Megan Rybarczyk, EM PGY2
I had the privilege of completing a (short!) rotation at Khayelitsha Hospital in Cape Town, South Africa during the spring of my PGY2 year this year. It was quite a challenge to arrange this elective, as no one from my program had ever been to this site (one resident had been in South Africa as a medical student and could give me some information and two attendings had some experience/contacts in South Africa, but no one had navigated the logistics of an elective experience at this particular hospital). The preparation started eight to nine months prior with paperwork through the University of Stellenbosch International Office and the ECFMG – which was an ongoing challenge right up until I left for the elective. This elective was even more labor-intensive than others as I also submitted research and was accepted to give an oral presentation at WCDEM (World Congress on Disaster & Emergency Medicine) 2015 – so I was preparing for a clinical elective as well as my first talk at an international conference!
For further information for those wanting to do clinical electives – I also had to arrange for transportation (flights on British Airways), housing (AirBnB), a rental car (Avis, purchased their – minimum – insurance and arranged for additional insurance; also, US driver’s license is sufficient to drive in South Africa; finally, I purchased South Africa maps for my GPS to use while there), and evacuation/medical insurance (InternationalSOS as BMC does not yet provide this for residents). I did not obtain malpractice insurance (I was planning on working <20 shifts, so I decided to ‘go bare’), and I did not need a visa (if you can provide proof that you will be there for <90 days, you do not need one). I also needed to read more about the country/area (I had never been to South Africa), attempt some language learning (Afrikaans and isiXhosa, although English is the predominant language), and to visit the travel clinic to update my vaccines and consider taking Cipro and PEP with me (Khayelitsha has a high prevalence of HIV). Finally – BMC does not allow for long-term parking in the garages during electives – so I had to find off-street parking somewhere (I chose Braintree Logan Express – approximately $200 for the month – and cancelled my BMC parking for the month). To top all of this off, I was working in the SICU the month prior to leaving (luckily – I had a 24-hour call two days prior, was post-call, and then off the day prior to leaving – thank you SICU team!).
I departed for Cape Town early in the morning on April 8, and I arrived in Cape Town April 9 via London. Driving on the left side of the road for the first time was interesting, but it is not as difficult to settle in with it as one would think. I drove to my host family’s house that was at the edge of the wine country and between Khayelitsha and Stellenbosch. They were amazing – they helped me settle in, had me follow them to the nearest grocery store, and even invited me for dinner!
The following day, I was supposed to be at the hospital in the ‘EC’ (Emergency Centre) at 7:30AM for orientation. Unfortunately, I was slightly late after blocked roads (due to construction) made it difficult to get to the hospital. On arrival, I met my supervisor – Dr. Sa’ad Lahri – who gave me a very brief introduction and then paired me with one of the residents in minors/triage/’the front’ to learn the paperwork/documentation system. After only an hour or two, I was in headfirst in ‘resus’, working with the resident placed there to see the most critical medical and trauma patients. By the next day, I was picking up my own patients (with supervision from the senior residents) and basically functioning as a junior resident – seeing patients, writing notes and orders, starting my own ‘drips’ (IVs) and obtaining labs (done only by residents – none by nursing; and often with patients sitting or lying on the floor), doing procedures, signing patients out, and so on.
The residents there are grouped into teams of 4-5 and you always work with your team. It makes scheduling a bit difficult and the already short-staffed team can be even shorter staffed (if someone needs off for a wedding or other personal event, or if someone is sick, etc.), but it fosters camaraderie within the team, and you learn to work with everyone’s strengths and weaknesses well to improve and to provide better care – especially during critical cases. Attendings are there only for rounds in the morning (excellent times for teaching!) and occasionally later into the day, but are available by phone overnight.
The residents there are incredibly strong. They work under extremely stressful conditions – they run a department that consists of minors (green), pediatrics (green, yellow, orange), trolleys (mainly admissions to medicine and surgery, but also a mix of potentially very sick new EC patients triaged yellow and orange), asthma (yellow and orange and definitely not just asthma!), psych, and resus (red adults and children). There is usually a pediatrics resident, medicine resident, and surgery resident for their admissions, but this team of (maximum!) 7-8 residents (with usually a few other foreign residents mixed in) is potentially caring for a department of new and boarding/admitted patients that probably numbered close to 150 patients or more on average! To name a few more challenges: they have a limited formulary, they frequently run out of consumables (gauze, tape, culture bottles to name a few while I was there), there are never enough beds (most patients are in chairs or on the floor), and they only have x-ray and an ultrasound (that does not always work well).
