Paula Logan, North Sea Medic and Registered Nurse, Transocean.
Johannesburg Experience 25th May – 4th June 2012
Introduction
In November 2011 a Practical Experiential Training Proposal was received from Mr Trevor
Justus of the ATA International Training Division (www.ata-international.com) located in
Johannesburg, Republic of South Africa (RSA) following a request from our company North Sea
Divisional Medical Advisor. This experiential training proposal was circulated via email to all
installation North Sea Medics for discussion and to gauge interest in participation. This resulted
in an active debate with respect to the pros and cons of experiential training taking place in
Johannesburg mainly focusing on issues such as
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Personal safety of the individual whilst in Johannesburg.
lack of practical experience and exposure to trauma obtained during our 2 day yearly
accident and emergency placement at Aberdeen Royal Infirmary (ARI)
What could be obtained from training in Johannesburg that couldn't be obtained at ARI
What is wrong with the training that we currently receive
Why the need to travel over 6000 miles, to a country that is in the top 10 of the most
dangerous places in the world to visit and to a place that is reputed to be one of the most
notorious murder/rape/robbery cities in the world?
At the end of November 2011 two Medics where offered the opportunity to go to RSA for the
purposes of evaluating hospital and ambulance placements. I forwarded an application to be
considered for one of the places, which was duly endorsed and was gratefully accepted, along
with Dylan Prentice, a colleague North Sea Medic.
As is the case with all Medics I have been trained in trauma, however after attending the 2 day
placement at ARI I found there were limited opportunities to participate in the actual trauma
process. Being given the opportunity to work in one of the top trauma units in the world and
working alongside Johannesburg Paramedics would increase my knowledge, by exposure,
observation and participation of real trauma situations. I realised this would be beneficial for my
own continuous professional development and also bring added value to the company and
indeed the crew of my rig should such knowledge and skill be needed in the future.
Preparing for the Experience
Thus started the long process of ATA International registering us with the Health Professions
Council of South Africa (HPCSA), which would allow us to treat and manage patients whilst in
Johannesburg. Clearance is required for each Medic by the Johannesburg General Hospital,
Wits Medical School, the Department of National Health, the Foreign Workforce National
Programme and the HPCSA. This was undertaken by ATA’s Tasneem Bowles who provided
help and assistance throughout the procedure.
Prior to departure ATA emailed essential guides to the Republic of South Africa and useful web
links, giving advice on clothes, money, safety, etc. which I found to be very professional and
useful.
A comprehensive guide to the Management of Trauma from the University of Witwatersrand
was sent to our home address prior to departure giving protocols and procedures for the trauma
unit where we would be working.
This aim of this information is to help junior doctors and casualty officers in the management of
the injured patient during the first critical hours. It is also intended as a study guide for senior
medical students. This is a comprehensive pack for health care professionals practising under
adverse conditions, including lack of resources, extremes of climate, extremes of time and
distance, giving an insight into injuries that would be encountered on the ambulances and within
the trauma unit in Johannesburg. Reading all this prior to departure made me ask myself “what
had I let myself in for?”
Practical issues
Transport
After a 12 hour overnight flight from London Heathrow to Johannesburg, Dylan and I were met
at the airport by 'Marshal' - our dedicated driver for all our time in Johannesburg. He was very
polite, helpful, happy and informative at all times and 'Lucky' the other driver was equally so. We
were able to make private transport arrangements with Marshall as required.
Hotel
We stayed at the Sunnyside Park Hotel close to the hospital. This was a nice hotel with great
staff and food (unfortunately we were not in game season and the Spring Bok goulash was off
the menu!) and there is a pub within the hotel complex where you can have a couple of pints
and a blether about the day's experiences. James the hotel manager comes around in the
evening and checks everything is OK for all his guests. There is free transport at 1700hrs every
evening to the local shopping mall and they collect you at 1830hrs. It’s was a pity that due to our
working hours, we could not go during the first few days of our stay. Being able to do this would
have made us settle in quicker into the relaxed RSA lifestyle. The hotel can also organise trips
to tourist attractions in the area.
ATA Meeting
Trevor Justus Director ATA ITD, Tasneem Bowles ATA International Training Coordinator and
Janine Arendze ATA ITD Manager met us on the first day to give us an overview of the course
and what to do / not do whilst in Johannesburg. They particularly concentrated on our safety
and security - such as not walking outside the hotel at nights and not to take unregistered taxi’s
because there were no regulatory controls on them.
