In order to make the South African elective more generalizable to our CUMC IM program, the department has asked the residents going abroad to revive a blog that was started several years ago (but no longer updated) about the resident experience in South Africa.  

Arriving in South Africa after a long, 33 hour flight including a 10 hour Munich Layover, I was met by Sipho the ITeach driver who gave me a warm hug, guided me to the rental car agency and led me to a grocery store which much like in the U.S., was packed with throngs of people on X-Mass eve.  Driving on the wrong, aka left side, of the road is not a new experience to me but disorienting nonetheless.  Everything has to be flipped in your brain and one constantly thinks of the reverse.  While I am now an excellent left sided driver, on day 1 (see below) I unfortunately failed.

Day 1 started on x-mass day with me misjudging the entrance gate.  Upon driving up the poorly paved back road to the hospital my car was stopped, searched, and subsequently allowed through a set of gate doors.  Unfortunately, the guard refused to open up the second gate and I ended up denting and scrapping the front part of my bumper;  South Africa 1, Mike 0…  After parking, wandering around for an hour or so, I was met by a very kind, soft spoken chief of medicine who came in specifically to orient me to the hospital.       

The Hospital gets the majority of its patients as referrals from local clinics.  These patients are sent to a waiting room and triaged by a registrar/medical officer (medicine resident).  Should the patient need admission they are sent to another back room where two interns (doctors who are doing two years of work prior to deciding on any specialty;  surgery, medicine, optho etc…) perform all of the necessary paper work, blood draws, IVs – scut work.  If the patient is too sick to stay in the waiting area until a bed opens up on the wards, they are sent to the medicine emergency department to be further triaged to the ICU, wards or referred out to a subspecialty service at another tertiary hospital which only takes referrals called Greys Hospital.   

After seeing the hospital, learning the above, and meeting some extremely nice registrars who were dumb-founded that I came in on x-mass day despite my explaining I did not celebrate, it was suggested that I not come in on Thursday and present Friday for a resumption of the regular schedule.

 

A view from the Lodge where I am staying!

Friday, day 3 was my first real day which started with morning report going over cases from the day before.  Eric (my pod mate) had flown in to join me for several days and we were assigned to the post call team to round which consisted of a consultant, a variety of registrars/interns and the consultant’s younger brother who had come to observe.  Rounds started in the ED where two patients had been assigned and admitted by a team, but no beds were available and where thus being co-managed by the ED consultant (Attending) and medicine team (This all sounded too familiar!!!).  Patient 1 had intentionally overdosed on combined organophosphate/synthetic warfarin pills and had improved somewhat on an atropine drip but now had a heat rate in the 150s (more on this later).  Patient 2 had AIDS and had been admitted and treated recently for cryptococcal meningitis.  While it is unclear how she re-presented, on morning rounds in the ED she had an SBP in the 60s, febrile, altered, and anuric AKI with a k that eventually came back at 6.  Her LP was normal and her lungs clear.  The consultant saw this data and stated the patient needed antibiotics, a renal consult for peritoneal dialysis, no fluids as the patient was anuric and she didn’t want to volume overload her and then requested that an inotrope, dobutamine be started.  She debated about Lasix to induce urine but the hypotension prevented this.    Eric and I stood there, still unsure what our role/responsibility was in all of this.

Rounds eventually went to the 5^th floor where an intern asked us to come over and help manage a patient in cardiogenic shock 2/2 to afib with RVR with an SBP in the 70s, altered mental status and a HR in the 190s.  This required multiple shocks and while sedation was given the patient was in an incredible amount of pain.  The consultant’s younger brother then asked if we couldn’t “hit him over the head to knock him out.”  I just stared…

Rounds ended and Eric and I circled down to the ED to check on the overdose and septic shock patients.  On our way down we tried to remember back to 2^nd year of medical school, the cholinergic effects of organophosphates and why this patient was tachycardic and not bradycardic.  The ED consultant stated “in Edendale Fashion” the atropine drip had been ordered off 24 hours ago but was turned off only minutes ago, thus he was now suffering from atropine overdose.   He was also altered and the patient could not go to the medicine wards until a head CT was done to r/o bleed given the warfarin OD and coags that were still pending .   As for the septic shock patient, renal had recommending a non invasive CVP which was 0, the ED consultant gave 1L NS and switched to epinephrine and the ICU had declined the patient 2/2 to no beds.   In addition to a failed LP on a patient which the intern then got in 1 stick, it was a fairly eventful Friday.

More later with pictures on our trips around SA, the hospital itself and our lodge.