Surgeries and safaris in South Africa
Nushin Ahmed MBBS, BAppSci (Physiotherapy)* |

*Medical student, The Australian National University

“Are you mad? Do you know it has the highest rates of HIV/AIDS in the world? Did you realise that muggings occur every single day?”

These were some of the comments people made when they learnt that I would be going to South Africa for my elective. Despite their warnings, I was still determined to go, even more so because of the lengthy application process!

Having spent two fantastic weeks doing trauma at The Canberra Hospital, I wanted to experience different types of traumas in a different country where trauma is prevalent. Armed with the warnings and advice of well-wishers, I set off to Durban, KwaZulu Natal, South Africa for my Orthopaedics and Trauma elective. I would be spending three weeks at King Edward VIII Hospital (KEH) and one week at Inkosi Albert Luthuli Hospital.

KEH is a 900 bed public hospital that was built in the 1950s for the non-whites (the blacks, Indians and the coloureds); however after the fall of the Apartheid movement, the hospital became open to everyone. As it was originally for the non-whites, the buildings were more run down compared to other buildings constructed at that time. During my time there, many refurbishments and renovations were occurring and thus much of the hospital was closed, however I was still able to observe a variety of different conditions that I had not previously encountered in Australia.

A typical day started at the gate where our IDs were checked, our bags searched and sometimes a metal detector run over us (figure 1). This certainly was very different from Australia! It was also a similar process when we left the hospital site.

The morning handover meeting was attended by the orthopaedic team of doctors, nursing staff, plaster technicians and medical students (another elective student and myself). The night intern presented the emergency patients and their X-rays. This was a great opportunity to learn about many different orthopaedic conditions and traumas.

Ward rounds followed this. The orthopaedic patients were spread across the hospital due to the renovations. The orthopaedic wards were segregated by gender, and the busiest was the male orthopaedic ward. The wards were one big open room, with curtains around the bed spaces, and surprisingly only one sharps bin for a ward of 35 patients!

Stroke death rates by sex, 1987-2007. Sourced from AIHW (6, p. 81.)

Figure 1. Entry to the King Edward VIII Hospital

Motor vehicle accidents, stab wounds and gunshot wounds were common. Many times, they were due to assaults or attempted robberies. It was common to see prison wardens around the wards, as many of the inpatients were inmates from the local correctional facility. I wondered how far a patient would be able to get with a lower limb external fixeteur; however, many were tied to the bed with shackles. Also, due to the great emergency burden, many elderly patients were waiting in hospital for weeks to have their fractured neck of femur fixed, as there was not enough theatre time.

KEH had recently built an operating theatre within the emergency department. I saw wound exploration following multiple stab wounds. Sometimes, during the procedure, analgesia ran out and if no more was found, the awake patient continued to be operated on without any pain relief, while many staff members held the patient down. Fortunately this distressing scene was a rare occurrence.

After ward rounds, I was able to go back and see the patients on my own. Although Xulu (one of the 11 official languages) was commonly spoken, most people also spoke English and family members and nursing staff were able to interpret. Frequently patients had tried traditional methods of healing prior to coming to hospital. One patient had presented with ongoing lower leg pain. He had tried several months of Xulu medicine; getting a razor and making multiple small nicks on the skin and then applying various herbs and roots (figure 2). Despite months of this treatment he did not improve, he was later diagnosed with osteosarcoma. It was very fascinating to see a combination of Western medicine and traditional methods of healing.

Stroke death rates by sex, 1987-2007. Sourced from AIHW (6, p. 81.)

Figure 2. Traditional medicine at the markets

The outpatient clinics were very busy. Arriving at 7:30am, the waiting room was already full and the queue of about 50 patients spilled outside, waiting for the clinic to start. As only the consultation rooms had air conditioning, it was common for these doors to be open to allow the cool air to reach the waiting areas. Sometimes multiple consultations occurred simultaneously in a very small room and it was common to have more than 15 people in that very small room. Often consultations occurred in the waiting room.