We were each given 2 bags with course information f, 2 pairs of scrubs and an ambulance
reflective vest. First impressions were of a slick professional outfit. The scrubs and paramedic
vest would identify us as ATA students within the hospital and ambulances (doctors and nurses
from Nigeria and Uganda, paramedics from Namibia were undertaking training with them at the
same time as us). Name badges were compulsory at all times, helping to break down initial
barriers.
Both Dylan and myself had been registered with the required authorities allowing us to perform
a “hands on” role when working. We were given our working pattern and informed of what skills
we could be expected to use depending on the situation. Various paperwork was required to be
completed daily as a record of our stay and also as evidence of the procedures and skills that
we had encountered or used. Some of the skills could not be met as they were aimed at
doctors; however we were able to achieve a large proportion of them.
After the administration aspect was covered we were taken to Charlotte Makeke hospital
(Johannesburg General) and orientated to '163 Trauma Casualty Ward' and '165 Medical
Casualty Ward'. Introducing us to the Hospital, Trauma and Medical unit, and some of the staff
before commencing work, reduced any initial reservations and fears.
The experience
Ward 163 Saturday-Tuesday
Upon arrival at 06:45hrs the area was already busy. The handover was in process, and patients
were waiting with paramedics for assessment and admission. Outside the trauma ward people
with injuries were sitting patiently and quietly waiting to be treated.
I introduced myself and started observing the initial trauma screening of casualties. I got the
impression that if an individual was unable to engage with the ward staff, opportunities would be
missed. Due to the nature of this busy unit, priorities were the patients and not hand holding
students. To get the clinical and cultural experience available Dylan and I found we required
three prerequisites.
1) Thick skin
2) Sense of humour
3) Good personality
The trauma team runs a slick operation, everyone has a role and everyone knows their place.
Each trauma case is recorded and every Wednesday tapes are reviewed for training purposes
and development of continual improvement, enabling the team to improve, identifying both
strengths and weaknesses within their practice. This has built a competent, capable and fluid
team and if I had just observed this one process whilst on the unit I would have been satisfied
with the experience.
The Priority 1 trauma patients come into the unit and immediately have a full body scan, upon
completion of this process the ‘team’ are in place and the results are being reviewed by the
trauma doctors and surgeon. Meanwhile the patient is transferred to the trauma bay from the
stretcher. There is a set format regardless of the presenting casualties’ injuries. Everyone has
their role ensuring the patient has a seamless, thorough and complete assessment of their
requirements. The pro-forma for this used on the unit gives an insight into this process.
Following a period of performing an “observer” role we felt able to get on and assist anywhere
that was required. Through communication, with staff and patients, and actively demonstrating
our resourcefulness and willingness to participate, we developed an enhanced learning
experience.
Dylan and I became competent at taking the 'Nurse 1' and 'Nurse 2' roles – cervical spine
immobilization, head blocks, catheterisation, attaching monitors, doing ECGs, etc. and the staff
were happy to let us take on the role. Log rolling so many critically ill patients has enhanced my
skills which I will pass to the first aid and stretcher team offshore. We both took a patient to the
CT scanner who required manual ventilation at and administering drugs to control his pain and
sedation was an indicator that we had gained the trust of the ward staff.
Types of Casualties
Lots of trauma from Motor Vehicle Accidents (MVA) - high speed with and without seat belts.
Pedestrian Vehicle Accidents (PVA) either being hit whilst crossing the road or falling in front of
a vehicle whilst under the influence of drugs or alcohol; numerous assaults against men and
women with sjambok, knives, machetes, fists and feet.
Some of the Injuries & Interventions Encountered on 163
Below are examples of the experiences encountered
 Pneumothorax for a stab wound - Chest drain insertion – Registrar training a junior
doctor in chest drain insertion on a patient - able to listen to the chest pre and post
insertion
 Spiral fracture of the tibia – impaired blood flow to the leg – felt and visualized the
coldness between limbs - fracture repositioned on the ward– traction set up on the ward
 Stab wound to neck, bilateral chest drains inserted prior to coming to the trauma unit –
these drains were in the wrong place and seeing the damage that was done – surgical
emphysema present - reinforces the correct way to do them
 Back Injury no feeling from the waist down – passenger had died at the scene –
reassurance and emotional support – neurological survey outstanding
 Ears, lips, eyes sutured by the plastic surgeons that are in great demand on the ward able to watch and assist.
 Blown eye socket
 Dog bite - nail debridement and reconstruction
 Head injury – blown pupils – observations - x-rays
 Women who had been beaten – extensive bruising limbs swollen – potential
compartment syndrome to all limbs – treated for Rhabdomyolysis hourly monitoring –
provided emotional support.
