ATLS, protocol and thinking

Wednesday morning has a sort of unit meeting/academic meeting feel to it. There is the regular morning report on all the recent resuscitations, followed by the ITU ward round, the morbidity & mortality meeting and a rep plugging some white elephant.

The M&M meeting was interesting. One case, for instance, was a stabbed heart. The reg who tried to fix this (yes, registrars repair stabbed hearts here) explained what happened, how the patient was transferred in, quickly assessed, intubated, cannulated and pushed to theatre, how they tried to repair it, almost succeeded and watched the man die five hours or so later. Meanwhile the consultants opposite tried to decide whether this was avoidable, unacceptable or inevitable. I understand that these meetings are for apportionment of blame and to deflect liability from the hospital. And I understand that recording these things may be useful. But for one consultant to restrict his response to asking if there was any deviation from protocol, and for the other to try to decide from behind her computer if the transfer time from the outskirts of the city means this was an avoidable death (to well-deserved derision from the registrars), is absurd. During the ITU ward round the head of unit said that there is no intellect in what they do because they just go through the systems and fix them. He meant this to reinforce a systematic approach to patients. It was disappointing to see the obvious progression of automatism in his consultant staff.

I did an ATLS course a couple of weeks ago. It was interesting and useful: I sort of knew how patients were meant to be approached before, but being shown how to do it, as well as being taught how to actually do a central line, cut down, DPL etc, was really useful and while I won't try, I feel like I could lead a resuscitation if I needed to. Central to ATLS is sticking to the ABCDE principles. When you don't have much experience, this structures are necessary. As you progress in experience and understanding, they become a reflection of what you do rather than the instructions. I hope that when I am a consultant I don't revert to decerebrate reflexes: not did you treat this patient, but did you treat this proforma.

There's a movement towards scrapping the four hour wait target in UK A&E departments at the moment. I understand that it is irritating and sometimes interrupts clinical practice, and I understand that it has helped bring down waiting times as part of investment and restructuring. Here, patients who have the misfortune to walk in looking relatively alive can wait for hours with no facilities (a problem shared by staff) and no indication of when they might be seen. The four hour target is a protocol which probably helps. It makes the staff's lives more difficult by making them actually work (I would love to see it implemented here) but it probably doesn't change outcome much. I would hope that a properly run department would have no trouble seeing the patients who needed it in good time, and I wouldn't mind seeing primary care patients suffer for turning up to the wrong place - here they get sent away. It probably causes more problems in small units than large ones, who may need to overstaff or fail it to cope with variable patient loads. It is a protocol, and is useful up to the point where you don't need it any more.

Town & music

On Saturday we got up early-ish and went for a wander round the centre of town, a mission which most white South Africans would not accept. We started off up the Carlton Centre tower which affords views over the whole of Joburg (city as far as the eye can see to the north, looking south it ends abruptly in a goldmine's slag heap). You can also see onto the rooves of surrounding buildings, which host whole families. Then we went for a walk down through the town, where we played spot the white person, I think we saw three but one of those we weren't sure about. We skirted the edge of what I think was called Library Gardens, we were going to go on but I wasn't keen on passing the trade union demo and being identified as the enemy. Then we reached the old stock exchange, which along with the rest of the business district upped and left in the 80s and 90s for the northern suburbs, abandoning the office buildings, many of which are now inhabited and making for an exciting if tense tour of the district.

After lunch in the chinatown we left as soon as we got back for a music festival called Sonic Summer. We got there early afternoon as it was all getting started, beautiful sunshine, on a riverbank, and a reasonably priced bar tent. Then as the bands got started... so did the thunderstorm. Added a new dimension to the experience.

First two headliners were called Locnville and Jax Panik, they were both dreadful. The former were teenage boys jumping around and the latter wearing masks singing about something unmemorable. Then were Goldfish who were the best, dance act whose songs I recognised from the radio here. They played their tracks and saxophone, double bass and flute over the top.

The previous night Carrie and I had looked up some of the bands on youtube and had watched the next band's video and both woke up humming it. Brace yourselves. They were called Die Antwoord (the answer, probably) and ingratiated themselves with the crowd by advising us to go forth and multiply. They were pretty odd. When we mentioned them the next day they were apparently a reason to be ashamed to be South African when they toured in Europe.

He's a ninja. And he's got your nose.

I thought they were funny. Sandra didn't. It was difficult to tell what they were on about because when it wasn't in Afrikaans it was indistinguishable from it through the heavy accent. They had the crowd entertained though, apart from us who fled the storm for the fifth time. The beer stand was a shed with three sides, and in front of the open side a large tent with benches, which threatened to blow away and so was taken down some time during Goldfish. So we jumped into our taxi and tried to warm up. The festival was good, but next time we might pay more attention to who's playing before going.

