As a final-year medical student with a keen interest in Trauma surgery, applying for a medical elective in South Africa was an obvious choice for Rasa. In this elective report, he reflects on a five-week rotation with the Trauma unit at The Chris Hani Baragwanath Hospital in Johannesburg, between the months of April-May 2023, and what he’s taken forward to his foundation years.
Introduction
The Chris Hani Baragwanath Hospital, known simply as “Bara”, is the third largest hospital in the world, and the largest in the Southern Hemisphere. The hospital is situated in Johannesburg, a city notorious for being one of the most dangerous on Earth due to its high rates of crime and violence.
Conveniently located on the border of Soweto, the largest township in South Africa, this government-funded institution provides free access healthcare for much of the local population. Approximately 70% of all admissions to the hospital are emergencies, including an estimated 160 gunshot wound victims per month1. These patients are filtered through the ever-busy Trauma unit, where they are assessed, stabilised, and then await further treatment.
The Trauma unit
The Trauma unit is split into two sections: Resus and the assessment area, colloquially known as “The Pit”.
Both of these areas are covered at all times by a team of interns (equivalent to foundation doctors in the UK), registrars, an on-call consultant, and medical students from the University of the Witwatersrand. The team is supplemented by a revolving door of international medical students and doctors of differing grades, who have arranged placements ranging from one month to one year with the trauma team. During my time, there were several Italian emergency doctors, a group of medics from the Swedish military, and a handful of German and British medical students. This made for a engaging and multicultural environment.
Shift patterns for students fall into either day, night or 24-hour shifts. Full autonomy is given to shift decisions with the request that at least one student is on each night shift to support the interns. Throughout my time, I found that there were more trauma admissions at night and therefore more learning opportunities.
When choosing shifts, I would recommend doing at least one 24-hour shift, if anything just to get a sense of what the interns have to do twice a week as part of their contract (and to gain an appreciation of the FY1 rota). Also, try to get at least one shift covering pay-day weekend or one of the local football games, as this is when trauma rates rise to their highest and you get a chance to see the unit in full swing.
Rasa Sadoughi at the Trauma unit, Chris Hani Baragwanath Hospital.
The Pit
“The Pit” is the entry point to the trauma unit . It is here that all new admissions are screened, before the decision is made as to where they will receive the remainder of their care. This is the medical students’ bread & butter; an endless supply of clerking of new admissions, blood gases, and the opportunity to do more cannulas than in your entire medical school training, in the space of one shift. As a result, I rapidly developed more confidence with practical procedures, suturing and the A-E assessment of patients. However, beware, as the interns will readily reward your eagerness by distributing their heavy workload to lessen their stress. This is understandable, but may put you in some difficult situations.
Nurses are primarily in charge of organising and distributing medical stock, and have little involvement in practical procedures on the shop floor. This can, initially, be a shock when compared to their more hands-on role in the UK. However, as in the UK, taking a little time to introduce yourself, learning their names, and making small talk, can have a hugely positive impact on your relationship. It might be the difference between getting your suture pack in one minute or one hour, as well as having someone to maintain motivation with on a slow night shift.
Resuscitation
Resus houses 12 beds which are reserved for more urgent and complex trauma cases. Common mechanisms of injury include: motor vehicle accidents, stabbings, gunshots and, tragically, a high number of paediatric and adult burns.These burns are an unfortunate consequence of poor health & safety standards around cooking appliances and roadside bonfires to dispose of household trash.
Unlike the steady nature of new admissions to “The Pit”, Resus is very stop-start. Often, 3-4 hours of a shift pass by with nothing to do, before a sudden influx of several seriously unwell patients all at the same time. The benefits of spending time in Resus included learning more about the assessment and management of the more niche trauma cases, and the opportunity to get involved and perform specialist procedures (under supervision), such as FAST scans, central lines and intercostal drains.
Trauma electives can offer a unique opportunity for eager medical students looking to practise more advanced medical procedures, such as intercostal drains, which may otherwise be reserved for more specialist trainees in hospitals back home.
There is a high level of competition between international medical students, international doctors and even domestic doctors to get a chance to place a drain. Doing a procedure really depends on who comes through the doors, who happens to be on-call (and therefore, how willing they are to let you get stuck in), and who is closest to the patient when the drain kit appears. My recommendation for anyone keen on doing these procedures would be to let it be known to the team early, build a good relationship with the Reg on-call, and be confident enough with the procedure so that you know what to do when the opportunity arises.
Overall, what I gained most from this elective was much greater confidence in approaching and starting the management of a sick trauma patient. By the end of the five weeks, I felt much more adept at completing full clerkings and carrying out procedures. I gained more confidence in seeking senior advice and better prepared in presenting a complete picture of the patient. At the end of the day, it was these skills which I have found most useful to develop, and which I will be taking with me into my first FY1 rotation.
Along the way, I developed my suturing skills considerably, having sutured countless wounds on all sorts of part of the body. I quickly learned from a plastics trainee everything from suturing lips, ears and eyelids. This was a consequence of several particularly busy night shifts in “The Pit”. Other notable experiences were developing my technique with the ultrasound machine, assisting in several intercostal drains, and observing a Lateral Canthotomy of the eye at close quarters on my last night shift. The latter was a procedure I never thought I would see in person, and a memory I will never forget.
I have strived to give a brief but useful idea of what is practically involved in this elective, however, I am sure there are a lot of things I have missed. I would urge anyone looking for more information to look at Nick Dai’s YouTube videos on his time at Chris Hani Baragwanath. Nick does a wonderful job of breaking down the placement, and I found his videos immensely useful in preparing for my own time there.
