Why so violent?

I have been at bara nearly 2 weeks now, and the time has absolutely flown by.

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(The entrance to the hospital, with lots of security)

The patients here are brilliant, often putting up with long waiting times and stressed staff. Despite this, they still bring a smile to my face and make the whole experience completely worthwhile. However, when I’m talking to these patients a question I ask myself is “why so violent?”. There is a wide variety patients coming into the department and below is the Medibank form for resus patients, showing the commonest aetiologies of trauma:

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One commonest reasons for assaults is ‘Mob Justice’. The townships in Joburg don’t trust the police, so instead take justice into their own hands. One common method for this is using a Sjambok, a long leather whip which causes tram track bruising on the patient.

Sjambok_(plastic)

Reference: https://en.wikipedia.org/wiki/Sjambok

This in itself isn’t serious, but can lead to crush syndrome where the muscle cells die and release its contents into the blood – later causing rhabdomyolysis and an acute kidney injury (due to acute tubular necrosis). I have seen several patients here with crush syndrome, as a result of a Sjambok attack.

Soweto, an initial english abbreviation for “South Western Townships” is the nearest group of townships to the hospital, and where a large proportion of the patients I see come from. This week I was lucky enough to do a cycle tour around some of the townships in Soweto, visiting the houses of Nelson Mandela and Archbishop Desmond Tutu. Perhaps more interestingly, I also saw the wide ranging living conditions of the patients coming to bara, and with open sewers running through the streets, in certain areas there was real deprivation.

This coupled with my visit to the apartheid museum gave me new perspective into the injustice this group of people have experienced in the last 100 or so years and made me realise why there are so many issues with unemployment, lack of education and violence. This includes the direct consequences of what colonial Britain did, digging for gold for our own prosperity at the expense of native and migrant population of Joburg. Although this country has come so far with its antiapartheid struggles –  it seems there is a long way to go yet before equality is achieved.

The most interesting case I have seen this week was a a patient who came in after a pedestrian vehicle accident. The patient had a GCS of 15, Stable vital signs (BP: 144/80, Sats 97% on air and HR: 80) 

His abdomen was slightly hard and tender. The first FAST (Ultrasound) scan was carried out which was positive with a visible haemothorax and blood around the spleen. Whilst this was going on, I put in two large bore IV lines and a catheter as well as connecting up the leads for vital signs.

After the secondary survey was done it was noted the chest wasn’t expanding well , so it was decided to put a chest drain in – which one of my fellow students did, supervised by a registrar.

After an hour his vital signs were still stable and it was thought a good idea to send to CT PET. 

As the Intern and I were preparing him to go to CT his BP dropped to 80 systolic, then to 50 systolic and then to 30 systolic. Fluids were pushed and emergency blood was ordered. 

Because the drop in blood pressure was probably due to an internal bleed, the solution to this, of course, was to stop the bleeding. In this case, there were two main options. Firstly, REBOA (Resuscitative Endovascular Balloon Occlusion of the aorta) and secondly a thoracotomy. The REBOA was performed, which initially failed, so an ED thoracotomy was performed. This is when the chest wall is cut open and the vessels from the heart and clamped to stop any further bleeding and to stabilise the patient.

As both of these procedures were being performed, the patient went into Ventricular Fibrillation and CPR was started. As I was doing chest compressions the thoracotomy was being performed, having to move my fingers out of the way as the blade was coming down to cut the skin. The surgeon was AMAZING, staying completely calm and carrying out the procedure successfully.

After this, I ran to theatre to get the internal defibrillation paddles. We connected up the defib machine and the pads and charged to 20J. The shock was delivered and the patient went back into sinus rhythm. 

The patient then went to theatre to have a pericardial contusion stitched and a mid line laparotomy with a splenectomy to stop the bleeding. The patient then was transferred to ICU. 

Obviously, this is a first hand account of what was going through my mind throughout the resuscitation but there was so many doctors working their absolute hardest to resuscitate this patient and it was an excellent demonstration of a team effort. The surgeons at Bara are well experienced, and it really showed.

Although for a different indication, this was pretty close to what happened: https://www.youtube.com/watch?v=t2vMV4Te_DQ

This case taught me the importance of having one person in charge in these situations, someone not doing anything specific, but rather looking at the bigger picture, making sure people don’t get too fixated with something specific. It also taught me to recognise the ill patients compared to the very ill patients – something you can’t read in the books.

Josh

 

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