S4E3: “Pivot. And Pivot Fast.” Experience of a Trauma Fellowship in Johannesburg, South Africa
In Conversation with Dr Jimmy Lee
In our second bonus episode centered on South Africa (you can find the first here), Callum sat down with TCR veteran Dr Jimmy Lee, Consultant in Emergency Medicine in University Hospital Galway. Having worked all around the world in low income settings, Dr Lee is currently working in Afghanistan with Médecins Sans Frontières.
In this episode Dr Lee speaks of his unforgettable experience completing his Trauma and Resuscitation fellowship in Chris Hani Baragwanath Hospital in Soweto. With over 2,000 inpatient beds and a dedicated trauma unit, Barra hospital ranks as the 5th largest hospital in the world. Coupled with its location in an area with unfortunately high rates of violent crime, and variable reliability and access to resources, working in the trauma unit poses unique challenges not often faced here in Irish EDs.
Dr Lee’s experience and pearls of wisdom are not to be missed. Right then, let’s get to it. Get ready to pivot, and pivot fast.
Model of Emergency care
The hospital itself is split into 3 main sections - the medical unit, the surgical unit and the trauma emergency center. As the unit is a tertiary referral center, all trauma referrals are initially seen by the trauma surgery team. All trauma care falls under the trauma directorate - thus registrars are responsible for overseeing the trauma ICU and HDU, the burns ICU, overseeing the interns workload of initial presentations as well as the trauma wards.
Staffing
The department is made up of around 6 trauma consultants, 5 registrars from South Africa, as well as 5-8 international clinicians completing fellowships who act as registrars. The majority of these international registrars are European surgeons and anesthetists with a special interest in trauma. Dr Lee remarks on the trauma vs medical mentality, and views trauma surgeons as “emergency physicians who cut”, in reference to their pragmatic and practical approach. There is always a senior registrar who is available to operate, a registrar to give oversight to the interns and the rest are usually working in the resus. Dr Lee describes a “small army of interns”, who are well used to seeing over 30 patients each in a shift.
Patient Categorisation
Patients are split into 3 main characters based on their triage at initial presentation
Low acuity - without a referral - are sent back to the centre they originally presented at or directed to a minor trauma unit
Moderate acuity - assessed by the interns in the “Trauma Pit”
High Acuity - These patients are brought to resus for assessment and intervention
Resource limitation
The resus in Barra hospital essentially functions as a 15 bed trauma ICU. It can see a workload of between 20-30 gunshot wounds a day. It is equipped with 6 ventilators, 2 transport ventilators, a full xray body screening device, and an ultrasound machine which is split between the trauma and surgical units.
Despite regimented pre checks of supplies, Dr Lee observed that something seemed to always stop working or run out. On the misconception that one can only practice bad medicine in low and middle income contexts, may we present to you - the humble foley catheter. Used for its balloon, a foley catheter can tamponade a bleed while awaiting definitive management in theatre. “The use of Foley catheter tamponade for bleeding control in penetrating injuries” was published in the Scandinavian Journal of Trauma and Resuscitation in 2021.
As mentioned in our first South Africa special, autotransfusion is frequently used to good effect.
“It wasn’t uncommon to approach some patients with 5 tubes - one for the airway, one for the outputs, one for the bleeder and two for the chest.”
Reconciliation Day
In the second half of the interview, Dr Lee talks extensively about Reconciliation Day, a day notorious in South Africa for high rates of violence. From the simultaneous failure of 14 ventilators to using eFAST as a triage sort tool to setting the department to “Divert”, Dr Lee’s experience is insightfully pragmatic and contains many learning points, the concept of which can be applied to an Irish context. Listen in now to hear all about it!
