- Email: [email protected]
A night in a South African trauma hospital
AFTERTHOUGHTS
A Night in a South African Trauma Hospital Kathryn G. Sapnas, PhD, RN, CCRN, CNOR
am a trauma nurse researcher and faculty member at the University of Miami School of Nursing. My research interests specifically have included injury prevention, transcultural nursing, measurement of social phenomena, and theory development. During the past year I took an educational leave of absence from my research and teaching positions in Miami. I chose South Africa as the location in which to fulfill my role as Rotary Ambassadorial Research Scholar and to conduct trauma research. I lived in Cape Town and selected the University of Cape Town (UCT) for my academic affiliation, because of the international reputation of the Groote Schuur Hospital (GSH) and active Trauma Service. During my 1-year tenure at UCT, I filled the position of Honorary Research Associate in the UCT Department of Surgery. Shortly after my arrival in Cape Town, I met with Professor Del Kahn, the head of UCT Division of Surgery, and Dr. Andy Nicol, the Head of the GSH Trauma Unit. Unintentional injury, specifically, driving behaviors that increase morbidity and mortality risk, was the area of my doctoral dissertation work, which I had hoped to extend during this visit. However, upon my arrival, it was requested that I spend some time looking at the trauma unit, talking with the staff, and getting to know the community and community issues before determining the topic of my research project. I began by meeting with the nursing administrator, Matron Cathy Thorpe and Mrs. Patton, matron of trauma services. My discussions were with nursing, medical, and emergency medical services (EMS) staff, as well as commu-
I
Kathryn G. Sapnas, PhD, RN, CCRN, CNOR, is a trauma nurse researcher and assistant professor at the University of Miami School of Nursing. Reprints not available from author. Int J Trauma Nurs 2001;7:148-51. Copyright © 2001 by the Emergency Nurses Association. 1075-4210/2001/$35.00 + 0 65/1/119083 doi:10.1067/mtn.2001.119083 148 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Sapnas
nity members. The conversations always seemed to center around violence and injury. Injury from firearm violence seemed to be of paramount importance to most everyone I spoke to in Cape Town. As a result of the discussions, I designed an exploratory and descriptive study. It was a prospective hospital-based study that investigated the experiences and attitudes of patients who had been injured as a result of firearm violence. The aim of the study was to identify the context and nature of injury by gun violence.
After 24 years of critical care/trauma nursing experience in urban trauma centers . . . I am not new to violent injury. However I was new to the culture of violence in Cape Town. After 24 years of critical care and trauma nursing experience in urban trauma centers in Philadelphia and Miami, and as someone who has earned a master of science in nursing degree with a critical care/trauma focus, I am not new to violent injury. However, I was new to the culture of violence in Cape Town. I decided to use the GSH Trauma Ward and the community as my laboratory to examine the phenomenon that I was about to study outside of my own country. I spent my first month at GSH hospital getting to know the nursing, medical, and ancillary staff. I visited on all 3 shifts and on weekends. I wanted to let people know what I would be doing and that I was interested in hearing their perspectives on violence and injury. I spent a weekend on the night shift at the University of Cape Town, GSH trauma resuscitation ward from 11 pm Friday night until 6 am Sunday morning. I would like to share journal notes from a portion of that weekend. VOLUME 7, NUMBER 4
Figure 1. Nursing staff in Trauma Unit C5 at the Groote Schuur Hospital. (Mr. Toby, Sr. Mackie, Mrs. Benjamin, Sr. Noshumi Tya, Sena Oerson J., and Sen Jacobs C.)
