aka Postcards from the Edge 016
Each time we feature a ‘postcard from the edge’ from the somewhat infamous New Zealand-trained emergency physician Dr Sandy Inglis he is somewhere new — we last heard from him as a patient in Italy, now he is back in ancestral lands in Kwa-Zulu Natal.
Only 2 months have past in this, the wild west of Emergency Medicine, and yet the drama, the excitement, the frustration and the chaos make it feel like we have been here for years. I am employed here as the Head of Department for Emergency Medicine, plucked from the comfort of Australasian Emergency Medicine (EM) to come to this province of Kwa-Zulu Natal to make some sense of EM here. It is ironic that in this country where trauma kills more people than cancer and where 1200 died on the roads over last Christmas, EM, as a specialty is so undeveloped. I am one of only four EM physicians in this province and the only one in this town, serving a population of over one million. Other parts of the country are relatively flush though and nearly 100 EM physicians exist throughout the country. Academic EM abounds and registrar training is active, but we have a long way to go. “Casualties” are everywhere and, even here, I am at pains to explain to ED and in-patient colleagues alike, that casualty is dead and even ‘A&E’ is a dated term, but old habits die hard. Let me take you through some of what I went through to get here……
Despite being South African, holding a South African MBChB and being on the HPCSA (SA medical council) general register, as well as being a registered specialist in NZ, Australia and UK, my initial application to register as a specialist was declined; “lack of proof of training and specialist qualification’! What followed was a painful and drawn out exchange and a final review which successfully got me on the specialist register. Then my interview was the next hurdle. A telephonic interview to me in London; date change 3 times and then time changed twice; then the teleconference didn’t work, then it did; then I heard nothing for weeks (or was it months?). Then a colleague in the hospital managed to find and film my contract in the HR department and e-mail me the pics so I knew that I had a job! Then, despite calling the HR staff and requesting my contract it was never sent and on arrival I discovered that my original contract, signed by the highest authority, was in fact lost!
I arrived to start work on the 2nd January 2013; I was vaguely expected and on presentation to HR a few sheets of paper were thrust into my anxious hands to fill in. These were bank forms to ensure I got paid and overtime forms. On numerous later visits to HR to check progress further forms were issued in a torturous drip-feed fashion revealing departmental dysfunction beyond belief. Then, as if this wasn’t bad enough, on discovering that I had not been paid for January by mid February, I returned to HR to discover that HR had lost all of my paperwork and had to start the entire process again. Then to top it all, my ‘resettlement’ payment (outlined in my contract) to get me and my family and possessions to South Africa, was rejected by the hospital ‘cash-flow’ committee.
Then to work. My predecessor was still firmly entrenched in his (my) office as his was yet to be built. Thanks to this, we were obliged to share office, telephone and move internet cable from one computer to the other to check e-mail etc. We did the same for the printer. Parking for the HOD was hit and miss and if I didn’t arrive well before 0730h to claim my spot under the kitchens, where pipes drip old cooking oil and dirty dishwater onto your car, then I was traipsing around the campus through mud and debris to see where I could squeeze in.
With all the admin in order (I did get paid in late February!) its off to the ED. EM here is in its infancy. It has been born out of the surgical department and as such is very surgical with nothing like an ECG or nebuliser in site. The ED is essentially a trauma unit seeing an incredible volume of spectacular trauma; as much penetrating as blunt. Pedestrian MVA’s are prolific, knife wounds to every zone of the neck, belly, back, scalp and chest and bullets everywhere else. Trauma here is not sanitized or packaged on shiny yellow spinal boards with bright orange head-blocks; vehicles are unsafe; children sit unrestrained in front seats; seatbelt use is rare and airbags just don’t exist.