 Compartment syndrome to forearm after assault – loss of sensation and feeling to hand
– examined the arm – followed to surgery, assisted intubation and watched the operation
(Fasciotomy) to relieve the pressure.
 PVA – fractured pelvis (a sheet was used as a pelvis splint) - Blood in urine possible
bladder tear – ruptured spleen
After the busy weekend of trauma on the unit, the following 2 days were quiet, allowing us to
consolidate our learning, communicate with patients, and clean the ward. After the busy
weekend cleaning up was a task taken on my Dylan and myself, the ward staff were taking
advantage of a quiet day! This did highlight problems with sharps discovered lying around and
differing standards of cleanliness, maintaining the requirement for universal precautions at all
time on the ward due to the high instances of HIV in the population. Dylan undertook the task of
cleaning the cervical collars and head blocks which due to the high number of head injuries
where not clean!
Day off Wednesday
We desperately required a day off at this stage, and were feeling confined and claustrophobic
working 12 hour shifts and never having seen anything outside except the hospital and hotel. It’s
very difficult to get a feel for a place if you haven’t been out and about!
We arranged a trip to the Lion Park with the hotel and Jimmy the driver delivered a history of the
RSA on the ride there and back, he also drove the taxi into the enclosures. Dylan managed to
get photos of a Zebra and Ostrich for his children which they requested. It felt so good to be out
and about. We went shopping in the afternoon to Sandton City a huge shopping complex
surrounding Nelson Mandela square. This is an amazing high end designer shopping complex.
Dylan and I immersed ourselves in a good shopping experience. Whilst waiting for transport I
tried to distance myself from Dylan who had bought a huge elephant cuddly toy complete with
baby for his daughter.
Ward 165 Medical Casualty Thursday & Sunday
This ward was a challenge because it was obvious that they did not know what we were there
for, what we were meant to do or what we could do! It was difficult to engage with the staff and
proved hard work and took a lot of effort to start any dialogue.
Dylan got involved with a resuscitation attempt on a 28 year old that arrested and unfortunately
died from Meningitis. He then managed eventually to talk to a Consultant who allocated us to
work with doctors.
I started working with a doctor who was assessing patients referred from the triage clinic. I was
able to set up drips and inserted a couple of IV cannula. This gave me insight into tuberculosis a secondary infection relating to HIV, 4 of the 5 patients assessed had HIV. The doctor
explained that 35% of the population had HIV but not all people are screened so the figure could
be higher. I got to assess the biggest abscess / carbuncle on the back of a neck that I had ever
seen, the doctor explained that this was probably related to HIV infection.
In summary this ward to an offshore Medic working in the North Sea has a limited learning
value. If we were working internationally it would have more benefit.
ER 24 Ambulances shifts 0800-1700 and 1500-0130
This was the start of something special and a real highlight of the Johannesburg experience.
We were initially delivered to the wrong ambulance base, however we were unaware introduced
ourselves and ‘got stuck in’. Dylan was straight out to an RTA with a blue light ambulance. I got
to talk to some returning paramedics and ambulance drivers who had been to another RTA
involving a Taxi (this is the RSA so it holds 14 persons). I asked how they had approached the
scene and how they had performed the triage. They assessed the scene and immediately called
backup. They performed a triage screen and wrote P1, P2 or P3 on everyone’s hand and then
dealt with the P1 patient with a shattered pelvis, and the 8 month pregnant female with severe
abdominal bruising who was not wearing a seat belt. Other ambulances then arrived to recover
the remaining casualties.
We were then informed that we had been taken to the wrong base and that our driver would
collect us and take us to the correct place. Oh well go with the flow!
We were taken to the ER 24 training base and met up with 'Morne' and 'Dave' ER 24 chief
instructors. We would be going out with them in the response car which attends all P1 & P2
casualties they would take us all around Johannesburg and take any calls in the area we
happened to be in. These guys were great providing us with their experience as they drove us
around for 2 days taking us to the best and worse parts of Johannesburg. On one occasion, we
went for a Thai meal and they also provided a South African picnic because we had not eaten
anything specifically from the region. The meelie pap, tomato sauce and sausage and the milk
tart was a winner.
During the day we went to Chris Hani Baragwanath Hospital, Soweto (named after a Cornish
man!). Because Morne and Dave knew the trauma Consultants we were taken on a tour of the
trauma areas and the unit in general. This place was so much cleaner than the Charlotte
Makeke hospital, despite the number of patients in the area waiting to be seen. The general
atmosphere of the hospital was much brighter than the one that we had been working in. This
had been the primary hospital used during the football world cup and it was evident that money
had been well spent here. It was easy to pick up on the general work ethic; the staff seemed
much more upbeat and relaxed. We returned to the hospital late on Saturday night with a
patient suffering from 50% burns, however the trauma unit was full, the resus bays and burns
unit were full, so they rearranged people to take the patient into the ward without any drama and
just adapted to the situation presenting itself. This hospital had an air of competence and strong
leadership. Numerous student doctors and nurses were working along with the Medical team
you got the impression that this would be a good place to work.