Johannesburg Academic Hospital

The hospital may be large but it has large problems.
If it were a "resource poor environment" I would forgive it if it did the best it could in the circumstances. But it has facilities on a parallel with anything in the UK or even better. The fundamental problem seems to be that nobody really cares about making it better.

Let's go through a typical resuscitation. Patient arrives at the door without warning. Eventually somebody looks up and opens the cage door, letting the ambulance crew in. After a while a doctor will wander over to ask what they're doing there. Then they will call "resus" and walk to the resus bays, hoping the crew will push the patient after them. Once someone has remembered to bring a bed in from the corridor they'll carry the patient onto it. Following a brief argument over who will take each role, the airway etc will be dealt with expertly by doctors with more experience in their internships than I can imagine on most UK registrars. However, once the drainpipe-gauge cannula has been effortlessly slid into place, the needle is dropped on the floor because leaving it on the bed would be dangerous. Now our patient needs a chest drain. "Blade please" and one is dutifully produced, but no handle so you just hold the blade in your hand. "Exposing" - what? Oh, the radiographer has marched into the next door bed and just zapped everybody's gonads: everyone there is wearing a lead apron but nobody warned the ten people round the other bed. Now our patient is stepped down into the sort of ITU bays - where they kick resus patients after half an hour or so. Not clear what's intensive about it though as nurses are usually nowhere to be seen in this area. They are more likely to be on a break, or chatting in zulu behind the desk ignoring the queue of patients, or singing hymns for half an hour every morning at the same time as handover so nobody can hear a word that's said. Certainly they won't be restocking the drawers or shelves or cleaning the pools of blood in the resus bays or covering up the patient who's dropped their sheet or asking why they're moaning with pain or keeping an eye on the one with the tracheostomy and bleeding face or keeping up the sedation on the guy with the head injury who's meant to be knocked out for two days but is now trying to pull out his tubes in every orifice.

Yesterday I asked them to do the observations they're meant to do one everyone who comes in.
"But we have doctor". Where? Oh, on this bit of paper I left on the desk without the patient's name and nowhere near them or the file. Right. So what's the blood sugar? "Should I do that doctor?" Yes good idea sister. Ten minutes later she finds the machine (hidden so it doesn't get nicked), right, so what's the temperature? No can do, we don't have any thermometers. Yes, really.

It's not just nine out of ten nurses who are pointless. This is a country with first world chronic disease, third world infectious and malnutritive disease, and the whole gamut of untreated AIDS. The doctors here have seen every kind of pathology you can imagine and they are expected to be able to treat all of it, in contrast with our one hour lecture on "malaria and other diseases". Some of them are pitch perfect every time. Others are hopeless. I have watched one registrar receive a patient, decide the endotracheal tube is too small, and spend twenty minutes trying to change it, demanding the bed be moved backwards, up, down, a chair fetched, a chair taken away, and shouting at everybody present because she can't do it, before deciding to give up, then trying to carry on with the rest of the resuscitation and finding the massive haemothorax. She was clearly inexperienced despite being notionally in charge, and had no idea how to control the room with the result that nothing happened. The next week she spent an entire Friday night shift sat in a back room, while the two SHO-equivalents spent the night resuscitating patients and I dealt with the rest. On the other hand, thinking about a different one now, nobody in the UK would do a thoractomy without their consultant breathing down their neck.

Case reports to follow.

Johannesburg

Firstly, it is difficult to find a computer here. So that's why I've been incommunicado.

The accommodation is serviceable, the hospital is large, the city has a range of standards.

The city does not appear to have a centre. It used to, but it was abandoned when it became the biggest crime district. There are areas for going out which you must drive to (and drive home again in an almost-straight line) and areas for living in, none of which are near us: we have Hillbrow which is marked on the map I was given on arrival with a big red X as a no-go area. Leaving the campus on foot is both ill-advised and pointless as there's nothing nearby. The city is covered with trees. Looking out of the windows it resembles a forest, and indeed satellites apparently register it as such. Much more is difficult to say about the city because nobody seems to want to look at it: there are malls which are safe and that's about it. You can't just go out for a walk like I've done in every other place I've ever visited.

The accommodation is pretty basic but acceptable. There are loads of elective students here, coming and going, although currently there are five from UCL which was a surprise. The roof (12th floor) is accessible if you know where to find the door and we've had a couple of barbecues up there. You get a panoramic view of the city which is great, and the regular evening thunderstorm makes it more interesting, watching the lightning hit the tower blocks around and the sky darken in minutes.