He’s the guy who ‘makes and loves the coffee’ – which is probably just as well, because he’s one of only two emergency medicine specialists on night duty at Khayelitsha Hospital, and will soon have to hyper-focus; it’s pay-day weekend. The against-the-odds saving of lives that takes place is as unbelievable to less trauma-hardened medics, as is the sure-fire predictability of this month-end patient influx, says Dr Sa’ad Lahri. Only the types of severe trauma differ as he, consultant colleague Dr Hendrik Lategan, four other doctors and 15 nurses make snap decisions that will save the lives of 80% of their patients, most of whom are inebriated. The million-plus-strong township thrums on a pay-day weekend as shackland taverns, open houses and street parties generate music, frivolity and profit, belying the chaos that inevitably ensues as disinhibited energies (read: pent-up frustrations) spill over into multiple episodes of uncontrolled violence. Small worked-up crowds ebb and flow between venues, and long-standing gang animosities often explode, sparked by seemingly minor incidents. At the same time, domestic disputes boil over behind brick, corrugated-iron or cardboard walls, incurring multiple casualties as neighbours also living on or below the breadline try to intervene or take sides. Lahri and his colleagues meanwhile savour what could at any second be their last cup of his much-loved special coffee blend as the admission rate begins to pick up …

Mending hearts in more ways than one

‘Most of our cases are penetrating traumatic injury to the chest – these criminals read the anatomy books, they know where to stab.’ His team’s stab-heart survival rate is 75%, an incredible 60% above the international survival norm listed in the medical literature. They’ve had 60 stabbed hearts at the emergency centre over the past 2 years, and have saved 45 of the patients. One case he’ll never forget: the youth’s left anterior descending coronary artery was severed. ‘We managed to stabilise and get him into theatre. The surgeon used a feeding tube to create an artificial artery, and we were then able to get him to Groote Schuur for a bypass.’ The second highest trauma category is traumatic brain injury from community assaults, ‘and then we get the car accident patients, mostly off the [nearby N2]’, Lahri says, pausing to field the barrage of questions that countless interviews have taught him will ensue. Yes, 90% of the trauma cases are alcohol-related, but the thing that has stood out during his 2-year tenure is the timing of this human tidal wave of patients: ‘It’s very clear; it’s the first or second day of every month; whenever there’s money and alcohol.’ What ‘bugs’ him most, though, are the three to four new patients with drug-induced psychosis admitted every day (about 110 per month), most of whom have committed active crimes. Very few have schizophrenia or other psychiatric conditions. Police baulk at arresting these people because they are ‘deurmekaar’ (confused) and need to brought down first – meaning that the emergency unit staff faces the brunt of their destructive behaviour. Says Lahri: ‘They break windows, equipment, assault staff. We had one guy fall through the ceiling after he somehow got into the roof through a trapdoor. It’s a major issue. They also sell their parents’ stuff. One mum came in crying, saying he’d sold everything in the house, fridge, stove and chandeliers – the lot. We just treat symptomatically and wait for the psychiatric professionals to come. They sometimes lie with us for days. We try to interact with FAMSA and SANCA and the community health centres (who have psychiatric nurse practitioners), but our job is to deal with the critically ill. Drug abuse gets in the way of everything else.’ Asked to quantify the problem, he responds: ‘It’s about 3% of my load but 70% of my problem.’

Vigilante violence puts police in the shade

The other disturbing phenomenon for Lahri is the community assaults. ‘We have people being beaten for stealing chickens. The community gets hold of them and beats them to a pulp, mostly resulting in severe traumatic brain injury, or just simply burns them alive via the necklace method’ (a legacy of the civil warfare that raged in townships during the apartheid years, when suspected ‘impimpis’ (sell-outs) were beaten, and a petrol-filled car tyre slung around their necks and set alight). Asked to quantify the mob attacks, he puts the figure at around ten victims per weekend and ‘at least 30’ per month.

