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.

Cape Point

The day after Table Mountain I was having trouble descending stairs, my legs having had enough of that running down, but Sandra was having trouble getting out of bed having picked up a bug somewhere. That evening we decided physicians could heal themselves and on Tuesday we would join a tour down to the other end of the Cape peninsula. On enquiry however we balked at the fifty pounds a head cost (there is no pound sign on this keyboard!) and were changing our minds, when a voice behind us lamented the same problem... and suggested hiring a car to do the trip ourselves. So, with newly met Irenka (of the unsuspected Huddersfield Polish clan?!) and Jerome from Paris working as a trapeze artist in Mauritius, we did.

After a full hour spent trying to extract a car from the reluctant car rental company, who preferred to timestamp our hire and then have us wait in their foyer indefinitely, we set off southwards, me navigating, along the sea roads. Which were beautiful. One section was actually reserved as a scenic drive, called Chapman's Peak, although this could have been an excuse to make money from tolls as the whole lot was amazing. At the other end we found Simonstown, containing a naval base (who practiced helicopter manoeuvres over the bay while we were there) and an African penguin colony.

We followed the boardwalks down through the trees and past containers half-immersed in the ground (for nesting) to a small beach covered with small birds. They were very quiet which was a surprise. There seemed to be two groups, one dug into the sand on the open beach and one under the boards standing about. Those in the middle seemed pretty calm and looked like families (penguins mate for life) but the other group appeared pretty aggressive, they kept going for each other and ganging up. I even caught the moment of treachery when one slyly pecked his neighbour in the back.

This one looked lost



We progressed from there down towards the southern point, the actual Cape of Good Hope. Encountering some baboons on the way. These pictures are actually from later but still baboons.

I will try to finish this post later when there is time... but there was the Point itself, and zebras.

Table Mountain

WE CLIMBED TABLE MOUNTAIN it was very exciting.

There is a cable car to the top of the mountain, which I didn't know about. So most of the people on top had travelled the thousand metres up on that. Losers. We went up the proper way. We had a false start on this, the day before there was cloud over the top of the mountain so we wouldn't have been able to see anything, and we were too late to climb it in the morning before the noon sun. So last Saturday we (I) packed the 3 recommended litres and set off.

The so-called easiest route up is via Platteklip gorge which is roughly in the middle of the mountain as you look at it from the city. It starts with what would have been a pleasant hike up through some woods, with streams, lots of flowers and life etc, had it not been for the armada of flies which attached itself to each hiker as soon as they stepped onto the path. We saw some poor peroxide blonde whose hair now looked leopardprint. Once we got through the woods however and onto the barren rocks the flies stopped.

The next part of the climb was over boulders. Here they were all of a fair size and trodden in heavily (into each other) so they were at least stable, but orange rock for an hour is hard work. We were rewarded with steadily improving views on the way up. The worst part of this section however was the complete lack of shade. The tree cover had fallen away and this part was on the bare face of the mountain so we were in full sun for this whole time.

Eventually we started to climb into a depression in the mountain face which transformed into the gorge. Here the path began on a switchback route, necessary as I would estimate the slope as about sixty degrees. The rocks here formed occasional stairways, more by accident than design I think, and the "steps" were between one and two feet high throughout. Being a gorge there must be some streams that run through, and some vegetation reappeared. Fortunately without the flies! The best part of this section was that as the folded ribbon of the path reached the western edge of the gorge, some shade was to be found. Better still, here some water dripped from the peak which cooled the rocks we leant on and the leaners. Following our first proper rest of the climb and a liberal reapplication of sun cream, which with the sweat was dripping off us in unpleasant white rivulets, we progressed steadily up the gorge. The bright point of sky at the head of the gorge contrasted with the dizzying walls of rock surrounding us as we climbed, and the ground fell away behind us to a vista of the flat city below and bright sea beyond. The only animal life to be seen were birds wheeling overhead, flying between perches nestled in cracks in the vast bare rockfaces, orange flashing from their wingtips and their calls the only sounds, aside from our footsteps and the echoes of climbers ahead testing the acoustic properties of this funnel.

