My elective as a medical student in South Africa

Since my arrival, I worked every day between 10–12 hours on average, including one night shift so far. That night really hit hard – like being in a war zone. Words can’t really describe how i feel after that shift, it is just so different to everything i have ever experienced. At around 3–5 a.m., there was just this sudden influx of patients – all with gunshot wounds or stabbings. Some of them were quite stable, while others got an ICD (intercostal drain) instantly. Out of nowhere, the area with the critical patients is full, all monitors are beeping, and just a lot is going on at once. And i got told that this was a normal night! Nothing special, just the baseline. Already looking forward to a night at the end of the month, where it usually gets even worse.

I’m still not fully adapted to how things are done here. Organization is still the biggest critique I have so far – nothing works simply, you always need some form. But finding it and then filling it out correctly is not intuitive and just insanely frustrating at times. And asking the nurses is also not always the solution, some are so helpful and nice – while others are just unfriendly and don’t even look at you when you want something from them.

The medical part is still absolutely fascinating. Yesterday night I saw my first tension pneumothorax after a stabbing to the heart – including emergent thoracotomy in the ER. Just mindblowing how this works here. I think there are not many places in the world where doctors have more experience in invasive procedures. Everyone is calm, focused, and just does their job.

My own skills I gained so far: I often get sent to look after patients when they get a CT done – and that can be someone who just got shot or stabbed in the thorax or abdomen. I’m there on my own, without any monitoring, and I just have to trust my education and gut. Feels a bit wrong, but always turned out to work very well. I’m very, very happy to have quite a bit of experience in anesthesiology – that makes me a lot more confident in doing all of this. Also, bringing my own pulse oximeter was seriously one of the best ideas I had – in those circumstances it’s often the only monitoring the patient has. It just gives me a bit more objective evaluation of the situation.

Other skills so far: a mindblowing amount of large-volume IVs. Haven’t counted, but in one week maybe 30? More than I’ve ever done before.

I learned what it means to “scrub” a patient. It’s a procedure you do in burn patients to remove all the dead skin. You’re on your own with the patient, get some basic monitoring, give them an oxygen mask, insert an IV, and then you give ketamine (0.5 mg/kg). After that, you scrub down all the excess skin with gauze soaked in normal saline and some soap. Two points I learned: ketamine is a nice drug in war medicine because you don’t really have to worry about apnea or cardiovascular collapse – but the trip patients experience on ketamine is just not nice. Almost all of them cry and complain about the pain; they just don’t remember it afterwards because of the amnesia. It is very difficult to handle some patients on ketamine, and being on your own there is quite challenging. Luckily, I had some help from another, more experienced student.

During scrubbing, I also got my first official and really bleeding needlestick. At 3 a.m., I was scrubbing a patient with approximately 45–50% burned body surface, and the thick skin of the hand wasn’t coming off. So I asked for a needle to penetrate the skin more easily – and when sticking the needle through the dead skin, it went straight through to the other side and into my left index finger. Not nice. Being tired and needles are a shit combination. Consequences? Every needlestick here – even when the patient tests negative for HIV – means 28 days of PEP.

Two days earlier, I had a very minor needlestick after suturing a meth guy who wasn’t calm and kept moving around. All my registrars told me they wouldn’t even take PEP for a non-bleeding injury, but I decided to be safe and started it anyway. So the only consequence of the needlestick during scrubbing is taking PEP for some more days…. First days of PEP were quite bad – nausea, diarrhea, and especially insomnia (dolutegravir causes this). Right now I don’t really feel a lot of adverse effects anymore. When I talk about this with other doctors or students, I usually hear something like: „Oh, I’m on PEP as well, don’t worry – this happens all the time here.“

Needles don’t have safety locks here. Sometimes you find needles in a patient’s bed that somebody forgot there. Some are lying on the ground. The general awareness regarding HIV PEP is really high here – but basically no preventive measures are being taken.

To come back to scrubbing: it is by far one of the most disgusting things I have ever done. I think I have already seen quite a bit in medicine, and almost nothing can really shock me. But I was really trying hard not to throw up while scrubbing the large area burned patient – and I scrubbed this dude, together with another student, for almost 2- 2.5 hours. Including the face. And you just know that he will die in septic shock very soon. The feeling of loosening superficial skin and pulling it off like a tape is just insanely disgusting. Sometimes even the fingernails just fell off when i pulled at the skin nearby – the amount of disgust you feel can’t be described with words. The only good thing about that: because this patient also had massive inhalational injury as well he was tubed and put into a coma – so i did not had to experience a patient going mad on ketamine with this kind of burns. Also i am pretty sure that wont be worst burn i see here.

Other skills I really practiced so far are suturing and drawing arterial blood from the femoral artery. Only yesterday night I did this 15 times. It still feels wrong, but that’s for sure a skill that will come in handy when I’m a doctor. The suturing is sometimes very complex, and when I come to this point, I always ask more experienced students or doctors for advice. Somehow, I’m still trying to keep European standards… let’s see when this will break.

Because almost every patient in this ER was somehow confronted with some kind of force, I’m usually worried about internal bleeding. That’s why I performed in about one week 10–15 FAST examinations. So far, every single exam turned out to be negative – but I don’t think it will take long for that to change. Classical mechanism of injury here? Car versus pedestrian.

To sum it up a bit: It is still an absolutely mindblowing experience. The work is insanely exhausting, i think i was never that tired before. I started to learn how things work, but i will need atleast one or two more weeks to really get into how things work – other students also told me they didn’t find out how things work after 8 weeks. So we will see where things end up. The medical part is fascinating, i still want to do more procedures. Absolute number one on my list is an ICD for pneumothorax, my personal goal would be doing around 5 of these. In the end i think it will take a bit of luck, the right patient and the right doctor to supervise me. Some students leave after 4 weeks without having done a single ICD, others get 15-20 in that time frame. There are good and bad sides, i still believe it was the right decision to go here. But i want to be absolutely clear about one thing: It is not only fun and nice, it is mentally and physically challenging. Some colleagues are complicated or just dislike foreign students which makes it sometimes very challenging to enforce yourself.

Staying in your comfort zone kills you eventually, always!