Casualty department

Geez, the week has gone quickly. Fridays are slower at the hospital, until things get crazy in casualties in the evening.

Today I spent my day with an 83 yo doctor who has been practicing for like 59 years! He is also retired, and just does weekly clinic. We had grand rounds in the morning, topic was on the new forms for psychiatric patient holds and their legal rights. The doctors were not very pleased with all the changes and hurdles.

The older doc mostly does dermatology stuff. When in doubt, freeze it off, seems to be the common denominator… Saw molluskum contageousum for the first time. Also learned that having those lesions gets you an automatic HIV test because of the higher prevalence in HIV positive patients. Nail removals, candida, dermatitis.

I went home in the early afternoon, and relaxed until my late night shift. This weekend is pay day, which means lots of ETOH with a side of violence. I arrived around 9:30pm, already the ambulances were busy dropping of patients.

In the resuscitation room were two young boys, maybe 5 years old, whom had drank their parents amitryptilline. One boy required intubation, both got activated charcoal. X-ray is not immediately available, but they have a portable wheeling one that came later. The hospital is a small community site, so they transfer him to Tygerberg academic hospital.

Next patient, 16 year old guy, out drinking with family and somehow things escalated and his nephew stabbed his neck with a broken beer bottle. You can see the picture above. Right over his posterior triangle and barely missing his carotid. The hole was huge when we reflected his skin. He consented to me taking his picture. When I showed him the pic, he said “holy shit, f*** f***.” I don’t think he had any idea how severe the injury was. The pic sobered him up for a short time. The attending sewed him back up, good as new. He was transferred to tygerberg for an angiogram of his neck

Another younger guy was stabbed in his chest. Exposing the wound, you could see the bubbles of air coming out. X-ray would take a while. Given the skin crepitus from air, and hyperessonant left chest to percussion, he bought himself a chest tube. Its really neat how much they use physical exam, and do it well. Chest tube placement was just like the states.

Casualty is a pretty crazy place. From the back area with Whitney Houston playing from the stereo, to the ample blood soaked bandages from stab victims, to the flickering light in the stab room. The interns and staff are great teachers, and just really fun people. I’ll be doing more late night casualty shifts in the future.

Broken bottle neck stab



All better


stab/resuscitation room


Pic of Silvan and the views from our student flat.

Day 3 and 4

Yesterday I went on medicine ward rounds with the internal medicine team. As expected, the common denominator was TB and HIV. My intern recommended to answer any question asked by an attending with “it is likely caused by TB.”

I kept hearing the team refer to RVD, and RVD treatment. Given the strong stigma associated with the term HIV, they just refer to it as Retroviral disease… Not sure if I agree with this technique. With so many south Africans having the disease, I don’t know if using a code word around patients really makes sense.

Our hospital has a laboratory on site for basic labs, and sends out to the regional lab for more sophisticated tests. No electronic charts, which is refreshing. People write very succinct, but effective notes. If you want an IV, you place it. If you need blood, you draw it. Supporting staff and services are limited, but it still works surprisingly well. X-ray is widely used, as well as ultra sound. Physical exam skill are emphasized and very important in the assessment and plan.

What I find so interesting is how many similarities there are to medicine in the states. It is kind of neat that there is this thing we call allopathic medicine, which is conserved across nations. Similar presentations of patients, transudate vs. exudates, liver disease, BMPs… Just a shift in the diseases… They have a major issue of immigrants to south Africa from other African nations who go and visit their home and return with malaria. People assume they are immune but are not.

Today I attended orthopaedic clinic. This is run by a retired doctor who just comes in a few days a week to help out. He practiced 23 years in a very remote south African village as the family doctor. This clinic is mainly for assessing fracture healing, casting and cast removal. Same routine, grab a chart and just go for it…

Cutting off casts is a ton of fun. We had the vibration saw and scissors. My first patient must not have known the saw will not cut skin because he just about hit the ceiling when I bumped his skin… He had an open fracture, and when we removed the cast we found a few skin staples and a partially extruded bone fragment. Hmm, that must not have helped the wound heal… Came right out and he was on his way.

