Red Cross War Memorial Children’s Hospital
Cape Town, South Africa
November 2008 – October 2009
I knew I was interested in going to South Africa on elective as soon as I found out that it was an
option as a resident in the Pediatric Residency program at UBC. I was applying for a CaRMS
position and I decided very early on that I would actively pursue this long-term elective, which
was becoming an established opportunity by the time I joined the program in 2006. I spent my
first year of residency dreaming about it, my second year planning it, and my third year living it!
As far as the dreaming part goes, everyone can figure this one out on their own :) I got in touch
with the residents who had gone before me and found out what their experience was like, what
they learned, what they liked and/or struggled with; all of which got me even more excited about
my elective.
Once I got the go-ahead form the program director, I went into planning mode. Overall, it took
me just over 12 months to organise all the paperwork: secure the elective through Red Cross
Hospital (RXH), book flights, obtain a visitor’s visa, get a South African medical license,
arrange for travel and liability insurance, and pack up my life in Vancouver so it would still be
here for me when I got back. It can be very stressful to watch deadlines approaching and not
hear back from organizations overseas. I think it is fair to say that most people who have been
through this would agree: the best way to avoid that kind of stress is to start early and assume
that there will be delays, especially when dealing with countries in the developing world.
Then, November came around and I finally got to fly to South Africa and landed in the beautiful
city that is Cape Town. I took a few days to get familiar with the area where I was staying, sort
out banking issues, and eventually began the most amazing year of training of my life. I showed
up at RXH, a 330-bed hospital located in Rondebosch just outside of the city centre and the only
free-standing pediatric hospital in Sub-Saharan Africa, having no idea what to expect.
The first month was all about survival and adaptation. I thought I had prepared myself by
reading about tuberculosis (TB), HIV, malnutrition and keeping up with all kinds of other
international health issues that seem some foreign to us in Canada, but the reality was very
different. The sheer burden of disease and the severity of illness that surrounded me was more
than what I had prepared for. Luckily, the registrars, senior house officers (SHOs) and interns I
worked with throughout my stay in South Africa, but especially during that first month, were
incredibly friendly and supportive. They helped me find my way around the hospital and the
diseases. And even though I felt completely out of place initially, it did not take long to become
comfortable; likely the advantage of being thrown off the deep end into a completely different
environment.
I spent 3 months on the General Pediatrics wards, learning all about HIV-related illnesses,
complications of TB, approaches to the management of Kwashiorkor, rheumatic heart disease,
meningitis, etc. When the cholera epidemic hit Zimbabwe, we saw a few patients come through
and the whole hospital went under high alert in case things deteriorated, but luckily, we kept
things under control. I learned to round on 30 patients in under two hours and failed many
attempts at putting in IV’s in dark-skin patients with difficult access before I became more
comfortable with my skills. We frequently had to run codes (known as “red boxes” because of
the colour of the tool box that contains all the resuscitation equipment) on the ward, intubate and
ventilate patients or start peripheral inotropes until a bed was available in ICU. This was
particularly stressful on call as there are only one registrar and one SHO covering roughly 120
in-patients as well as sick kids in the emergency department overnight.
As gastro season reached its peak, I moved to the ICU for a three-month rotation that taught me
more about managing sick kids than I ever thought I would know! On any given day, there is at
least one patient on the unit with hypoxic pneumonia (PCP, CMV or both), myocarditis/dilated
cardiomyopathy, severe burns, paraffin ingestion/aspiration or traumatic brain injury. In the
summer months, half of the unit is occupied by babies with hypovolemic shock from severe
gastroenteritis. I never realized how much damage gastro can cause; we had to withdraw care on
a few because of extensive brain injury following hypotension and hypoxia. There were plenty
of opportunities to intubate, put in central venous and arterial lines, draw arterial gases, and place
peripheral IV’s. Since there are no respiratory therapists at RXH, the doctors are responsible for
adjusting ventilator settings, which means that one becomes familiar with the process quickly.
In May, I move on to the Nursery at Groote Schuur Hospital (GSH), the adult hospital affiliated
with The University of Cape Town (UCT). There, I quickly became familiar with looking after
very small premature babies. Likely because of low socio-economic status, poor nutrition, HIV
and suboptimal prenatal care, the babies are born at a much lower birth weight than what we are
used to here in Canada. As a pediatric registrar, I was also the most senior doctor on at night,
and therefore, I would get called as backup when the interns and SHO’s struggled with flat 800g
babies in the operating room. I remember being called urgently to the OR at 7am as I was
finishing a (very long) 24hr call and finding out that they were about to deliver a baby with a
prolapsed cord. There must have been 12 doctors and nurses with the mom, and I was the only
person with decent pediatric training in the room! When the baby came out flat, we resuscitated
him, intubated him and took him down to the nursery. When I got back to work the next day, he
was doing beautifully and went home a week later. Some of those babies are so resilient, they
surprised me on a regular basis… Some others are not so lucky and I ended up looking after
several neonates with hypoxic-ischemic encephalopathy, which is often devastating considering
how little community support is available to these families. Severely disabled children do not
survive long in the townships around Cape Town. I also saw a fair share of congenital syphilis,
necrotizing enterocolitis, sepsis, and meconium-aspiration syndrome while I was there. Again,
opportunities to practice procedural skills are endless: intubations, in-and-out surfactant
administration, peripheral IV’s, arterial lines, PICC lines, chest tubes, etc.
Finally, as the year came to an end, I went back to RXH for my out-patient rotation. I worked in
the Medical Emergency department (affectionately known as “the Box” because of the frequency
of codes that are run there) and the short-stay unit, room S11. The registrars who work in the
Box manage amazing things with significantly less support than in ICU. Multiple times a week,
kids come in shocked from gastro or hypoxic from pneumonia, others come in actively seizing or
even apneic and pulseless from unknown causes. We routinely dealt with organophosphate
poisoning, meningococcemia, dysentery, asthma exacerbations, etc. And there was no shortage
of procedures there either: IV access in shocked babies, blood-drawing, intubations and lumbar
punctures are routinely performed in both the Box and S11. Again, the doctors and nurses
working there are very supportive and I am forever grateful for their help.
As supernumerary registrars, Canadian pediatric residents can move around different services in
the hospital and have the opportunity to go to other affiliated hospitals if they want to get a
different experience. There is no nursery at RXH, so I chose to spend 3 months at the nursery at
GSH, but other people could choose to go to the New Somerset Hospital (NSH) in the city or to
Mowbray Maternity Hospital (MMH) if they wanted. There is also an opportunity to go to
George, 4 hours outside of Cape Town, on the Garden Route, to get a more rural experience.
In summary, I think that choosing to do an elective at RXH in South Africa is not a decision one
makes lightly. A significant amount of time, energy and money goes into the initial organization
well before one even gets there. And the elective itself is often frustrating: long hours, 1 in 4 call
throughout the year, lack of reliable access to personnel and equipment we are used to in Canada.
The children are so beautiful and resilient that it is very easy to get attached to them. And
therefore all the more frustrating when they fail to get better or when they die. The emotional
strain I had to deal with during my elective was my biggest challenge, but I think that it
contributed to personal and professional growth in ways that no other clinical or procedural
experience ever could. There are no words to explain just how much I learned from that elective.
In fact, I enjoyed my year at RXH so much that all I can do now is try to think of ways that I
would allow me to go back as soon as possible!
Karen Trudel, MDCM
Pediatric Resident, PGY-4
UBC/BC Children’s Hospital
ktrudel@cw.bc.ca