Friday, September 1, 2000: The night was cold. There was mist in the air and a fine rain had begun to fall. The parking lot was empty. There were no ambulances to be seen, other than a parked Western Cape Ambulance with a Rotary emblem. The ambulance had been provided as a result of a Western Cape Rotary project fundraising. There were no throngs of people at the casualty department doors, as I expected. I walked through triage and it was very quiet, with just a few employees in the lobby. The quiet was awkward. There were a few medical students doing their physiology practicum on the
Within a few minutes the woman had wandered down to the resuscitation area, wondering if her boyfriend was alive. night shift. A second-year trauma registrar (resident) was in charge of the trauma ward for the night, and would be on duty for the rest of the weekend. As I walked down to the hall toward the resuscitation ward, I saw a woman with torn overalls and a bandaged arm that dripped with blood. She was the girlfriend of a patient in the resuscitation area; he was an injured man with a left hemothorax due to a stab wound to the left lower neck area. The wound extended into his chest, causing serious bleeding and impairment to breathing and oxyOCTOBER-DECEMBER 2001
genating. He had another stab wound to his left lower back. Within a few minutes the woman had wandered down to the resuscitation area, wondering whether her boyfriend was alive. She sat there looking so sad. By talking to her I could smell that she had been drinking alcohol; however, she was coherent and able to communicate effectively. Alcohol intoxication has been reported in more than 70% of violent crimes at GSH. I asked the female patient how she had been stabbed. She told me that she and her boyfriend live in Langa, one of the Black townships outside of Cape Town. They had an altercation with their landlord concerning their rent payment. They had the money for rent but had not paid it yet. As they were having dinner in their flat, the landlord came in and started arguing with them about the money. She showed the money to the landlord but he slapped her. As the boyfriend intervened, the landlord stabbed him. Now the boyfriend was being sent to surgery and would be admitted postoperatively to the trauma ward. The girlfriend went home with a bag of her boyfriend’s clothes. This scene reminded me of similar cases I had seen in urban trauma centers in the United States. I was thousands of miles away, yet trauma themes in violence remained the same. After a complex resuscitation and surgery, the ventilated stab wound patient was transferred directly to the Trauma Ward High Care. The sounds, smell, and trail of blood from the resuscitation suite were familiar to me. I watched as the staff methodically and swiftly cleaned up and prepared for what would come next. It was quiet again, but just for a while. INTERNATIONAL JOURNAL OF TRAUMA NURSING/Sapnas 149
Figure 2. Sr Xakiwe “Betty” Ngindi, professional nurse at Groote Schuur Hospital Trauma Unit stabilizes a patient admitted to Trauma Resuscitation C-14 with the help of a staff nurse.
By 1:30 am things had changed. Within minutes patients were rolling in with the Western Cape Ambulance services. One patient had been shot multiple times (with large caliber bullets judging from the size of the entrance wounds) in the abdomen and in the upper right thigh, shattering his femur. The patient was unstable with tachycardia and required immediate resuscitation. In a few minutes, a man who had been assaulted with a blunt object to the head and another man who had been stabbed in the left upper chest were rolled in. The staff was organized and completed tasks methodically, calmly. It was obvious that the staff had done trauma resuscitating before. I went to look at the observation bays and saw a sister (registered nurse) suturing a head wound. Her technique was good and the wound was well approximated. There is no requirement in South Africa for a sister to have an advanced nursing degree to suture wounds, but the sisters receive classes and on-the-job training to become certified to suture lacerations and wounds in the GSH Trauma Ward and Casualty Department. A competency assessment based on the scope of practice and internal hospital policy is given to all nursing staff who are allocated or who work in the trauma/emergency unit. A suture team monitors the nurses’ work. Other competency assessments include changing underwater drainage bottles, checking trac150 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Sapnas
Figure 3. Sr Vatiswa Makie, professional nurse and matron of the Groote Schuur Hospital C5 Trauma Unit reviewed the Trauma Resuscitation Log for patients eligible to participate in the Nursing Research Study on Gun Violence and Injury. VOLUME 7, NUMBER 4
Figure 4. The Groote Schuur Hospital, Old Main Building, poised at the foot of Table Mountain, houses Transplant Museum, Medical and Nursing Schools, Research Laboratories, and Nursing and Hospital Administration. It was formerly the inpatient hospital.
tion, applying special bandages, changing intravenous fluid bags, and applying eversion strapping. I spent the rest of the weekend on the night shift in the Trauma Resuscitation ward meeting the staff and registrars in various parts of the trauma and casualty departments, as well as the Western Cape Ambulance staff.
The cost saving [of a hemoglobinometer] would be great, but the exposure of health care workers to blood would be undesirable. One interesting procedure I noticed was the nurses checking a patient’s hemoglobin at the bedside. They used a handheld device, a hemoglobinometer. The nurses took a drop of the patient’s blood, placed it between 2 small slides, and with a small, wooden toothpick-like implement, smeared and rubbed the blood on the slide to hemolyze it. The slides were then placed in a slot of the hemoglobinometer. The nurses looked through the eyepiece to see a green field. There was a light green stripe
OCTOBER-DECEMBER 2001
in the middle of the field and a darker green stripe to the left. While looking through the eyepiece they would slide a numerically graded sidepiece on the hemoglobinometer, adjusting the amount of light that reached the green field. When both sides matched and the light green stripe was in the middle, the hemoglobin value was ascertained. The location of the sidepiece corresponded to a numeric scale that displayed the patient’s hemoglobin level. The process looked tedious, but was quick and less costly than a serum hemoglobin. Strangely, neither the nursing sisters nor the medical students knew how the hemoglobinometer measured the hemoglobin. One of the residents (a consultant) stated that the hemoglobinometer was highly accurate. It would be interesting to compare hemoglobin calculated using various laboratory methods on venous and arterial blood to the hemoglobinometer for accuracy. The cost saving would be great, but the exposure of health care workers to blood would be undesirable. One night on the trauma wards of a South African hospital did not teach me everything I wanted to know about violent injury in that country. However, it did teach me that a lot could be learned about a culture that seemed so similar to my own but was different.
