Khayelitsha Diary - Two months working in a Cape Town Hospital
Updated: Dec 16, 2019
Mountains and Medicine
Both are now a defining part of my life. I arrived in North Wales in 1997 drawn by the climbing on offer, and it was one of the best decisions I ever made. Since then living and working in the mountains in the UK and overseas has led on to mountain rescue, medical training and now working as a doctor in the Emergency Department I first visited as a patient over twenty years ago.
When starting my medical training I wasn’t convinced I could make it work, the hours would be too arduous and I like my life too much – days off spend climbing, kayaking, long trips to the Alps or further afield. Six years later I have managed to juggle both facets of life. There has been plenty of alpinism, rock and ice climbing, kayaking, biking, mountain rescuing and family time amongst the hard work. A video of my thoughts on the challenges of that first year can be found here.
Ysbyty Gwynedd / Bangor Emergency Department
Bangor ED has been phenomenally accommodating and flexible in allowing this Doctor with a need to “feed the rat” the ability to continue working and developing my medical career while taking time out to pursue other ambitions.
In my final year medical elective I spent 5 weeks working in Tygerberg Hospital, Cape Town, South Africa, in the Emergency Department and Trauma Room. The work was inspirational and challenging, and left me determined to return to the country a few years later, when I could further develop my knowledge and skills by working out here as a Doctor.
Bangor ED have been totally supportive of this, allowing me to structure a less than full time working rota of 6 months ED work, alongside time spent doing “other things”. This includes personal climbing trips, developing my professional mountaineering work, and gaining further clinical experience overseas.
So now I am in Khayelitsha, working as an Emergency Medical doctor for 2 months.
Khayelitsha District Hospital (KDH) was opened in 2012. It serves the Khayelitsha township population of officially 400 000 people, but locals suggest is much larger due to transient migrant workers. The population is over 95% black African, mostly Xhosa speaking people, with over 50% unemployment and 70% of people still living in tin / wood shacks. Khayelitsha is Cape Town’s largest township.
During the week there is a mix of medical patients, from the simple infections to complications of HIV and TB which are rife. Paediatrics sees children often very malnourished, and currently there is a gastroenteritis peak among infants. There is trauma from road traffic collisions, and community violence – 99% of victims young males.
At the weekends, particularly at the end of the month, after “pay day”, the burden of trauma is enormous. Stabbings during fights, beatings with sticks, pipes and rocks, occasional gunshots, this is the “bread and butter” of KDH ED.
There is no ITU at KDH, and no CT out of hours. This is where the ATLS “Trauma x-ray series” still actually happens! Complex polytrauma is stabilised in the resus room, then transferred to Tygerberg Hospital if possible.
This is a snapshot of my first week in KDH, working with Team 4 in the Emergency
Haemorrhoids, HIV, TB and chest drains
'A classic introduction to emergency medicine Cape Town style.'
My first days was spent in “Triage” - seeing the less urgent walk in patients. My first patient was a male in his 30s with a painful, hard haemorrhoid. He also had a blood pressure of 220 / 140. Folk don’t go to their doctor here often, so may have undiagnosed pathology for years incidentally picked up like this. Renal USS was normal, so he was admitted to investigate his hypertension.
It’s common to ask people their HIV and TB status during a consultation, and there is a low threshold for testing if suspicious for HIV in patients presenting with infective symptoms.
My second patient was a lady with HIV on recently switched to 2nd line anti retroviral (ARV) treatment, as her CD4 count had dropped to 22 on previous treatment. She developed abdominal symptoms and loose stool for 4 days. This could be anything from the side effects of new HIV treatment, a routine GI infection to IRIS
(immune reconstitution imflammatory syndrome.) The immune system starts to recover (thanks to the new ARVs) but then attacks latent opportunistic infections such as TB which have been lying dormant in the body, with an overwhelming inflammatory response, .The ARV needs to be stopped while the infection is treated, then re-started. When this lady presented to the clinic 2 days ago her CRP was over 200 although her diarrhoea had settled a week prior. This may or may not have been IRIS but on todays bloods her Hb had dropped to 65 from 85 3 days before, with no active bleeding. Anaemia is a common side effect of most ARVs. She was admitted for a transfusion and further investigations.
A young man had been attacked with sticks and kicked 2 days ago. He presented, covered in dirt, in pain, with swollen hands and painful arms. He had bruising to his back and chest. On examination his abdomen / left chest was very painful, it was difficult to tell if he may have an intra-abdominal injury. Ultrasound FAST scan showed no sign of abdominal injury, but on examining the chest with USS – good movement of pleura on the right side, not good on the left side.
We re-examined the CXR I had documented as “no bony injury seen” and “no pneumothorax seen”. There was a clear apical and lateral pneumothorax visible on the left side, and 2 fractured distal ribs 9 and 10.
I was annoyed at myself. I had listened for reduced air entry and heard good AE bilaterally, but now re-listening more carefully, he had clearly reduced AE anteriorly on the left apex.