The common denominator at this clinic was “xxyo post MVA” or “PVA (pedestrian versus auto).” One of my patients was hit by a township taxi, which are these crazy taxis that drive by their own rules, stop anywhere, honk a ton. Casting is good old plaster. It gets the job done, patients seem very happy, especially when we remove the casts. Many fragrant smells to save the least. Many patients had been prescribed a drug called Panado… I’m like, what the heck is this panado. It is Tylenol. Why so many names!

It is very interesting to me the patient population. There are many xhosa speaking patients, and Afrikaans. But there are a number of older white Afrikaans speaking people who grew up in Strand and Somerset west. They speak excellent English and tell me they are very pleased with the governmental care they have received. They actually remind me of rural Minnesotans, haha. What a unique mix of patients here.

In the afternoon we did group neurology clinic with a visiting neurologist from the major tertiary tygerberg hospital. It was interesting because I was part of a group of doctors and interns (about 10), and we were sitting facing the neurologist and patient. Surprisingly the patients didn’t seem to mind the crowd.

Our first patient only spoke xhosa, somehow we found a person to translate. He had been having “spells” for the past year. He has them 2/week, and says his vision and brain go black. All of a sudden he turns his head to the right and stopped responding to our questions. He stand up, pulls his phone out of his pocket, and begins to lick it, walks outside and urinates, then comes back and sits down in a very tired state. All the us observers look at each other trying to figure out what was going on. Our patient conveniently showed us his complex partial seizure. Crazy timing. We just increased his phenytoin dosage, hopefully it helps.

Another patient is a white woman in her 50s with multiple sclerosis. Unlike in MN, MS is very rare so many general practitioners do not have much experience in management. She was dx in 2001, and since then has been taking cortisone. I mean, high dose, she said 8-10 pills per day (not sure of dosage). She came in on a wheelchair, very frail, big red cheeks with moon facies, muscle atrophy, tremor, skin brusing and lesion from thinning, stasis ulcers on back and ankles. The neurologist said it was the most extreme case of chronic cortisone overuse. They are going to very slowly reduce her prednisone.

Well those are some more of my experiences. I will be heading back to Cape Town for the weekend, but might spend Friday night in casualty. They get a lot of stabbing trauma on the weekends, and tons of opportunities to suture and place chest tubes.

Outpatient activities

Last night I went out with my roommate Silvan to the fanciest restaurant in Somerset West. I ordered the Kudu (a huge antelope animal) carpaccio, and for main course had Ostrich fillet, topped with mushrooms and parmesan, on top of sweet potato discs and drizzled with a port wine sauce. Of course we paired it with a local bottle of pinotage red wine. It is incredible! Ostrich is like a beef filet mignon, but little softer. Absolute bliss. The food here is spectacular. All total it cost about 200 rand, with is 7.5 rand to 1 USD, so it is about $26.

The last two nights have brought heavy storms, winds up to 150km and pelting rain. It really destroyed a bunch of vegetation, and woke me up like very hour.
Today at the hospital I went with Dr. V, Silvan, and two local University of Stellenbosch medical students to a clinic in Gordon’s Bay. We arrived at a single level white building, full of people waiting for us. From children, to elderly, white, black, colored, and everything in between.

The head nurse, also known as the head sister, brought over a huge stack of patient files. The building had a large waiting area, plus a pharmacy, and then our medical care open space with beds against the wall. Dr. V said, “ok, grab a bed and a chart...” We proceeded to just see patients one after another. No time to for being shy or hesitatnt. 10 minutes per patient was the challenge to us.

Every patient has their blood pressure, heart rate, weight checked. Diabetes patients get a HGT, which is a blood glucose, but it is in mmol, so normal is like 4-6. Some also get urine dips.

I saw all sorts of people. Many patients with chronic diseases come every 6 mo, since they need to get their governmental prescriptions renewed.

