DESCENDING INTO THE PIT

David Marcus Gore, a doctor, describes the

horror of working in the world's largest hospital

THE CHRIS Hani Baragwanath Hospital is the biggest in the world, with 3,200 beds. It is situated at the edge of Soweto, the sprawling collection of black townships near Johannesburg. Even within South Africa it is infamous for being a rough place to work. In the white northern sub- urbs of Joburg the beleaguered citizens are fixated by stories of Bara and violence in Soweto. It's like their worst nightmare the barbarians at the gate.

Black people tended to be more reflec- tive. Soweto still has a central role in the black South African psyche as the epicen- tre of the Struggle, the anvil upon which the nation was forged. Thus tales of my job at the hospital would provoke much specu- lation about problems facing the new South Africa — crime, violence, ignorance, alcoholism and unemployment.

The main surgical action in Bara is in the 'pit', the surgical casualty department. Structurally it is falling apart at the seams and when busy it's a special circle of hell. Interns and registrars mill around, tending to the great unwashed. Gunshot wounds and other assaults are the stock-in-trade. The wounded are brought in by ambu- lance, minibus taxi or private cars and laid on ancient red trolleys. If they are badly injured they have a red 'urgent' sticker slapped across their foreheads lest we for- get about them. If they are really bad they are wheeled at speed through into the resuscitation room en route to the theatre or the mortuary. `Resus' can get very excit- ing on a Saturday night or any day near the end of the month, when salaries are paid and liquor flows freely in the town- `I don't know much about art, but I know what I like.' ships. It's not a place for the faint-hearted.

I suppose many people's images of trau- ma in hospital are shaped by the American television series ER. The surgical pit at Bara has all the excitement of ER but beats it hands down when it comes to numbers and grossness. Moreover, the recurring theme of ER is one of care and commitment. The recurring theme in the Bara pit is one of weariness, cynicism and indifference. Compassion is absent. I had been told about the horrific injuries but I was unprepared for this. The black com- munity here may be good at looking after their young and old, but they demonstrate precious little concern about each other's physical suffering. At first I was amazed at how the patients can suffer: rarely do they groan and they never complain. They would be unwise to try for sympathy. The nursing staff, wholly black, does not toler- ate whingers. These are tough people.

Privacy and dignity are in short supply. Patients are examined where they lie. Com- munication skills, now fashionable in medi- cal schools, take on a new meaning when faced with dealing with patients who are uncomfortable speaking anything other than Zulu or Sotho and who associate interrogation by a white official with the police. Inevitably the finer points of the doctor-patient relationship are lost. 'Yebo baba! Is it paining? Kubunhlungu kuphi? My friend, we must put you to sleep and cut you, from here to here.' The quality of informed consent given by the patient prior to surgery is variable. If a patient is too spaced out to sign a consent form, their inked thumb is applied to the sheet of paper anyway. Advice given to a reluctant patient is blunt: 'Boba, without the opera- tion you die. Understand? If you don't want the operation you hamba kaya [go home] right now.'

Sometimes it all gets too much and tem- pers fray. For example, Easter Sunday was bedlam: three patients had died on the operating table by six o'clock that evening. One of my senior colleagues would lay into the gunshot victims as they were wheeled in. 'Did you get that going to church, baba? Did you have a nice Easter, my friend?'

The most abject cases are those shot in the head. The patients are brought in comatose; we intubate them with a tube in their airway and leave them to die. There's nothing to be done; the neurosurgeons don't even bother coming to see them. Gunshot wounds to neck, chest or abdomen are often much more challeng- ing. There's nothing quite like a badly injured patient to concentrate the mind. Patients with stab wounds to the heart occasionally need to have their chests opened by a surgeon there and then in a ghoulish orgy of blood and chaos. Alas, stab wounds are old hat in Soweto: any self-respecting tsotsi (thug) carries a gun nowadays.

The 'blunt' trauma of road-traffic acci- dents is much in evidence as well. I doubt there was ever a Green Cross Code here; people continually wander into the path of the ubiquitous minibus taxis. Perhaps it's because there aren't many footpaths in the townships, just dirt roads. I came to hate these hapless wretches with their smashed- up faces and limbs as they would need hours spent on them to sort them out, splinting limbs, cross-matching blood, plac- ing chest-drains, requesting X-rays from surly radiographers and arranging brain- scans. Gunshot abdomens were easy in comparison: you would simply take the vic- tim to theatre, gas him (it's always a him), open him and have a look. With 15 per cent of the patients being HIV positive, one has to be careful where one puts one's needles and scalpels.

The smell of liquor on breath is the ambient aroma when the pit is pumping. These black blokes can certainly drink and fight — I thought the Irish were good at it until I came here. All sorts of misery has alcohol at its root. Imprinted upon my mind is the sight of the drunk who fell asleep on a railway line and had both legs severed at the knee. When the ambulance fetched him he still had his bottle of Klip- drift brandy in his hand. He made it, but what a nightmarish hangover he had.

It took me two months until I really started to get a grip on what Bara was real- ly all about and what people's expectations actually were. Never have I worked in such a hostile and unpleasant atmosphere. Relationships with medical colleagues from other specialities are strained or non- existent. The surgical registrars generally hail from countries whose public health services are even rougher than that of South Africa. Nearly all my colleagues imagined the British National Health Ser- vice to be a scriptural promised land. About one third of the surgeons come from Bangladesh and Pakistan, one third from the rest of Africa and the rest from here and there, including quite a few from eastern Europe and a small number of voyeurs, like myself, from western Europe.

On the other hand, the anaesthetic department is wholly white and wholly South African. These white supremacists viewed us as the flotsam and jetsam of the world of surgery, and despite the colour of my skin I was tarred with that same brush. Anaesthetists and surgeons have differ- ences of opinion the world over, but here the appalling rapport was truly a wonder to experience. It was as if we worked in different dimensions: we would get through a three-hour operation without the slightest social pleasantry.

I found working with the nursing staff in the pit and on the wards quite difficult at first because a lot of them don't work very hard. It is a paradox of the hospital that one can get a state-of-the-art CT scan, but patients can quietly expire for want of basic nursing observation at night-time. There's a favourite northern suburbs joke to which tourists are subjected: what's the difference between a tourist and a racist? The answer, inevitably, is two weeks.

Twisted as this might sound, as I worked with some black nurses who ignored me and manifestly couldn't care less about their charges, and as I dealt with a sullen, mute and violent clientele, I wasn't far off illustrating that cliché myself. It was only through meeting some splendid doctors from the rest of Africa, working with the odd diamond of a nurse and seeing through to the basic humanity of the patients that I escaped that fate (I think).

It is said that life is cheap in Africa. As a generalisation this is untrue, but there's no doubt that life isn't at a premium in Sowe- to. Did I become brutalised by the car- nage? A little. Did I enjoy my spell at Bara? Yes, I did, but it wasn't all plain sail- ing. Would I recommend it to another? Yes, but not blithely. Certainly it was the most memorable year of practice I have ever had. Hospitals come and go, but it will be a long time before I forget the smell of the Bara pit on a Saturday night.

`Do you sell normal toothbrushes?'