Dr Amy Louise Collyer / Emergency Medicine Doctor / LSHTM Distance MSc Public Health Student / South Africa
Having worked in a private sector emergency department for three years, Dr Amy Collyer (@dr.amylouise) wanted a change. She packed up and moved to Limpopo, volunteering for an NGO called the Tshemba Foundation. Whilst working there she got a call to move to Zululand and work in a public hospital. A week later she packed her life into her car and made the ten-hour drive, arriving ready to start a new challenge.
An Introduction to Healthcare in Zululand, South Africa
Zululand is in the north of KwaZulu-Natal, one of South Africa’s nine provinces. It extends inland from the coast, and is home to almost one million people dispersed into cities, small towns and rural homesteads. Despite its’ middle-income status, there are significant inequities between South Africa’s public and private health services. Public healthcare tends to be poorly resourced, along with staff shortages and long ambulance delays. This is keenly felt in emergency medicine where a deep passion for the work is needed to survive. Here, we do early, late, and 19 hour-long “call” shifts. The latter is a misnomer, as they are long, busy on-site shifts that are made more tiring by the struggle for resources, including imaging and working technology, the language barriers and limited breaks. Despite these pressures, there is an unshakeable drive to do the best we can for each person who comes in through the doors.
A 19-hour emergency shift
Please note, this is a descriptive piece representing an accumulation of compiled memories and experiences that would reflect a typical 19-hour shift. It is not a true account of an actual shift.
It’s 13:55 pm on a Friday, and I’m walking along the corridor towards the emergency unit to start my 19-hour shift, with coffee in hand, feet a little sore from the late shift yesterday, and eyes heavy. From the corridor I can’t hear any chaos, so I stop at the bathroom to use the toilet. There are few things as excruciating as doing handover with a full bladder, and who knows when the next opportunity will arise. On entering the ‘majors’ section I see that all fourteen beds are occupied, with two patients ventilated. As we only have two ventilators, this is not a good start to the weekend. All of a sudden I can hear shouting and see all the doctors and nurses moving frantically around the first resuscitation bed in the trauma bay. I can feel my heart beating faster. One of the doctors catches my eye and I see a glimpse of relief in theirs, “Amy, quick, put on gloves, take over CPR!”.
I fling my bags to one side and grab the closest box of gloves I can find. I fumble to put the unfortunately over-sized pair on, while climbing onto the step next to the patient. The monitors are alarming noisily. Words are flying across me, “1 amp of adrenaline given!”, “What is the glucose?”, “Keep the C-spine stabilised”, “Get ready for bilateral finger thoracostomies!”, “Someone fetch the bear-hugger!”, “Let’s get a second line!”.
Right hand over left, arms straight, positioned above the chest, I begin chest compressions, “One, two, three, four… what is the story here?” I pant while compressing. The short reply of “Motor vehicle accident!” is all I get from somewhere at the end of the bed, where doctors are applying a plaster cast for a seemingly mangled limb. “… Twenty-eight, twenty-nine, thirty, breathe”, I lift my hands from the chest so some air can enter the lungs as another doctor gives two squeezes of the bag valve mask. As I continue chest compressions, I look across to see a doctor performing a thoracostomy, in an attempt to relieve any underlying blood or air that could be compressing the lung and accounting for the patient being in cardiac arrest. From behind me someone says, “Amy, don’t mind me, I’m going to do the same thing this side, just move over slightly so I can access the chest wall.”
All I can think about is doing my compressions well while everyone else focuses on their tasks. We are like one dynamic organism, all working together to try to save this life. The doctor repeats the procedure on my side of the patient, and sticks their finger in to access the pleural space. Within seconds a large gush of blood, probably two litres, escapes from the patient and hits the floor. As I continue CPR, more blood leaves the patient with each compression. The doctor behind inserts a tube into the patient’s chest and and connects a Sinapi chest drain. Within seconds the drain is filled to the brim. Shortly afterwards I am relieved when a colleague takes over chest compressions.
Despite the drains, CPR, oxygen, fluids, straightening of broken limbs, provision of warmth, and more, the patient does not improve. As time goes on, it becomes obvious to everyone that there is nothing else left to try. Eventually, the team leader calls an end to the resuscitation effort. There are no signs of life. Gloves come off, and most of the team disperse to see other patients. One doctor remains to document the events and break the bad news to the family. A nurse stays behind to organise a mortuary transfer. As I take moment to change scrubs, I feel a wave of sadness for the loss of this life. But I am consoled by how much the team did to try to save them. Sadly, we can’t help everyone.
On returning to the minors unit, I wade past stretchers, wheelchairs, relatives and nurses to survey the two most important boxes in the departments: waiting to be seen and needing review. There are two unseen patients and six needing a review. But I can’t start with any of this because we still have to do the ward round and participate in teaching. The ward round is quick as everyone is tired, and afterwards we pull up chairs in a circle for our “five-minute teaching”. Today it’s my turn and I discuss the diagnosis and management of septic arthritis. After feedback, everyone except the late and call teams go home, but one consultant remains available after hours for advice.
