Adventures — 10 August 2014 at 4:35 pm

Emergency Medicine in the heart of Zululand

Dr John Hickman / Clinical Fellow in Critical Care

After completing his FY2 in London, John Hickman traveled to the beautiful KwaZulu-Natal province of South Africa and found himself in at the deep end as a medical officer in a busy Emergency Department. Gunshot wounds, snake bites, stabbings and road traffic accident trauma became part of his daily routine. He recounts his incredible experiences for Adventure Medic.

Ngwelezana Hospital
Ngwelezana Hospital

At the end of Foundation Training junior doctors are faced with the decision of entering a training programme or seeking experience further afield. The lure of the antipodes has for some time been the most popular option, but for many, this lacks a sense of adventure and they find themselves seeking a different and perhaps more challenging experience. South Africa has become an increasingly popular destination for UK doctors to work.¹ It offers a new and exciting clinical experience in a culturally diverse and rich country. The process of getting a job is made significantly easier by Africa Health Placements (AHP), a charity which facilitates the application process, although this can still take up to 18 months. I was fortunate, and 10 months after starting the process I had my first day working as a medical officer in the Emergency Medical Unit (EMU) of Ngwelezana Hospital, KwaZulu-Natal, South Africa.

Ngwelezana Hospital is situated in the heart of Zululand, an hour north of Durban (see Figure 1). It is a 550-bed tertiary referral centre serving a population of approximately 4 million people from 22 peripheral hospitals. The EMU comprises a casualty and two-bedded trauma resuscitation area with LODOX scanner (full body x-ray in 10 seconds). The resuscitation unit is a 14 bedded ward with two designated adult and one paediatric resuscitation bed. The resuscitation unit functions to provide care to the sickest medical, surgical and trauma patients.

Ngwelezana map
Figure 1. Map illustrating location of Ngwelezana

The clinical pathologies are varied often presenting with florid clinical signs. Complex medical cases are seen daily, and the burden of HIV always present. Surgical patients tend to present late, often decompensated requiring invasive monitoring and optimisation pre-operatively. South Africa has one of the highest burdens of trauma in the world (see Table 1).²  Gun shots, stabbings, burns, snake bites and road traffic accidents become part of a normal days work. The number of trauma cases rises with alcohol consumption, so peaks tend to be seen on public holidays, weekends and national pay day.

Cause of injury deathHomicide or assaultRoad traffic accidentSuicide and self harmFireDrowningPoisoningMiscellaneous
% Total of injury deaths4626.79.16.92.31.17.9
Table 1. Percentage of injury deaths by cause, total 59,935 ³

I approached my first day on the unit with much hesitation, having never led a resuscitation let alone running an emergency unit overnight. As medical officer I would lead 24hr on calls in the unit with consultant cover. There was excellent in-house training focusing on common presentations and skills used on a daily basis, such as intercostal drain insertion and intubation. The first few months were hard but the learning curve was steep and before long I was treating snake bites, running cardiac arrests, intubating and inserting chest drains.  Some nights it felt as if I had managed half of the emergencies in the Oxford handbook.

Cobra
Cobra snake brought in by the family of a patient requiring antivenom

I recall one night in particular. I had cardioverted a patient with unstable SVT, someone with a gunshot wound to the abdomen awaited theatre and a gentleman with severe head injury lay on a bed intubated awaiting transfer to the neurosurgical unit. I had been asked to review a STEMI in casualty and then, with a crash of thunder, the lights went out. Fortunately I had been warned this may happen and proceeded to get my head torch as the nursing staff prepared the flood lights. Work continued, and several resuscitations later, the power had come back on, the sun had started to rise, and the nurses sang their morning song to bring in a new day.

The learning opportunities on the unit were excellent. As an emergency medicine training centre, morning ward rounds had a heavy focus on teaching. We also had mandatory teaching sessions on Wednesday and Friday and a strong consultant presence during the day to facilitate skills teaching. The hospital is also a provider for ATLS, APLS and this year is hosting the South African Conference of Emergency Medicine.

After 8 months of working in the unit, my days as an FY2 in London seemed a long way away. The clinical experience I gained was greater than I had ever expected and I was a better doctor for it. The work was hard and the hours were long, but once I had settled in I began to enjoy the challenges I faced in the unit. In my free time I was able to experience a country that is incredibly rich in culture and natural beauty and have picked up a bit of Zulu on the way!

Useful information

Applying to AHP / The process of applying for work within the state system in South Africa is made significantly easier with the help of Africa Health Placements. AHP are a non-profit organisation based in SA who assist with your application. They liaise with the Health Professions Council of South Africa (HPCSA), the Department of Heath, and the embassy on your behalf. Be aware that this is a lengthy process which requires persistence and can take up to 18 months in total.

Finances / AHP do not charge a fee. Working for the state system in South Africa is well paid. I earned a salary comparable to my previous FY2 job in the UK. The costs of flights and accommodation are the applicants own responsibility.

Indemnity / As in the UK, the state system do offer a level of indemnity, but this is far from comprehensive. It is recommended that you organise indemnity with your own provider e.g. MPS prior to travelling.

References

¹ Africa Health Placements. www.ahp.org.za. 2014

² The injury chartbook: a graphical overview of the global burden of injuries. Geneva: WHO; 2002

³ The high burden of injuries in South Africa. Bulletin of the World Health Organisation. Volume 85, Number 9, p695-702, 2007

Useful resources

Africa Health Placements / social profit organisation working to provide healthcare professionals to areas of need

Educational Commission for Foreign Medical Graduates 

Department of health KZN, Vacancies / Department of Health medical, nursing & allied health vacancies in Kwazulu-Natal province

Health Professions Council of South Africa / South African equivalent of the GMC

Medical Protection Society: Working Overseas / advice from MPS on arranging indemnity for work abroad