We went to an RTA and got involved with assessing the scene and casualties, we observed the
state of the cars bent steering wheel and crazed windscreen. The driver, who was well
intoxicated, was feeling no pain and didn’t want medical help (he would definitely be sore in the
morning) the driver of the other car he hit (driver side impact) had neck pain and was taken by
an ambulance to hospital. We left this scene to go to a stabbing!
The paramedics meet up at service stations and restaurants around the city for free coffee and
a chat with other paramedics whilst they wait for shouts (they were letting Morne and Dave
know if they had anything worth seeing for us students) We were able to chat about the
paramedic role, “what if’s”, “how do you do’s” etc. This was a great learning experience because
they were all more than happy to pass on their skills and expertise, and were interested in the
role we perform offshore, on rigs.
Mopping up
ATA Debrief and recommendations
Tasneem, Janine and Trevor wanted feedback on our experiences over the previous 9 days.
We expressed how much we had enjoyed the experience and were able to suggest
improvements to enhance the learning opportunities.
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Improve the pre course administration,
Drop ward 165 - little or no value to North Sea Medics
Start with an ambulance placement to orientate students to the location,
Placement at Chris Hani Baragwanath Hospital, Soweto as well as Charlotte Makeke
hospital
Add an ACLS or ITLS course
Information on how to say hello in the 9 languages and information on handshaking to
aid initial encounters. (South Africans are in general very polite)
Conclusion
There are a few issues worth reviewing.
 Personal safety of the individual whilst in Johannesburg.
I never felt unsafe or in danger at any time during my stay. Johannesburg is no different to
any other town or city some areas you avoid others are OK. Listen to the locals and follow
the local advice, we went to some very poor areas but the people were always polite. The
paramedics are held in high esteem within Johannesburg and danger was never an issue.
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lack of practical experience and exposure to trauma obtained during our 2 day yearly
accident and emergency placement at Aberdeen Royal Infirmary (ARI)
With such low incidence of trauma in the UK, how can Nurses/Medics retain trauma skills
particularly within ARI where the exposure to trauma patients is significantly less than in
Johannesburg?
Whilst doing the experiential training in the Trauma unit and with the ambulances I have
learnt and been exposed to so much more than I was at Aberdeen as you can tell from my
account. This was a total experiential learning experience where you can learn from
observation, action and others.
In the RSA
• Trauma accounts for 40% of emergency centre attendances
• Highest rates of traumatic deaths in the world
• South Africa has 1,200 deaths on the road a month and 60,000 South African’s meet
their end violently every year
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What can be obtained from training in Johannesburg that cannot be obtained at ARI
In Johannesburg there are more opportunities to be involved with trauma as the
placement is longer and there is more of it.
The annual patient workload is approximately 20 000 trauma patients per year, including in
excess of 2000 admissions and 1700 major resuscitations annually. The Unit is one of two
major referral centers in the Johannesburg area, receiving patients from throughout the
Province, neighbouring provinces and neighbouring states.
2006 http://www.trauma.org/index.php/resources/elective/351/
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What is wrong with the training that we currently receive
There is nothing wrong with the training that we currently receive. I believe our company is
forward thinking and innovative in their approach to Medics training by compulsory 2 yearly
Medics course instead of 3 yearly as per HSE requirement, yearly 2 day ARI placement and
doctors assessment. So adding a placement in Johannesburg would complement the
training already provided by exposing Medics to actual trauma situations better ensuring that
Medics are capable and competent to meet any given situation.
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Why the need to travel over 6000 miles, to a country that is in the top 10 of the most
dangerous places in the world to visit and to a place that is reputed to be one of the most
notorious murder/rape/robbery cities in the world?
In my personal opinion Johannesburg is just like any other city there are areas that you
would not choose to go on your own and others where you feel safer. As a female this was
important to me.
My lasting impression of Johannesburg and the RSA is that the majority of people are polite
and happy and willing to help anyone. There is a positive culture where they are striving to
improve their country and themselves just as we are in the UK.
In summary would I go back? – Absolutely, without hesitation and I know Dylan is of
the same mindset.
Paula Logan
North Sea Medic and Registered Nurse
August 2012