The pathology there is incredible – unfortunately, a lot of very advanced TB and HIV/AIDS. I remember performing a thoracentesis on a 23-year-old woman with a pleural effusion from pTB (pulmonary TB) who also had disseminated TB and various complications from HIV/AIDS. We wore masks and isolated people as much as possible in the open rooms, however masks were often in short supply and the true isolation rooms were often already occupied with others with MDR and even XDR TB. Other common infections were PCP, CAP, and diarrheal illnesses. We even saw a couple of cases of varicella pneumonia.
There was also quite a bit of complications from chronic disease, especially diabetes – DKA/HHS were incredibly common. Also, CAD/ACS, COPD, asthma, CHF… It was rare to see someone above 60 or 70.
And then the trauma – what Khayelitsha is, unfortunately, known for. Weekends near holidays and/or the end of the month are the worst as people have the time/money (payday) for alcohol (a huge problem there along with certain other drugs, like tik = crystal meth) and more socializing. Stabbing with pangas (large knives) and community assault (beating with bricks and other objects) are common, along with MVAs and PVAs (pedestrian struck). The register book on Friday and Saturday nights is often full of the following entries: ‘stab neck’, ‘stab chest’, ‘stab head’. You often meet patients at the door of the resus room with a suture in your hand (usually a 2-0 nylon with a needle large enough to place the suture by hand without instruments) to temporize any arterial bleeding before moving them to a bed (if there is one). It was not uncommon to have patients who had been stabbed sitting in chairs in the hallway, or young men walking the halls with their ICDs (chest tubes) in place.
Those that are stabbed are usually young men involved in the gangs in Khayelitsha, but other family members, bystanders, and others also suffer. My last day there we had a young woman who had been mugged on her way to her work in the morning, and in addition to taking her belongings, she had been stabbed in the face with a panga. Intimate partner violence (IPV)/Sexual assault is also a huge issue – so big that there is a special area of the hospital that patients go to (we did not see them in the EC).
The staff at Khayelitsha can take care of the most advanced pathology in the EC, however, there is no ICU to admit to, no CT or MRI, and limited higher level surgery beyond trauma. Anyone who was intubated and needing ICU or specialist care was transferred to Tygerberg or another surrounding hospital. Unfortunately, we also did a lot of ‘aggressive palliation’ for those whose condition would not allow for a good outcome, or even survival on the at least 20 minute transport to Tygerberg (if one could get ambulance transport quickly, which was often a challenge).
Some additional challenges: given the under-staffing, patients would go for hours, and occasionally a day or more without being seen – sometimes with significant pathology (even CVAs, MIs). ‘Stable’ patients would occasionally pass away quietly in trolleys (waiting for admission) or asthma as it was difficult to round back through every patient on a busy night. As I mentioned, consumables were often in short supply, and it was often difficult to obtain beds for resus.
Overall, it was an amazing clinical experience – I worked twelve shifts (mainly 12-hour overnight shifts), saw quite a bit of advanced pathology, I spent quite a bit of time in pediatrics (where we all could use more training!), I learned to do some new procedures and to learn new ways of approaching others I already knew with limited resources, I learned a new/different health system, and I worked with and learned from some of the most amazing attendings, residents, and nursing/support staff I will probably ever meet.
I also had a great experience at WCDEM – attending several amazing talks, meeting leaders in the field of international disaster medicine and emergency medicine, catching up with old friends, and having my own personal experience of giving a talk at an international conference!
Finally, I did have a couple of days to explore Cape Town and the surrounding areas, such as going to Cape Point/the Cape of Good Hope, Robben Island, and the District 6 Museum. On my return journey, I also had an eleven-hour layover in London and was able to explore that city for the first time for a few hours as well!
Overall, an amazing and incredibly worthwhile experience – I am still trying to mentally process it all!