There is no warning and trauma arrives brutal and bloody, in arms, dragged in, out of backseats, deformed limbs, battered brains, spilling guts. Burns are horrific and are mostly hot water in kids but electrical and lightening burns are common and, worse of all, are the explosive fire burns and the revenge acid burns where palliation is the only option. The trauma support in the hospital is excellent with world class trauma surgeons who balk at nothing. We work well with them. The surgical side is more challenging. Thanks to its surgical origins, the ED has inherited the so called “SOPD” and together with it, a sort of hotchpotch triage where everything that is not medical, comes. Medical (or triage) officers wade through everything from sprained ankles to 3-week-old abscesses to goiters to lipomas to foreign bodies, directing traffic, signing forms, booking clinics, taking bloods, phoning in-patient teams. It is a monster that the ED needs to shed fast but the surgeons are way ahead of us and plan only a name change for this inconvenient collection that impinges on time in theatre.
Adjacent to our 6 trauma beds are 8 medical resuscitation beds. These have been provided to be part of this token casualty (sorry ED) and, although staffed by ED nurses, are administered and run by the physicians with ED coming in to help with resuscitations, ACLS and ventilating patients, as there is no piped oxygen or suction on that side. The pathology here is beyond belief with HIV, TB, renal failure, very sick DKA’s, sepsis, CVA’s, seizures, CCF, all sorts of toxicology, etc, etc etc. We would love to look after this part of the department but with SOPD around our necks and limited staff, that option is on hold.
I am the only Emergency Medicine consultant in the department. I have my predecessor who is a retired surgeon who has made amazing progress thus far. He is also a wizard with hospital admin and committees. Otherwise, we have 4 medical officers, 3 registrars (and 2 out on rotation), 2 community service (post intern) docs and 3 interns. It is a small team to run a busy ED (and triage and SOPD) and we have changed the roster from the original 28hour shift (8am to midday the next day) to a 12 hour shift, a day off post call and a late start the next day. A classic ED roster is impossible with the numbers I have.
Mind-boggling, as Head of Department, is the enormous administrative burden and interminable meetings; strategic planning, leadership discussions, committees for everything from resusc to disaster to quality to adverse events….core standards, MANCO, HOD’s, and every other acronym you can imagine. It is a battle to stay in touch with the coalface but twice daily ward rounds in ED provide ample clinical exposure and a Monday ‘on the floor’ keeps the stethoscope swinging. The academic programme is impressive with ED CME meetings, radiology, ICU round, Reg teaching, M&M and more. Opportunities for research abound.
The biggest challenge now is to transform this trauma unit/SOPD into a fully fledged ED. I envisage a transition involving a move away from SOPD, embracing medical emergencies and then defining ourselves as a critical care ED seeing only Code (triage) reds. (triage 1&2). The Oz/NZ model will not work here. We would sink in a week! Focus on the reds; do it well and then review. We are working on core business for ED for the province; getting it right will be make or break.
You don’t come back to work in SA for the money. Not only is getting paid a battle but I just realised that my 3 week locum in Oz last year paid one third of my annual salary here this year. Put it this way; I could resign my post here and work as a volunteer, do 3×3 week locums in Oz and I would be earning about the same amount. One bonus here is a 13th cheque on your birthday month but then there is no CME allowance, no company car, no communications package and only 22 days leave per year. Luckily the cost of living is minimally cheaper!
Outside the hospital life is definitely different. South Africans live on the edge. Angst is everywhere; dogs bark incessantly; you run watching your back; we sleep barred, bolted and alarmed. Our telephone lines have been stolen twice, valued for their miles of expensive copper and armed response is the norm. Many live closeted in gated communities, secure behind high voltage electric wire and security guards. They live comfortable and immune from the drama that is South Africa.
Beyond all this is the joy of being in South Africa. Society here is not pampered, not protected, not predictable, like in NZ or Oz. The thrill of being part of a slightly unstable social experiment; rules are vague. The beaches are golden and isolated, ruffled only by the prints of a giant Leatherback turtle coming up to lay her precious load of eggs; rugged game parks harbour stalking lion, gangly giraffe and massive rhino in their lush green bush and majestic vultures soar silently high above the dramatic Drakensberg. Eland graze quietly on sweet pastures nestled below the krantzes of these massive mountains. One feels, acutely, the joy of being alive here. Nothing is taken for granted. The rich scent of African earth after a vicious electric storm; the deep choral voices of Zulu men singing; the sight of Inguni cattle, with their marble-like colouring, drifting down our street like apparitions.
We feel privileged to be a part of it…..
from the edge
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.