In the outpatient clinics I saw many rare conditions such as tendon injuries due to rat bites, amniotic constriction bands of the leg requiring foot amputations of a toddler, and compartment syndrome requiring fasciotomy as a result of snake bite in a little girl. I also saw many deformities as a result of Blount’s disease, as well as tuberculosis affecting many parts of the skeletal system. This was a great learning opportunity to see such conditions. I also saw many fractures, where I was able to assist in closed reduction of upper limb fractures with Bier’s blocks, which was done without any resuscitation equipment (Figure 3).

Stroke death rates by sex, 1987-2007. Sourced from AIHW (6, p. 81.)

Figure 3. Traditional medicine at the markets

Another aspect of my elective that I enjoyed was theatres. Often there was a lot of downtime due to lifts breaking down and the fact that theatres were on the second floor. Theatres was one of the times I had an opportunity to perform practical skills such as drilling. However I was not allowed to do any suturing and rarely allowed to take blood as the team was very concerned about the risks of needle stick injuries. Despite these limitations, I learnt a great deal from bserving the doctors. I also had the opportunity to do some on-call shifts with the interns. The interns were on-call once every five nights; this shift was 30 hours!
Being a public hospital, patients’ fees were based on their incomes. Unemployed or beneficiaries of social pension were entitled to free treatment. The casualty fee was R120 per visit (AU$17). There was also a Road Accident Fund that could be used for patients who were involved in motor vehicle accidents.

I saw a patient one night after he arrived at the clinic following a fall a few days previous, where he sustained a fractured neck of femur. He had initially presented to another hospital, however as he was not able to pay the fees he was transferred to KEH. Unfortunately, a few hours later, he passed away. This was a most eye opening experience for me to see a patient not being able to receive medical treatment due to a lack of funds. This situation made me realise how fortunate we were in Australia. Although there was often a lack of resources, the staff did an amazing job in looking after the patients and everyone was very helpful and welcoming of foreign students.

For my last week I was at Inkosi Albert Luthuli Hospital, also in Durban. Although these were both public hospitals, I was amazed by the vast difference. It was only a few years old and a paperless hospital. The orthopaedics subspecialties included hand and upper limb surgery, orthopaedic malignancy, deformity corrections and a trauma ICU. It was a training hospital run only by registrars and consultants. I was very fortunate to spend some time there, as this hospital did not take any local students.

Although the hospital looked very similar to hospitals in Australia, the medical conditions seen were very different. It was strange to see total hip replacements due to avascular necrosis rather than osteoarthritis! Additionally, I saw acute renal failure due to sjambok injuries. A sjambok is a whip made from synthetic material (originally hippopotamus hide) frequently used in assaults, injuries from which may cause rhabdomyolysis. I also saw patients having bone transposition with the Illizarov method, due to non-union of fractures.

Every day was a fantastic opportunity to learn about different conditions, different presentations and different managements of conditions, as well as the different cultures within this country. The two hospitals I spent my elective in reflected the rainbow coloured nation.

I was also very fortunate to be able to do some sightseeing around the different parts of South Africa. In Kruger National Park, I saw four (lion, elephant, buffalo and rhinoceros) of the big five animals but missed out on the leopard. I also saw many other animals (figure 4). I was also able to visit townships. Townships were built for people of one colour to live together, after being forced to leave their original homes. Informal settlements were also common, people living in houses with no electricity or running water. One of the most amazing experiences was visiting Soweto (the largest township in South Africa) on an evening bike ride on New Year’s Eve.  

Food was another aspect of this trip that I thoroughly enjoyed. Staples included pap, which was polenta made from maize, served with tomato bredie (stew).  I enjoyed Boerewors (snail shaped sausage) at Brais (barbeques) (figure 5). Commonly found in Durban was Bunny chow, a loaf of bread carved out and filled with curry (figure 6). Other delicious foods were Koeksisters (sweet pastry) and of course biltong (cured meat)! I also saw shebeens (informal bars and taverns) and many informal markets (figure 7). I was able to visit Nelson Mandela’s prison cell in Robben Island as well as District 6, where many people were forcibly removed during the Apartheid regime. It was amazing to actually stand in the place where such historical events took place.

Despite the repeated warnings and advice not to go, I am extremely glad that I was able to complete my elective in South Africa. It was an awesome experience and an incredible opportunity to learn about not only medical conditions but also the culture. I am very fortunate to have had the chance to experience this elective and recommend South Africa as the ideal elective destination for those students interested in trauma.