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Sapnas 151
A Night in a South African Trauma Hospital Kathryn G. Sapnas, PhD, RN, CCRN, CNOR
am a trauma nurse researcher and faculty member at the University of Miami School of Nursing. My research interests specifically have included injury prevention, transcultural nursing, measurement of social phenomena, and theory development. During the past year I took an educational leave of absence from my research and teaching positions in Miami. I chose South Africa as the location in which to fulfill my role as Rotary Ambassadorial Research Scholar and to conduct trauma research. I lived in Cape Town and selected the University of Cape Town (UCT) for my academic affiliation, because of the international reputation of the Groote Schuur Hospital (GSH) and active Trauma Service. During my 1-year tenure at UCT, I filled the position of Honorary Research Associate in the UCT Department of Surgery. Shortly after my arrival in Cape Town, I met with Professor Del Kahn, the head of UCT Division of Surgery, and Dr. Andy Nicol, the Head of the GSH Trauma Unit. Unintentional injury, specifically, driving behaviors that increase morbidity and mortality risk, was the area of my doctoral dissertation work, which I had hoped to extend during this visit. However, upon my arrival, it was requested that I spend some time looking at the trauma unit, talking with the staff, and getting to know the community and community issues before determining the topic of my research project. I began by meeting with the nursing administrator, Matron Cathy Thorpe and Mrs. Patton, matron of trauma services. My discussions were with nursing, medical, and emergency medical services (EMS) staff, as well as commu-
I
Kathryn G. Sapnas, PhD, RN, CCRN, CNOR, is a trauma nurse researcher and assistant professor at the University of Miami School of Nursing. Reprints not available from author. Int J Trauma Nurs 2001;7:148-51. Copyright © 2001 by the Emergency Nurses Association. 1075-4210/2001/$35.00 + 0 65/1/119083 doi:10.1067/mtn.2001.119083 148 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Sapnas
nity members. The conversations always seemed to center around violence and injury. Injury from firearm violence seemed to be of paramount importance to most everyone I spoke to in Cape Town. As a result of the discussions, I designed an exploratory and descriptive study. It was a prospective hospital-based study that investigated the experiences and attitudes of patients who had been injured as a result of firearm violence. The aim of the study was to identify the context and nature of injury by gun violence.
After 24 years of critical care/trauma nursing experience in urban trauma centers . . . I am not new to violent injury. However I was new to the culture of violence in Cape Town. After 24 years of critical care and trauma nursing experience in urban trauma centers in Philadelphia and Miami, and as someone who has earned a master of science in nursing degree with a critical care/trauma focus, I am not new to violent injury. However, I was new to the culture of violence in Cape Town. I decided to use the GSH Trauma Ward and the community as my laboratory to examine the phenomenon that I was about to study outside of my own country. I spent my first month at GSH hospital getting to know the nursing, medical, and ancillary staff. I visited on all 3 shifts and on weekends. I wanted to let people know what I would be doing and that I was interested in hearing their perspectives on violence and injury. I spent a weekend on the night shift at the University of Cape Town, GSH trauma resuscitation ward from 11 pm Friday night until 6 am Sunday morning. I would like to share journal notes from a portion of that weekend. VOLUME 7, NUMBER 4
Figure 1. Nursing staff in Trauma Unit C5 at the Groote Schuur Hospital. (Mr. Toby, Sr. Mackie, Mrs. Benjamin, Sr. Noshumi Tya, Sena Oerson J., and Sen Jacobs C.)
Friday, September 1, 2000: The night was cold. There was mist in the air and a fine rain had begun to fall. The parking lot was empty. There were no ambulances to be seen, other than a parked Western Cape Ambulance with a Rotary emblem. The ambulance had been provided as a result of a Western Cape Rotary project fundraising. There were no throngs of people at the casualty department doors, as I expected. I walked through triage and it was very quiet, with just a few employees in the lobby. The quiet was awkward. There were a few medical students doing their physiology practicum on the
Within a few minutes the woman had wandered down to the resuscitation area, wondering if her boyfriend was alive. night shift. A second-year trauma registrar (resident) was in charge of the trauma ward for the night, and would be on duty for the rest of the weekend. As I walked down to the hall toward the resuscitation ward, I saw a woman with torn overalls and a bandaged arm that dripped with blood. She was the girlfriend of a patient in the resuscitation area; he was an injured man with a left hemothorax due to a stab wound to the left lower neck area. The wound extended into his chest, causing serious bleeding and impairment to breathing and oxyOCTOBER-DECEMBER 2001
genating. He had another stab wound to his left lower back. Within a few minutes the woman had wandered down to the resuscitation area, wondering whether her boyfriend was alive. She sat there looking so sad. By talking to her I could smell that she had been drinking alcohol; however, she was coherent and able to communicate effectively. Alcohol intoxication has been reported in more than 70% of violent crimes at GSH. I asked the female patient how she had been stabbed. She told me that she and her boyfriend live in Langa, one of the Black townships outside of Cape Town. They had an altercation with their landlord concerning their rent payment. They had the money for rent but had not paid it yet. As they were having dinner in their flat, the landlord came in and started arguing with them about the money. She showed the money to the landlord but he slapped her. As the boyfriend intervened, the landlord stabbed him. Now the boyfriend was being sent to surgery and would be admitted postoperatively to the trauma ward. The girlfriend went home with a bag of her boyfriend’s clothes. This scene reminded me of similar cases I had seen in urban trauma centers in the United States. I was thousands of miles away, yet trauma themes in violence remained the same. After a complex resuscitation and surgery, the ventilated stab wound patient was transferred directly to the Trauma Ward High Care. The sounds, smell, and trail of blood from the resuscitation suite were familiar to me. I watched as the staff methodically and swiftly cleaned up and prepared for what would come next. It was quiet again, but just for a while. INTERNATIONAL JOURNAL OF TRAUMA NURSING/Sapnas 149
Figure 2. Sr Xakiwe “Betty” Ngindi, professional nurse at Groote Schuur Hospital Trauma Unit stabilizes a patient admitted to Trauma Resuscitation C-14 with the help of a staff nurse.