Lahri counts himself lucky staffing-wise (he only has to compare his situation with similar hospitals anywhere in the country), but cannot escape the dearth of appropriately trained nurses. Many of his are agency or locum nurses, which he, like many of his frustrated colleagues nationally, considers unsustainable when it comes to quality control. Six are trauma-trained, a result of smart forward thinking when he and Lategan sent two a year on trauma and resuscitation courses, leading to short-term work pressure but substantive long-term relief. Given a magic wand, he’d conjure up a third consultant, giving himself and his colleague more time to handle admin and write up some of their more noteworthy resuscitations and treatment (he’s managed to get just four papers published in over 2 years). Both he and Lategan are family men with young children. ‘We’re the only two, so we have to have one another’s backs; it gets rough sometimes – it’s not just the volumes, the patients are complicated, we have polytrauma, airway injuries, patients with gunshot-face and stabbed neck, it’s not simple stuff.’ Then there are the medical admissions, also driven by poor housing, lack of potable water and sanitation, and other poverty-related factors. ‘We see a lot of the massive HIV/tuberculosis (TB) burden via presenting emergencies. They will arrive in septic shock, with cardiac tamponade from TB or have massive diarrhoea with a potassium count of 0.5 mmol/l.’ The unit sees about 700 children a month on average, rising to 1 200 per month in the December - April ‘surge season’ when diarrhoea and pneumonia are most prevalent. Overall, paediatric mortality in the township has dropped by more than 50% since the hospital opened its doors in on 17 April 2012 (all trauma-related deaths have plummeted by 80%). Lahri’s team deals with an unusual amount of pulmonary embolisms and has thrombolised ‘at least 20’ patients over the past 2 years (compared with, say, Victoria Hospital or the ultra-modern and also relatively new Mitchell’s Plain Hospital, where thrombolysis is normally associated with myocardial infarction).

Most memorable cases

Besides one horrific night when a crazed knifeman slit the throats of several local residents, Lahri’s most memorable cases include a child who was playing with an electric live wire and was electrocuted. ‘A member of the community ran in with him and we immediately defibrillated the child. We intubated, ventilated and got him to Tygerberg – he survived,’ he says with barely disguised pride. The ‘night of the knifeman’ included a patient whose neck had been ‘slit open like a sheep at the Adam’s apple’. Emblazoned in the memories of all who helped save him are his gurgling screams and the blood spray-painted across themselves, the room and the walls. Overseas doctors who ‘parachute in’ for the unparalleled work experience are generally the most ‘freaked out’, Lahri says (there’s a waiting list of foreign-qualified doctors stretching to 2016).

Asked about the prevalence of post-traumatic stress disorder among his colleagues, Lahri responds: ‘We actively manage all the situations. Whenever stuff happens, we actively debrief. We go through about 5 kg of coffee a week! We begin by asking them what they think they did well, what could have been done better, and then ask if there’s anything troubling them about the case. It always comes down to “Hey! You didn’t shoot the guy, you did your best!”’ The unit’s caseload stands at about 3 000 patients a month and has remained relatively static, peaking at over 100 patients per day on month-end weekends.

Asked about travelling to and from the hospital and security at the hospital itself, Lahri says he has ‘no issues’. ‘To come in and travel out has been fine, and our hospital security is awesome. They tend to block a lot of the nonsense, with guns and knives usually handled by the ambulance staff or our security searching patients. We’ve had patients coming in with weapons, but it’s sorted out very quickly.’ Contrary to a widely held negative perception following reportage of an official probe into the township’s police force, he has nothing but gratitude for Khayelitsha’s policemen and women. ‘Every time we’ve called, they’re here within 10 - 15 minutes. Take an alleged rapist the community beat up: the cops come in, take a statement and then guard him. We had one cop here the other day who stepped into the middle of a mob that was busy savaging one guy and saved him, promising on his life that the suspect would go back to jail from the courts and giving the crowd his personal cell phone number. He stayed here well past his shift – until the guy was discharged – and then took him back to a holding cell.’

Lahri, a former consultant at the notori­­ously busy GF Jooste Hospital Emergency Unit in the heart of the Cape Flats ganglands, shut down in a rationalisation/modernisation initiative early last year, knows that the latter only partially contributes to his hospital’s 131% overall bed occupation level. The other major factor is Khayelitsha’s highly migrant population, whose healthcare in the Eastern Cape cannot match that available locally. About 70% of the adults living in the township come from the Eastern Cape, while most people under 19 were born locally. ‘We have a major influx from the Eastern Cape, often chronic patients, especially cancer, many in the last stages.’ He gave one heroic example of a child with a fractured femur, brought in via long-distance taxi from Umtata by his barely older sister, who had extracted him from a hospital where he had lain unattended for ‘weeks’.