And eventually, after two hours of steady hard climb, the top. Which was crammed with the aforementioned cable-car losers. They were easily recognised by their sandals and dry shirts while we were pretty drenched with sweat. Again, losers.

The view from the top was incredible. You would expect the best to be had from looking over the city, but in fact the outstanding aspect was looking south. The Cape Peninsula has a backbone of a line of separate peaks known as the Twelve Apostles (there are about fifteen). Following the path along the southern edge of the table, we came upon the shop and restaurant and rewarded ourselves with some kind of yoghurt muesli thing for Sandra and a cold beer for me. While we sat in the garden the birds which until recently had been flying over our heads now hopped along the walls next to us.

As for getting back down again. Our plan had been to hike up and take the cable car down. However we had left ourselves impecunious... so Sandra took the cable car and I walked. Two hours up but 40 minutes down! My legs were like jelly and I had to stop a couple of times because I couldn't stand, before charging again headlong down the mountain. I only lost my footing once though.

Our legs were sore afterwards. It was worth it.

 

Robben Island

Friday saw us take the trip to Robben Island. The island is just outside the harbour of Cape Town and is infamous for being the site of incarceration for political prisoners during Apartheid, most notably Mandela.

We were warned that the trips book up weeks in advance but we just walked into the ticket office and bought a couple for the next sailing. Which was handy. The boat over was a hydrofoil and the waters here are rough. I did not enjoy the crossing. Once on the island itself we began with a coach tour around it which was good, as a desert island off the coast it is quite pretty if slightly bleak. Before use for a prison it was variously a leper colony, a slave colony and a prison again, and there was a museum of its history at this viewpoint:

After finishing the coach tour we were taken into the prison itself by a former prisoner, who explained how it was organised and how the political prisoners were separated from the ordinary criminals so they could not spread their ideology - reminded me of concerns about radicalisation in British jails. The ordinary prisoners were kept in large communal cells like these:

Now our tour guide said he was kept in such a cell. Which, reading between two not so tricky lines, means he was an ordinary prisoner. We didn't ask why. The mural in the shot is because after it was closed as a prison in the 90s it was used as... something else. Children? Can't remember. The sisal mat in the picture is what they slept on before the wardens were prevailed upon to install beds. The longest serving member of the South African parliament was a (white) woman who campaigned against Apartheid for most of its life, and it was she who was responsible for many of the basic amenities provided to the prisoners.

During the coach tour, as well as the standalone single pen in which Sobukwe, founder of the Pan-African Congress and the only political prisoner ever officially to be called that was held with his six guards, we were shown the quarries where the prisoners worked. Part of the prison was built with stone extracted by the prisoners themselves, who were then locked in it. Political prisoners, maintaining separation from the ordinary population, worked in the limestone quarry, which is why most of the leaders of resistance to Apartheid suffered from sight and respiratory problems: they did not have any eye protection with the bright white stone under the blazing sun all year round, nor was there any protection from the dust (which the guide alleged caused TB, clearly indirectly).

After visiting the prison sections for ordinary criminals we continued to the political area. Here prisoners were kept in single cells, the size of which shocked me. They were square, eight or nine feet across. A mat on the floor, a bucket and a small cabinet were the furniture. Mandela's cell (9) had its furniture:

Criticism of Mandela or any of the other leaders seems to be taboo in this country. They were locked up for terrorism after all. The only mention of this was in the gift shop, where newspaper cuttings from the Cape Argus newspaper at the time (biased against them naturally) gave descriptions of the crimes they organised. The roundups however were general, of all the organisation leaders.

The prisoners were numbered by the order in which they arrived in that year, stroke, the year. So Mandela's number was 466/64, which I've seen adorning t-shirts and I recall Mandeep in connection with it.

Last thing: the Cape being one enormous nature reserve/park and this being a desert island, there is a penguin colony. More on penguins in a forthcoming post about Tuesday's tour of the peninsula.