Bloody Hell, Mate, Bloody Hell.

It's hard to believe that less than a week has passed since I landed in Johannesburg... so much has happened already that it's difficult to keep track, even in my own mind, and harder still to reiterate it all on paper. For starters, I'm working crazy hours... this, of course, is mostly my own doing (we're required to work a minimum of 3 shifts per week, while I'm working 5-6), but although it's nearly impossible to roll out of bed in the morning (I swear, I don't sleep, I hibernate), once I'm actually at the hospital it's *fantastic*. As of this post, I've worked three 12 hour shifts so far... Sunday, Monday, and Tuesday afternoons. I took today off, and am going to be working Thursday, Friday, and Saturday nights this upcoming weekend (that's 6pm-7am). Since I'm only here for two months (well, working for two months, anyway!), I want to put in as much time on the trauma unit as possible to get the most out of it... though, honestly, even one day in Johannesburg is equivalent to about a month back home... the learning here curve is steep, but the rewards - skills, confidence, and of course adrenalin - are second to none.

The emergency rooms here are set up differently than in the US; due to the enormous volume of severe trauma (gun shot wounds, stab wounds, MVAs, train crashes, etc), the "major accidents" division is separate from the medical and pediatric units, which means that the only thing we see (non-stop), all shift long, is serious trauma. And although places like Camden, NJ and the Bronx boast high patient volumes, they don't even begin to compare with the insanity of Johannesburg. Even though apartheid ended over a decade ago, the terrible social and economic situation hasn't really changed for most black South Africans... if anything, because of the mass emigration of whites out of the country and re-distribution of jobs into not-so-competent hands, a great deal has gotten quite a bit worse. Widespread unemployment is contributing to social unrest, alcohol and drug abuse, and, inevitably, to violence (in poor areas like Soweto and Alexandria, unemployment is as high as 50%, and even higher amongst young adults). It seems that there's an ever-growing culture of violence... young men (and, occasionally, women) come in with brutal injuries from stabbings, shootings, beatings... there are constantly reports of random violence around the city, and the entire population seems to live in fear. Driving around, there are walls everywhere - 10 foot walls with electric fences and barbed wire, fancy surveillance systems, and guards. The poorer neighborhoods are a no-go for anyone not from there (and frankly I don't think the residents are particularly thrilled about it either); the culture of violence is driving a culture of fear and distrust, which, of course, perpetuates itself in a predictable cycle. Johannesburg is one of the worst cities in the world for all of this... which, I suppose, is exactly why I came here... so, to begin...

I was only scheduled to start this Monday, but after settling in on Saturday (I bought an electric tea pot and some local tea, called 'Rooibos', so I'm set :), I decided to go in for a few hours on Sunday to get oriented. Well, about 15 minutes in, my "orientation" was cut short by - what else? - a major trauma. Any time a seriously injured patient is brought in, somebody yells "resus!" (resuscitation), and everyone rushes over to one of the trauma bays in anticipation of their arrival. Although the physicians here are generally very well trained (and obviously, quite experienced), things don't always go smoothly, mostly due to equipment problems... for starters, most of the monitors don't work, there's only one (poorly) functioning manual blood pressure set, and supplies beyond the basic bandages, tapes, and tube sets are nearly non-existent. Just to give you an idea: the other day, we applied traction to a patient's femur fracture using several saline bags in a plastic garbage bag, tied to the end of his splint! And this is a level one trauma hospital in a major city... and apparently, things used to be even worse. Anyway, so getting back to this patient... as this was my first resus, I stood back to watch the flow of things... another elective student, Colin (a Scotsman from the UK) started an IV drip while the two docs intubated the patient, drew gases, and started a central line... all in minutes. It was honestly kind of like ER but, well, real. Very real. Unfortunately, this patient actually had to be resuscitated in a procedure cubicle instead of a major resus bay... why? Because the resus bays were all being used to monitor post-op ICU patients! That's right folks, critical ICU patients - on vents and all - were being monitored in the emergency department by a skeleton nursing staff... and displacing the trauma patients coming in to surrounding bays and, well, the hallway (The ICU - and the entire hospital in general - is terribly overcrowded and patients who need intensive montoring are constantly spilling over into the ERs...) In any case, halfway though the resuscitation, the physician placing a chest tube suddenly got a massive shot of bright red blood all over his scrubs... all was quiet for a moment, and then the startled doc shrugged and said "oh, bloody hell, mate!" and continued on. To survive this place, you have to be laid-back about pretty much everything, or else you just won't make it.