International study dovetails with trauma profile

Khayelitsha and Rio de Janeiro were recen­tly the subjects of a 32-month international comparative study by the Human Sciences Research Council, (HSRC) on the role of social cohesion (or social solidarity) in understanding the link between inequality, poverty and urban violence.1 The report cited Khayelitsha’s murder rate as between 76 and 108/100 000 at the township’s various police stations (the South African average being 31), and said there were ‘high levels of fear of violence in all social spheres, including many public spaces’. Evidence at the recent Commission of Inquiry into policing in Khayelitsha indicated that the police perceived the township as an impenetrable space that they could not police. As a result, they failed to intervene and appeared to police ‘at the margins’ of the community. The HSRC report said that youth gangs were ‘a significant form of social organisation’. Although not organised in the same way as the gangs on the Cape Flats, they were shaping the nature and meaning of public space in places such as parks and schools. They were ‘highly territorial and shape identity, as young boys in particular areas feel obligated to join their local gang’. These gangs had a particular language of violence, which was very much about a public display of power. The report said that the collective violence residents engaged in was also organised as a public spectacle, intended to enforce a moral community against an ‘other’. This ‘other’ shifted, and might be a foreigner, a criminal or some other category of person.

Embrace your heroic work – and stop whining

Lahri’s 47-bed accident and emergency unit is 30% larger than a standard district hospital trauma unit, and the hospital has a heliport and a fleet of 11 ambulances and 110 paramedics and drivers.

Asked what his core message was for his emergency medicine colleagues (70% of them female), who work 9-hour days and every second weekend, Lahri replied: ‘I tell the younger ones there are very few chances in life to be a hero(ine) – and sometimes being a doctor here is just that. I define a hero as someone who finds the strength to persevere in spite of the obstacles – that’s certainly my motto. Things will always be difficult – it’s about persisting. When you see that mother hug her child, it’s all worth it. I sometimes tell my guys on night shift, when they’re really tired and irritated: “Just remember someone else still has a family member because of you … so stop whining!”’

Chris Bateman

chrisb@hmpg.co.za

S Afr Med J 2014;104(11):727-729.
DOI:10.7196/SAMJ.9004

1. Barolsky V. Violence in Khayelitsha: Finding a way out. HSRC Review 2014;12(4):8-11.

1. Barolsky V. Violence in Khayelitsha: Finding a way out. HSRC Review 2014;12(4):8-11.

Doctors who discard the placenta after a newly born infant dies or is permanently impaired – seemingly during the birth process – could potentially be throwing away their last chance of a legitimate defence should the angry and grieving parents decide to sue.

Prof. Colleen Wright, an anatomical patho­logist at the National Health Labora­tory Services in Port Elizabeth, had specialists and GPs paying close attention at the South African Medical Association’s Millennium Development Goals conference this August. Reminding them that the oft-discarded afterbirth placenta was a crucially important fetal organ and therefore a ‘map’ of what had happened to the infant in utero, she said it was a priceless tool in determining the pathophysiology of an adverse pregnancy outcome. The placenta could uniquely show whether injuries were primarily related to labour/delivery or to an in utero insult long before the onset of labour. Determining the timing of such injuries was invaluable in the medicolegal assessment of cases. Without placental pathology, the attending doctor could be left high and dry in responding to litigation.

Wright said numerous studies had shown that babies who had ‘an event’ during the course of their mother’s pregnancy went into labour already compromised. The placenta was normally ‘relegated to the sink’. Her experience at Tygerberg Hospital in the year 2000 was that she saw just six placentas from an ‘excellent’ and extremely busy neonatal unit that year. Through her advocacy and that of her colleagues, this improved to 848 placentas a year (still just 15% of deliveries) by 2004/5, when there were only 30 cases of clinically suspected intrapartum hypoxia. On examination, the placenta was normal in only one of these 30 cases, the remainder all showing some degree of pathology unsuspected by the attending clinician. Existing data from developing countries showed that 90% of neonatal injury occurred before the onset of labour, while the only existing comparative data (from developed countries) showed the percentage of injury due to intrapartum hypoxia to be just 6 - 10% (estimated to be higher in developing countries). Wright said that the commonest causes of intrapartum hypoxia were placental abruption and cord accidents (i.e. cord prolapse), both sudden and unpredictable events. Where she was now working (Dora Nginza Regional Hospital in Port Elizabeth), nearly every baby delivered with a low Apgar score was labelled as having birth hypoxia. ‘If that’s seen by a lawyer, it’s a field day because you then have to prove it was not,’ she warned.