Some patients I saw:
- 55yo male with dermatitis, and concerns about weight loss… turns out he was observing Ramadan, problem solved.
- 19 yo guy, who looks about 14. Very charming smile, his mom tell me he has Prader Willie syndrome. Turns out he has had issues with hygiene and repeated episodes of dysuria. Plan, referral to the hospital for a circumcision. The other issue is his out of control diabetes, with glucose levels at 19, which is like 3 times normal; and spilling glucose into his urine.
- 84 yo female with hx of CVA, angina, hypertension… She is very frail, but well dressed, and has a nice little zippered flower purse. She had a number of symptoms she was concerned about. Listening to her heart, she has a loud systolic murmer, and has an irregular rhythm with dropped beats. She had just been seen recently at another clinic for angina, but never had any cardiac work-up… Referral to the hospital for a ECG and possible echo. Not sure how long it will take, we checked the box for urgent. --- It is so wild to be given almost full responsibility with patients. If I had not listened to her heart diligently, I might have missed her heart block. I wonder how long she has had it, since she is symptomatic from it…
- Then I had a patient that was dealing with concerns for her safety and domestic violence issues. Privacy is pretty much non-existent… Yet I pulled the curtain around. She became tearful. I learned there aren’t many services for women in abusive relationships.

That is just a snapshot of my first away clinic day. I can’t believe its only been two days, I’ve done and seen so much already. Dr. V pulled me aside and asked me to reflect about my experience yesterday. He is a true family doctor at heart, very interested in how we process experience, and our psychological welfare.


In a follow up to the mom from yesterday who was breech. I also told Dr. V about some articles I had read about using Chinese medicine for breech presentation. A few recent reviews have shown greater success by using moxibustion compared to control, which is burning a Chinese herb, and placing the warm end on the lateral fifth toe. Sounds crazy right… Well its cheap, no side effects or risk (that’s been studied too), and could potentially reduce their c-section rate. He laughed, but said, well get this moxi, and lets give it a try with our breech pregnant moms.

I’m exhausted. Time for bed.

Hottentot Holland Hospital

Day 1:
Today was my first day at Helderberg Hospital. What is curious is that, a few years ago the name was changed from Hottentot Holland hospital (HHH), yet none of the signs from the road or on the hospital have been updated.

I am living with a Swiss medical student who speaks German and English. His name is Silvan and is doing general surgery and has been at HHH for 3 weeks.
There are like 14 national recognized languages in South Africa, from Afrikaans, to xhosa. Somerset west is in a very africaans area, which is really a crazy mix of dutch german and English. Usually every other sentence is English, so they mix languages together.

Here in South Africa medical school is 6 years right out of high school. Then you do 2 years internship in just general subjects, plus an extra year of community service (at a remote or underserved site). After that you are a general practitioner. Then if you want to specialize you do it after that. That means to do internal medicine and then GI, you would need to do like 3 years IM and then a GI fellowship. That’s a lot of years, but it is great because every south African trained MD will have atleast 2-3 years of just general medicine skills (you name it, they do it).

The doctor who is the student coordinator is Dr. V. He is a very youthful, fun guy, who has been at HHH for 13 years. Originally he wanted to do surgery but fell in love with family and community medicine. He is actually trained in hypnotherapy! Very cool. At the hospital he runs from outpatient high risk OB clinic, to doing C-sections, ectopics, appendectomies, then does medicine rounds. Here family medicine means, you do it all… As he put it, you become a “master of all trades.”

Turns out I am the only the second US medical student to spend time at the hospital. Lots of Germans and other Europeans visit. He is excited that I am interested in seeing everything, because most foreign students come just to do surgery.

The staff is a mix of young interns, young attending, local SA medical students, and international students (a german, sylvan and me).

