No shortage of teaching opportunities in Johannesburg trauma unit

The 21-year-old Tanzanian refugee had no pulse when paramedics rushed him into the Johannesburg General Hospital. It was Friday morning. “He had a 1% chance of survival,” said Dr. Jacques Goosen, senior surgeon in the hospital's Trauma Unit.

Figure. Curbing the flow: violent crime is a daily fact of life in the Hillbrow area, an inner-city suburb of Johannesburg. Photo by: Canapress

But the thoracotomy proved unsuccessful. The man had been found, shot, in a high-rise hallway in the notorious Hillbrow area of downtown Johannesburg, which is considered the world's most violent place outside of war zones. “This is one of the busiest trauma units in the world,” says Goosen. The burden on the unit, which serves a catchment area of 2.5 million people, has increased because the government closed other facilities. It remains South Africa's sole dedicated trauma unit, staffed by 12 doctors backed by specialists and a surgeon.

In Johannesburg, the intense action starts around 10 pm each Friday and lasts until Monday. Goosen's unit will admit a dozen people each night, most arriving because of domestic violence fuelled by alcohol and firearms. “The end of the month is worst,” said a British army surgeon completing a sabbatical at the Johannesburg General. That's when people get paid, he explained, and problems related to substance abuse multiply.

“In South Africa, 76% of all deaths after interpersonal violence are alcohol related,” Goosen and 6 coauthors concluded in a recent report that chronicled a 13-fold rise in the number of gunshot patients requiring resuscitation at the hospital during the past 17 years. The study, conducted at the University of the Witswatersrand and the Johannesburg General earlier this year, found that the unit saw 719 patients who had been shot and required resuscitation in 2001, compared with 55 in 1985. South Africa's rate of violent death — 137 per 100 000 people — is now 6 times that of the US

Although the hospital sits at the edge of one of the city's most crime- and drug-ridden zones, police say it faces relatively few threats from nearby residents. “Yes, people have been robbed and hijacked, but it's a general problem not related especially to health care workers and professionals,” said Captain Ronnie Naidoo of the South Africa Police Service.

But violence remains pervasive. Dr. Daniel Ncayiyana, editor of the South African Medical Journal, was “angry and baying for revenge” after 2 surgeons were “gratuitously shot” in separate carjacking incidents (SAMJ 2002;92:557). Only one survived.

Such violence has had a huge impact on the medical profession (CMAJ 2002;167[7]:793), with many doctors leaving for Canada's safer climes. There are now 1738 South African physicians practising in Canada, a number roughly equal to the annual output of all 16 of the country's medical schools.

But the violence does provide some real, if distressing, benefits — the British army surgeon training in the trauma unit, who would not give his name because of military regulations, said Johannesburg provides unmatched training opportunities. “It's very rewarding. The patients in trauma are generally young and fit and it's great if we can get them back to a productive life.”

On a recent Saturday night, one of those patients was 22-year-old David Grobler, who attempted to thwart bandits carjacking a Nissan Sentra from a woman and her 13-year-old daughter. He was shot in the neck and needed 8 units of blood after the helicopter delivered him to the Johannesburg General's Trauma Unit. It was his second carjacking in 3 months, his mother said. — Colin McClelland , Johannesburg