By 1:30 am things had changed. Within minutes patients were rolling in with the Western Cape Ambulance services. One patient had been shot multiple times (with large caliber bullets judging from the size of the entrance wounds) in the abdomen and in the upper right thigh, shattering his femur. The patient was unstable with tachycardia and required immediate resuscitation. In a few minutes, a man who had been assaulted with a blunt object to the head and another man who had been stabbed in the left upper chest were rolled in. The staff was organized and completed tasks methodically, calmly. It was obvious that the staff had done trauma resuscitating before. I went to look at the observation bays and saw a sister (registered nurse) suturing a head wound. Her technique was good and the wound was well approximated. There is no requirement in South Africa for a sister to have an advanced nursing degree to suture wounds, but the sisters receive classes and on-the-job training to become certified to suture lacerations and wounds in the GSH Trauma Ward and Casualty Department. A competency assessment based on the scope of practice and internal hospital policy is given to all nursing staff who are allocated or who work in the trauma/emergency unit. A suture team monitors the nurses’ work. Other competency assessments include changing underwater drainage bottles, checking trac150 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Sapnas
Figure 3. Sr Vatiswa Makie, professional nurse and matron of the Groote Schuur Hospital C5 Trauma Unit reviewed the Trauma Resuscitation Log for patients eligible to participate in the Nursing Research Study on Gun Violence and Injury. VOLUME 7, NUMBER 4
Figure 4. The Groote Schuur Hospital, Old Main Building, poised at the foot of Table Mountain, houses Transplant Museum, Medical and Nursing Schools, Research Laboratories, and Nursing and Hospital Administration. It was formerly the inpatient hospital.
tion, applying special bandages, changing intravenous fluid bags, and applying eversion strapping. I spent the rest of the weekend on the night shift in the Trauma Resuscitation ward meeting the staff and registrars in various parts of the trauma and casualty departments, as well as the Western Cape Ambulance staff.
The cost saving [of a hemoglobinometer] would be great, but the exposure of health care workers to blood would be undesirable. One interesting procedure I noticed was the nurses checking a patient’s hemoglobin at the bedside. They used a handheld device, a hemoglobinometer. The nurses took a drop of the patient’s blood, placed it between 2 small slides, and with a small, wooden toothpick-like implement, smeared and rubbed the blood on the slide to hemolyze it. The slides were then placed in a slot of the hemoglobinometer. The nurses looked through the eyepiece to see a green field. There was a light green stripe
OCTOBER-DECEMBER 2001
in the middle of the field and a darker green stripe to the left. While looking through the eyepiece they would slide a numerically graded sidepiece on the hemoglobinometer, adjusting the amount of light that reached the green field. When both sides matched and the light green stripe was in the middle, the hemoglobin value was ascertained. The location of the sidepiece corresponded to a numeric scale that displayed the patient’s hemoglobin level. The process looked tedious, but was quick and less costly than a serum hemoglobin. Strangely, neither the nursing sisters nor the medical students knew how the hemoglobinometer measured the hemoglobin. One of the residents (a consultant) stated that the hemoglobinometer was highly accurate. It would be interesting to compare hemoglobin calculated using various laboratory methods on venous and arterial blood to the hemoglobinometer for accuracy. The cost saving would be great, but the exposure of health care workers to blood would be undesirable. One night on the trauma wards of a South African hospital did not teach me everything I wanted to know about violent injury in that country. However, it did teach me that a lot could be learned about a culture that seemed so similar to my own but was different.
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Sapnas 151