My first day started dramatically. We are called to the maternity ward for a full term xhosa woman who was transported by ambulance from a surrounding clinic for active labor and cord prolapse. The women was laying on bed, her membrane had ruptured, and was having contractions. Surprisingly, the feeling in the room was very calm, the mother seemed neither excited nor worried. The intern used an older model ultrasound to look for the fetal heart rate, and only found a faint irregular bradycardic rhythm. Using suction, a very pale blue baby boy was delivered. He was not moving, no crying. Cord cut, to the room next door, chest compressions, oxygen, few attempts at IV placement… After a few minutes there was no sign of life. Dr. V and I walked back to the mother, “I am very sorry, but your baby had died.” She relied, “Died?” “no no no…” Shrieking and crying. “oh jesus, why why.” I didn't quite know how to process what I just saw. It was such a beautiful baby boy, and there he was not breathing... If only she had come earlier. Dr. V put his arm around me and said, “Well Justin, welcome to Africa." There are more patients to see.

The rest of my day was spent in the high risk OB clinic. To be high risk you need to have a hx of pre-eclampsia/HTN, previous complicated pregnancy (aka, ectopics)… What is interesting is that have a previous C-section puts you as high risk. How different is that than the US where c-sections seem to be the norm. Here it means something went wrong, so we need to watch out. Patients are called in groups of 4-8 and then seen one by one. HIPPA shmippa. Efficient and effective is the name of the game. Ultrasound is available, there is a skilled tech onsite to do AFI and dating.

Here they expect you to do the full Leopold maneuvers… man oh man, they still do those. Luckily he had time to teach me.. Within no time I did them on all my patients. By the end of the day I felt pretty confident.
39 week gestation, just seen for the first antenatal visit last week at an outside clinic. Now her first time here. She comes with her green card that all pregnant women are given in the governmental system (pregnancy hx, fundal growth, tests). It is my job to do exam and ask the pertinent stuff, checking your work consists of the attending popping their head in for a second. Hmm, can’t feel the head of the baby engaged… Pressing on the vertex… could be a head or just the butt. Ultrasound is busy. Pt was sent for an abdominal x-ray to see where the head is… Wow, didn’t know you could do that. The goes off for a bit and returns with her films. Baby is breech. Very cool to see an x-ray of a gravid female, don’t get to see that every day. Plan totally changes, now a scheduled c-section in a few days. Good thing we picked that up. Thank you Leopold, looks like I underestimated your maneuvers.
Another patient with epilepsy (well atleast thats what we called it), being managed on tegretol… Drug levels? Too expensive said Dr. V, they do the best med management they can without blood levels.

The rest of clinic consisted me calling for patients to a full waiting room with like 50 people, all staring at me. Eeks, how do pronounce ‘Ndw.’ I butchered the name, and I could hear the young docs having a chuckle.

It seems as though the general consensus is to work hard, but have fun. I couldn’t ask for a better match for me.

The day ended with a ruptured ectopic pregnancy… whaa… No general surgeon… Family doc specialist scrubs in. Open her up, clamp, cut, clamp, suction, sew her up… All done. No cautery, no fancy tools, get in and get it done. Wowza.
Well what a crazy, exciting, and full first day.

Howzit! Greetings from sunny Cape Town, South Africa

Hello Everyone. This will be my first time doing a blog to follow along with my travels. I'm excited to document my experiences and share them. I arrived in Cape Town last week, and have just been acclimating. Its been many months since I've just had some time to relax.

So why come to South Africa? Two reasons of many...
1) I was here during undergrad with a group of pre-medical students. We went to Johannesberg, Cape Town, Durban, visiting all sorts of clinics, hospitals. I fell in love with the culture and people, and vowed to return as a medical student to learn more.
2) I have like some 40 relatives that live in Cape Town. My mom's mom, Dorothy Roth (maiden name) Yach grew up in Sea Point, which is a suburb of Cape Town. She met my grandpa, Saul Roth, a member of the US army, during WWII when he was in the Cape Town port. After the war she left South Africa to marry Saul. So thats how I got stuck in the US...

Well I head off to Somerset West this weekend, a small city outside of Cape Town to spend time at their governmental hospital. Its called Helderberg Hospital, or Old Hottentot Holland Hospital. I'll post more once I begin my first elective.