After some hard graft in minors, it is time for a dinner break. The call room is a bubble of peace in the chaos. From here I can see the exquisite orangey-pink sunset descending over the community and distant rolling hills. Nearby taverns have already started to pump out very loud amapiano (a type of South African music), and taxis are whizzing along the main road that the hospital entrance gate leads onto. After eating, I try and put my head down for a short nap, but I struggle against the noise of the people and buses in the parking lot below. There are limited transport options in Zululand, and some patients live up to five hours away from the hospital. To help with this, intermittent hospital buses take patients who have been at the specialist clinics back to their base facility. It feels like I’ve just closed my eyes when my alarm sounds, signalling my return to the emergency department.
I survey the emergency department. Fortunately, most of the patients in majors unit are stable, so I head back to minors. Despite our hard work earlier, the boxes are full. I take one of the unseen files, a paracetamol overdose. This is, heartbreakingly, one of our “bread-and-butter” cases. The typical patient profile is a young adolescent who has engaged in deliberate self-harm. It is usually triggered by a fight with a lover, or after receiving subpar results in school. It can be serious, even life-threatening. But we see this presentation so often that the management is automated for me: consult, examine, counsel, evaluate suicide risk, take blood tests, start fluids, offer symptomatic treatment for any dehydration and vomiting, and decide on whether the antidote is required. These patients are either referred for hospital admission and ongoing management, or are sent to see a social worker before discharge home.
After this, I pick up the review files. Two can be referred onwards to surgery and internal medicine. The rest are still waiting on blood results. Time has flown by, and it is time for an evening telephone round with the consultant. They listen to the patient list and give advice on management, and on overcoming barriers to flow on the floor. After the late team leaves, a team of three to four is left to cover the next twelve hours until the morning. We head back to the minors unit and see that two patients from a motor vehicle accident have arrived with the paramedics on scoop stretchers due to concerns about spinal injury. My colleagues attends to them, so I continue with other unseen patients and answer calls from the clinic phone. The rural outlying clinics, some up to 50km away, often call for advice or to refer patients that are too unwell for them to manage. I accept a patient who has been stabbed in the chest with a broken beer bottle, giving the nurse on the other end some advice to make sure the patient is stabilised prior to being transferred.
In between my next few patients I make sure to rehydrate and refuel. It is easy to get bogged down by tasks and forget to look after ourselves. But I’ve no sooner closed my lunch bag when a concerned looking nurse approaches me. “Dokotela, (doctor in isiZulu) the patient in bed thirteen is becoming restless”.
It is a patient with head injury secondary to assault. Unfortunately, this is also a common presentation. This patient’s head injury is severe and they have been intubated and placed on a ventilator for prevention of secondary brain injury. I begin troubleshooting and looking for causes for restlessness in a head-injured patient. It could be pain, hypoxia, hypoglycaemia, low blood pressure, even seizures. Ruling these issues out, I decide to increase their sedation so that the patient will tolerate the ventilator better.
While I’m in the majors unit I decide to check on a patient with diabetic ketoacidosis (DKA). They came in really sick with a pH of 6.9 and are surrounded by drips and pumps. They need close monitoring of their sugars, electrolytes and acid-base status, while insulin and fluids brings down their high blood glucose, and we look for an underlying cause.
The rest of the night is a constant flow of sick and injured patients to sort out. The team is kept busy. Patients keep arriving. These include a patient with a snake bite for blood tests and limb elevation, a breathless, immune-compromised patient for oxygen and antibiotics, one with heavy chest pain for four hours management of a likely myocardial infarction, a patient with a dislocated knee for reduction, and a patient with an angle-grinder injury for tying off an arterial bleed and admission for amputation of two of their fingers. Eventually, the patient who was stabbed in the chest with a beer bottle arrives. They are drunk and frustrating to work with, but fortunately I can see on X-ray and bedside ultrasound that none of their vital organs are affected. I clean their wound, suture it closed, apply dressings, and give them fluids and a thiamine drip owing to their intoxication and chronic alcohol use. Later I send the patient home on pain medicine.
As the night wears on I can feel my concentration dipping and thought processes slowing. Caffeine helps but I’m willing time to speed up. Eventually, there is a lull. There aren’t many more expectant cases, especially no more red codes requiring laborious and heart-wrenching resuscitation efforts. Some of us sit, chat and laugh together, others put their heads down on the desk to rest their tired eyes.
6am rolls around. It is still two hours before the handover round but I can see through the glass windows that first light has emerged. This is my signal to make instant oats, and head outside to devour them while watching the sun rise over the community from the helipad. The air is fresh and I feel a renewed sense of hope. The night is almost over, and I’ll be home in my bed soon. Only to do it all again later that evening.
Interested?
You can apply for a job at Zululand hospitals through this website. Doctors will require a right to work in South Africa (see this page for advice), and registration with the HPCSA.
International medical students and doctors interested in emergency medicine experience in KwaZulu-Natal, either for university requirements or personal interest, can email mbanjwaa@ukzn.ac.za or go to this website to read more.