My 36 hours of work have been busy, incredibly rewarding, and, admittedly, a bit sobering. I'm doing my best to cope - the long hours, wide array of accents (I think I'm starting to sound a bit British?), different culture, city, names for things... and, of course, the ever-present undercurrent of tension that is steadily, constantly palpable. So far, I've placed a chest tube, assisted with a central line, set up countless IVs and drawn more ABGs than I can count, and sutured like crazy. Yesterday I had a marathon suturing session - an hour and a half of standing, straining, and threading, with a woman named Elizabeth. Elizabeth is a black maid from Soweto who works in an upper-middle class suburb of Johannesburg. She was on her way to work yesterday morning when she was hit by a speeding car, apparently flipped over the roof and was thrown down onto the pavement. She was airlifted out and brought to our trauma bay in severe hypovolemic shock, with a broken femur, head injury, and massive degloving injury of the scalp. Once she was stabilized (somehow, amidst the chaos, we do manage to save some people...), I was given the job of suturing her. Now, I can't stress enough how difficult it is to neatly suture up a degloving injury, particularly one in a highly vascular area like the scalp; back in the US, even a senior EM doctor probably wouldn't do it, instead leaving it to an experienced plastic surgeon. But, of course, this is Africa, and I was the best we had. Elizabeth was heavily sedated, but sometimes patients can hear what's going on around them anyway, so, I guess for lack of any better ideas, I spoke to her while I sutured. I told her what I was about to do and why, explaining the procedure and promising to do my best. The longer I stood there, the more, well, human she became to me... even with all of those tubes, bandages, and bright lights, even with the swollen face and broken teeth, she somehow reminded me of, well, any middle-aged woman... it could happen to anyone. I thought about my family - what kind of care would I want my mother to get in such a situation? I spent a lot of time suturing Elizabeth, thinking... when the orthopedics intern introduced her to the attending as an "unknown female", I hastily corrected her; It became important to me that she was recognized for who she was - Elizabeth, a maid from Soweto, with a husband and two young children. Probably because she wasn't just another gangbanger or thief, but just an ordinary person trying to go about her life, I was willing to see her as more than just a body to resuscitate... it's dangerous, perhaps, to get attached to patients, but I think it's also what makes you a good physician. I checked on her this afternoon, looking a bit better and now in a proper ICU bed upstairs; She'll live (though the extent of her brain injury is still unknown), and, hopefully, she'll like her forehead when she finally looks in the mirror. It's a small thing, I know, but then it's the small things that, bit by bit, make me feel that - at least once in a while - I can make a difference, and perhaps through that contribution, make sense of the chaos that is otherwise overwhelming in its senselessness.

I'm learning so much here - about medicine, people, politics, and, as always, about myself - I made friends with Colin (who happens to have a car! yay :), and his landlady's dog, so I have company... we're spending our days off exploring the city; I went out to dinner in Melville yesterday, walked around the Johannesburg Zoo today, and am working on organizing a walking or cycling tour of Soweto for next week. The next few days are going to be hectic, but I will definitely update the blog again on Sunday, once i've caught up on sleep... and, as always, I will continue to post up more photographs! Below are three from the safari days... my god, that feels like a lifetime ago...


Relaxing at Lake Manyara, Tanzania


Photographer on assignment! :)


Photographing up close (I need a longer lens!) in the Serengeti... this bird wandered around our campsite, scavenging for food...

Me with Maureen in Tanzania (the daughter of the teacher/ ice cream maker)