Also my CXR interpretation was very lacking! (we've all had those moments ED)
I placed a chest drain under my colleague’s supervision – I hadn’t done one since my last visit to SA, so was a bit rusty. He drew up 100mcg of Fentanyl, and we moved to a “procedure room” (it’s actually just a “room”). He was very happy about sedating the patient in the “procedure room” without any monitoring, resus kit etc. but I was a little uncomfortable so took an oral airway adjunct and bag valve mask to at least be able to support his breathing if required. The patient was pretty drowsy anyway so I didn’t want to knock him off. The procedure went well – my muscle memory from having done this a few times 2 years ago came back quickly, and helped prop up my confidence after my previous diagnostic errors!
night shifts got me familiar to the concept of “community assaults”. Essentially, an individual (usually young males) caught or suspected of stealing or other nefarious acts in the local community is given a proper beating by all and sundry, often with sticks or metal pipes. If they survive, they get to the hospital. Defensive wounds to arms and multiple bruises across the back and torso are common. Rhabdomyolysis (“crush syndrome” as they call it here) is common also, with patients getting plenty of IV fluids and regular renal monitoring. I review such a patient in resus, he is GCS 15, airway fine, reduced breath sounds in left upper zone (I listen very carefully now). Trachea central no obvious bony abnormality. Sats 92% on air, rr 24. Upper arms welted and bruised, tender but good ROM. Abdo soft, but he is FAST scanned anyway – no free fluid seen.
I ask for oxygen to be given – the nurse looks a little flustered then returns and puts a face mask on the patient. I am busy requesting a CXR, when I turn around he has been placed on a 40% venturi tube attached to a paediatric mask which barely covers his mouth and nose.
His CXR shows a clear left sided pneumothorax, which I knew it would, so have already prepped a drain kit. No seldinger kits here, everything is blunt dissection. Gareth my Aussie medical student colleague assists and it goes well.
A man who fell over a week ago and cut his leg open has presented as it is now twice the size of his other leg, oozing pus and red spreading up to his groin. He keeps asking if he needs to stay in and have his cannula in. I keep replying “yes” and refer him to surgeons.
A young man has a large left pleural effusion. It is almost certainly TB. I use perform a therapeutic tap under USS, over 2 litres of straw coloured fluid is drained, samples sent to the lab. He is discharged and will see the clinic (his GP) for the results, if positive for TB he will start treatment in the community.
TB is so prevalent that we should really be wearing N95 respirators all the time. Many local doctors have long since stopped doing so, but certainly when there is any actively coughing patient in the department, we try to keep them on. It is a blissful relief to take the stifling mask off during our breaks in the FIKA room. One of the consultants spent some time in Sweden – where Fika means “coffee and cake break” - so decided to rename the staff coffee room. Our team is friendly and welcoming. Myself and 2 medical students from Australia are made to feel part of the group instantly, and we are all benefiting from the experience of guys who have been doing this regularly for years, dealing with limited resources and doing a pretty incredible job despite this.
Later, sat at a desk completing some paperwork, I immediately sit bolt upright. I can hear persistant, severe stridor. I scan the patients sat in front of me, some on chairs, others sleeping where they can find space on the floor. I follow the sound to a man lying on the floor sleeping. His breathing is clearly stridulous. I wake him to examine and find out what is going on. He has HIV, on 2nd line treatment, with a clinic letter stating his CD4 count was 2! If true this makes him suseptible to just about any co-infection and AIDS. His mouth was flecked with white lesions on the tongue and right tonsil, which was inflamed and his uvula was tethered. Otherwise he was comfortable, not in respiratory distress, not drooling, and no stridor when awake. He had come in with abdominal pain, there was no comment in the letter or from the patient about any breathing difficulties. “Are you sure you don’t have problems breathing”? I ask. He points to his neck, there is a surgical scar over his trachea which is visibly tugging when he inhales. “Well I was shot in the neck 2 years ago, I’ve had this noise since then.”
The rest of the night is spent intermittently reassuring any other doctors who come out to find out where the worrying sound of airway obstruction is coming from every time he falls asleep.
My last patient of the shift has come in with a week of feeling generally unwell and vomiting. She has a butterfly rash across her face sparing the nasolabial folds. Similar cutanous lesions on the forehead and cheeks, and posterior surface of arms. No joint swelling. Widespread ucerations on tonge and oral mucosa.
She is referred to medicine? Lupus / vasculitis. Blood results go on to show she has almost certainly got SLE with discoid cutaneous lesions.
In 2 weeks I’ve learned a lot, with a lot more to learn. It’s varied, interesting, challenging, sometimes a bit scary. I suppose that just sums up Emergency Medicine.
I have climbing friends in Cape Town so am lucky to be able to get buddies to go out with on days off. The rock climbing is outstanding, and Cape Town has other fun places to visit, beaches, surfing, eating out etc. I’m enjoying the days off, but it’s not my main focus, so I’m okay with just getting a few days out here and there.
I’ve invested a lot in this experience. The placement was organised through Stellenbosch University, who also organise undergraduate electives around Cape Town. There was a lot of frustrating paperwork to do months in advance, and the bureaucratic hurdles are annoying and numerous.
Accommodation was arranged with the University, it allows me to share travel to work with student colleagues. A hire car is pretty essential for getting to work and for days off. Overall the whole trip will cost me more than £2000, which I regard as a solid investment in my medical training and experience.
There is a lot of complaint in the NHS about “burn out” and “lifestyle”. Rightly so. These are serious issues which are unlikely to get better without proactive outside-the-box thinking by both doctors and their employers. I am grateful to live in a stunning part of the UK with a flexible and friendly hospital working environment, that has allowed me to continue enjoying and thriving in my medical work, not just surviving.
My thanks to Bangor Emergency Department who have allowed me continue this great work / life balance. Come join us!
Dr. Jamie Barclay is an FY3 Doctor currently working in Emergency Medicine in Bangor, North Wales. He is a professionally qualified Mountaineering Instructor (MCI), and member of Ogwen Valley Mountain Rescue Organisation.
Dates and patient demographics have been adapted to maintain confidentiality.