students serve a pivotal role in improving outcomes, functioning above their training level. My responsibilities include taking q3 30hour call, with advanced procedure exposure such as chest tubes, central lines, and assisting in resuscitations. There are considerable safety risks. I will take careful precautions against HIV/AIDS (>50% prevalence) and live in an enclosed neighbourhood. I have spoken with peers who have rotated through previously. They report that the risks are real, but there is no ceiling to the learning and experiences.



This blog will follow my four-week experience from beginning to end.

I am as excited as I am frightened.

I fly out today. Let the adventure begin.