Surgery in the "2nd" World

Arthur Cotton

Brighton & Sussex Medical School

As part of my ongoing medical training, I spent 6 weeks gaining experience and training in the trauma unit of the largest hospital in South Africa’s Eastern Cape.

Port Elizabeth, the “friendly city” of the province, is a large coastal city of 2 million people situated c.470miles from Cape Town to the West, and 1000miles from Durban further Northeast.  The racial population is generally made up of White, and Mixed Race peoples speaking Afrikaans and English.  However, as the largest city in the region, it also serves a significant Black population speaking mainly Xhosa.  The government hospital complex is made up of 3 hospitals, each in their own racial area, reminiscent of the Apartheid era. However, since 1995, each department became centralised to allow equal care to all.

General and Trauma surgery resides in Livingstone Hospital.  The department is made up of 5 firms each with their own Attending, Residents, and interns.  Due to massive corruption, and a multi-million dollar deficit in the healthcare budget, budgetary constraints mean that true elective surgery no longer operates, and only semi-elective surgery can be attempted (in the rare cases the emergencies leave the theatres free).  The cases are extremely varied ranging from laparoscopic cholecystectomies, mastectomies, and hernia repairs right to exploratory laparotomies.  Later on, these same doctors would be taking the on-call, which was done in 24h shifts.  It was not uncommon for an SHO working on a Monday, to do a 24h shift on the Tuesday and then run an outpatient clinic on the Wednesday afternoon.

South Africa, in terms of medicine, is generally known for two things: HIV/AIDS & Trauma.  Indeed, 40% of patients admitted to surgery were HIV positive (and only 30% of these were on treatment.  Moreover, in terms of traumatic injury, 50% of patients with a trauma were from either stab wounds or gunshots.

With the huge volume of patients and the lack of healthcare professionals, I was welcomed into the department, seen as an extra pair of hands and treated and given the responsibilities of a first year intern.  On a typical day I was expected to do a pre-ward round on my own ward, assessing the patients’ progress (our firm had up to 20 patients in each ward), writing up blood results, chasing scans etc.  During the ward round proper the resulting jobs would be shared between myself and the other interns, which included taking blood, arterial blood gases, removing/re-doing sutures, removing chest drains, nasogastric tubes and catheterisation.  On a non-operating day, I would clerk in the pre-op. patients, while on an operating day I would assist in theatre.  Normally leaving the hospital around 6:30pm.  24h on-call days were the highlight of my elective, involving clerking, triaging and operating, all in an emergency setting, with cases ranging from gunshot wounds to tertiary abdominal sepsis to gangrenous feet.  With much supervision, I was able to take on the primary role in theatre.

Experience was of top class techniques dealing with the gross pathology of the poor majority.

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