Pilanesberg Safari Park, South Africa
Life down south
South Africa is a beautiful country with incredibly friendly and warm people. No conversation starts without first greeting each other and asking, “How are you?”. I cannot stress this enough, especially given the fear culture built around violence and crime in South Africa. I found that a little common sense goes a long way, and I was able to relax and enjoy my time there in social spaces.
Johannesburg, though arguably not the most beautiful city in South Africa, has plenty of places to explore. In my downtime, I enjoyed evening drinks with the other students at the bars on Jan Smuts Avenue, explored the Sunday markets up in Rosebank, watched a rugby game at Ellis Stadium, and made the most of the insane exchange rate to enjoy fancy dinners at local restaurants. There were plenty of cultural activities available, such as a trip to the Apartheid Museum and Constitution Hill, or a guided cycle around Soweto, all of which give a much greater context for the communities you are treating and the society within which you are temporarily staying.
For nature lovers and hiking enthusiasts, there are a multitude of options if you want to venture out of town with several incredible areas of nature all within a day’s drive from the city centre. I would recommend Mountain Sanctuary Park and Thendele camp in the Drakensburg Park, both of which have mind blowing views and the option to stay overnight in a cabin.
If you have a little time before or after your rotation to travel, I’d highly recommend a visit to Cape Town. Cape Town made for a relaxing final destination, after a busy elective and week-long tour along the famous South-East coast, known as the Garden Route. Again, there is the opportunity for many nature escapes, wine tours, a trip to Robben Island, and lots of great bars and restaurants in the city centre.
Elephants in Pilanesberg, South Africa
Application process
Applications for this elective, as well as all other electives at the hospital, are done through the University of the Witwatersrand. Applications can take a very long time to be processed, with minimal contact from the university. For context, I applied via email in March 2022 and did not receive my confirmation until September, with no indication of any progress. I recommend applying as early on as possible and requesting regular updates from the administration team at the University of Witwatersrand.
Accommodation & Travel
When your elective is confirmed, Witwatersrand University will normally send an email with several recommended accommodation options. Most students, and doctors, stayed in one of two accommodations: Christine Loukakis’ house or Dr Alan Peter’s house. Both are great options and overall provide very similar experiences. Christine’s, where I stayed, had the added benefit of free laundry and a cleaning services as a part of your bill, whilst Alan’s seemed slightly more intimate and social, with the opportunity to accompany Alan (a doctor, ordained priest, and certified park ranger) on the occasional safari trip. Again, broadly, both offer the same experience for a very affordable price, and there is plenty of social contact between the houses.
The only two travel options are hiring a personal car or using Uber. As someone who doesn’t drive, I was lucky to be able to carpool with other students from Christine’s to commute to Bara, and used Uber on the days when I was heading out on my own. Uber is very similar to the UK, in that it is very readily available everywhere and generally safe. It was recommended to travel in groups, with the added benefit of being ridiculously cheap thanks to the exchange rate at the time (between £2-5 per trip).
Recommendations
Fairly early on in the elective, you’re going to have to decide whether you want to spend more of your time in the hospital on placement or outside exploring South Africa. I found myself being torn between the two early on, and opted to spend more time outside exploring, as that’s what mattered more to me. It’s very much a personal choice. The students who opted for more hospital experience tended to take on more regular shifts, meaning that they bonded a lot more with the team and had plenty of opportunities to carry out procedures. However, in my experience, they were a lot more tired and less inclined to spend their evenings exploring the city, and missed out on several of the hiking trips and safaris which ultimately ended up being the most memorable experiences for me.
I was particularly concerned about needlestick injuries and HIV transmission before coming on this elective. I was keen to get a post-exposure prophylaxis (PEP) pack to bring with me, but was put off by the hefty price in the UK. To give context, needlestick injuries were very common in the Trauma department, mainly thanks to sleepy suturing in the middle of a night shift. However, to reassure you, this hospital was responsive to needlestick injuries, with the Infectious Diseases department rapidly issuing PEP, and investigating infection risks.
It is essential to bring your own personal protective equipment (PPE) with you on this elective, along with medical equipment for yourself. My personal recommendations include: a decent sized bumbag, head torch, trauma shears, medical tape, Tegaderm, alcohol gel and a box of gloves.
Goggles are also an absolute must. I cannot begin to list the number of times they stopped a jet of Lidocaine or indeterminate bodily fluid from spraying me in the eyes, and sending me straight down the corridor to the Infectious Diseases department.
In addition, a hospital name badge or ID card holder is a great way to make yourself more recognisable to both staff and patients on the ward.
If you find time, try to arrange trips to other departments and with other services. Your time in South Africa is brief, after all, and there is much to see about how medicine is practised there. I was lucky enough to accompany Dr Peters on a medical post-take shift, seeing various pathologies diagnosed with expert clinical skill, and a variety of signs that we were never taught about in the UK. Christine is also able to arrange helicopter paramedic shifts for some of her students, another experience that I will never forget.
Finally, regular power outages (known as “load-shedding”) are part of the reality of living in South Africa. They can be unpredictable and last for a long time, so make sure to bring a decent book or a chess set.
Mountain Sanctuary Park, South Africa
Conclusion
I hope this report will serve as a useful resource for students considering a trip to Bara, if only to give a vague sense of what life and work in that busy Trauma unit can be like. For others, I hope it was an interesting read.
I deeply enjoyed my time at Chris Hani Baragwanath Hospitaland and in South Africa, and I am already planning to return later in my medical career.