US insurance companies insist on placental pathology

Wright cited some insurance companies in the USA as suggesting that every placenta delivered by their clients be sent for pathology, as some adverse outcomes may not be immediately apparent at birth – a highly pragmatic and effective means of saving on litigation payouts. More practical in our setting, however, was for each hospital to agree on guidelines for submission of placentas appropriate for their setting and budget, based on internationally published and accepted guidelines. She also outlined four essential criteria needed to define an acute intrapartum event as being sufficient to cause cerebral palsy, one of these being the exclusion of any other identifiable cause, saying that this further pointed to a need for placental pathology. Placentas with decreased reserve would still function adequately, yet be unable to cope with the stress of a normal delivery, she emphasised. Among the reasons the placenta was ignored was the limited exposure students and doctors had to it during training, difficulties in terminology, interpreting findings and examination, and the dearth of qualitative studies. Another reason it had become ‘the outcast’ among pathology specimens was that ‘there are simply too many of them’. She said that some indications for placental examination would not be obvious at the time of delivery. Not only did determining the pathophysiology of an adverse pregnancy outcome help determine the timing of events to assist in a medicolegal assessment, but it also contributed significantly to the management of subsequent pregnancies and the management of the newborn child in the acute and longer term. It also helped define health policies and the allocation of resources.

Seventy-three per cent of US obstetricians sued more than once

Driving home her message, she cited a 1985 National Institutes of Health report putting the number of mentally retarded children in the USA at 850 000, cerebral-palsied young children at 750 000 (with 10% of all schoolchildren disabled), and 42 million neurological, communicative disorders. In 2003, a full 73% of obstetricians in the USA reported being sued at least once – most often related to cerebral palsy. The median award for ‘medical negligence in childbirth cases’ was $2.3 million (just over R23 million). Wright proposed that in South Africa (SA), where litigation is on a sharp upward curve given the predisposing conditions for adverse events in public hospitals, ‘we pay more attention to our own placentas and their role in contributing to the statistics we have in our neonatal and perinatal deaths. If we do, I think you’ll find the placenta has a great deal to contribute to reducing the shocking statistics we have.’

The SA Saving Babies 2010 - 2011 report puts the early perinatal mortality rate as 21/1 000 live births, with the majority of these deaths occurring in the 1 000 - 1 499 g weight category. Deaths due to intrapartum asphyxia are reported as being linked to healthcare provider-associated avoidable factors in 44% of cases. The top five health worker-related factors were: (i) fetal distress monitored but not detected; (ii) fetal distress not monitored and not detected; (iii) no intervention for prolonged second stage of labour; (iv) delay in referring the patient; and (v) delay in calling for expert assistance.

Wright told her doctor audience that the only time a placenta would not help them was if they were negligent. The ‘ideal’ would be to identify problems prior to delivery. Here the Doppler ultrasound scan may prove to be of great assistance in avoiding having to tell parents ‘sorry, you have a dead baby, but we can point to the cause’. She was involved in a large international study trying to correlate data on Doppler ultrasound use v. placental pathology, and added: ‘In SA we are in the early stages of identifying our problems, but there is much more we can do.’

‘I believe when a baby is compromised, everybody is the loser – the baby, the obstetrician, the neonatologist and the parents. Sometimes the best you can do is sit down with the parents and say we looked at everything we could, there was a natural cause for it. If you don’t have an answer for them, they will take you to court – they’re angry. But if you can truly say it was nobody’s fault, that nature can be cruel, they won’t sue,’ she said.

Chris Bateman

chrisb@hmpg.co.za

S Afr Med J 2014;104(11):729-730.
DOI:10.7196/SAMJ.8991