General Information

Here are some links that you may find useful:

• South African Tourist Board

Western Cape

Tygerberg Hospital, Parrow

Introduction

With a frenzy of paddling I found myself and my rather long rental surfboard heading out into the Atlantic Ocean, the sand gradually getting further and further away and the large swell of the waves throwing my high into air. It was starting to occur to me now that I was far enough out to attempt stand up on my board and gloriously and majestically surf back to Muizenburg beach, where I had come from, stop just before the beach and cheer in triumph of mastering surfing on my first attempt.

So, I turn the board around and pointed it directly at the beach, glancing behind myself watching the waves form behind me, I didn't really know what I was looking at, I was just copying everyone else around me. I watched and felt wave after wave come hurtling towards me and shower me with icy cold water. After a few minutes I decided to choose a big wave and use that for my march towards the shore for victory. It just so happened to be the biggest one in a set of five waves that where within sight. I waited patiently as the wave approached, and my excitement grew.

As the wave approach I paddled ferociously to match my speed with that of the waves. I had done it, I had caught the wave and was now lying in a prone position on my surf board, travelling at what felt like a vast number of knots towards the beach. As I careered towards the beach I heaved myself off the boards in an effort to get into the pro like standing position. Well, that was the plan but in reality I was tumbling through the air, then plummeting into the water, into the barrel roll of the wave. Tumble and roll after bash and bump I found myself consuming plenty of salty water, and eating plenty of sand which seemed to find its way into most orifices! I eventually got washed up onto the beach, and dragged myself back onto my board and paddled myself back out to sea to try again... perhaps I should have invested in some lessons!

The feelings experienced during that day of attempting to surf where the constant rollercoaster of feelings I experienced everyday on placement in Tygerberg Hospital. The first day was much the same as the first day trying to surf. The hospital grounds where large, and well protected by the large security fence with razor wire, after a long stroll around the perimeter fence I found the entrance gate and swiped myself in. It turned out that this gate was actually just behind my student accommodation and I had walked past it already that morning.... I blamed the 7am start! The hospital was like a king size version of the Royal Liverpool Hospital, only it was a red brick building and actually had architectural features that where worth looking at.

About the hospital

Tygerberg Hospital is a tertiary hospital located in Parow, Cape Town, and was officially opened in 1976 and is the largest hospital in the Western Cape and the second largest hospital in South Africa. It is owned, funded and endorsed by the Department of Health (Provincial Government of the Western Cape).

With the hospital being opened in 1976 and with the political and racial situation the South Africa at the time with the apartheid, the hospital was built perfectly symmetrical. One half was for the whites, and the other for the blacks. There where two accident and emergencies, two sets of theatres, two of every ward, and in the middle of each of the floors was a metal gate to stop patients crossing over sides.

During the decoration of the hospital the board of directors wanted to use a lyno style material to decorate all the walls as it was very cheap, hard wearing, and easy to clean. There was however a problem with this as the fire safety officers where not happy as it posed an enormous fire risk. Instead of changing the decoration it was decided that all the doors and door frames to all the wards and side rooms should be steel to stop the spread of fie, and that a fire station should be built next to the hospital so that if there was a fire the fire brigade would be able to respond quickly and arrive at the scene in no time at all!

The hospital's mission statement is "to provide affordable, world class quality health care to public and private patients within available resources, as well as excellent educations and research opportunities". This mission statement would appear to be very similar to that of the majority of the National Health Service's hospitals.

The hospital operated an income assed policy, whereby those who earned very little or where unemployed received there health care for free, and gradually as patients started to earn more money they would have to pay a percentage of the treatment costs back. This sometime posed a problem as those who new they would have to pay some of it back would request less of everything and would not want there dressings changed and would ask for less pain relief.

The following table is an overview of figures for the Royal Liverpool Hospital and Tygerberg Hospital. As you can see, the Royal receives far more money and employs more staff yet it runs less beds and is responsible for the care of fewer patients. This means that at Tygerberg the budget has to stretch very far and resources are limited, outdated, and worn, something that would rarely be seen in practice in England.

Comparison between a UK teaching hospital and the Tygerberg Hospital:

Training and Experience

The career pathway of the doctors in SA is reasonably similar to that of doctors in the UK. They take a seven year university course, then following that they apply for their junior doctor jobs, and then follow a system much the same as in the UK to become consultants. There is a great shortage of jobs for the more senior ranked doctors so many of the registrars find themselves unable to advance for a number of years more than they anticipated.

During my period of study in plastic and reconstructive surgery with Professor Bass and his colleagues I was allowed to develop my understanding and knowledge of anatomy, physiology, and pathology, through a very hands on learning process and through formal teaching. I was regularly asked to give bed side teaching following ward rounds to the South African students about the patients we had seen on the ward rounds. I also received teaching from them about HIV and tuberculosis, and other common conditions that where highly prevalent in the hospital.

During my time with Professor Bass and his colleagues I was permitted to develop and advance my basic surgical skills. Under the supervision of the team I was able to learn, practice and fully understand many methods of suturing. I also developed skills such as assisting in an operation, use of bi and uni-polar diathermy, incision, correct surgical planes and correct use of surgical implements, wound dressing and closure, and a wide variety of skills in trauma medicine.

In developing my surgical techniques I assisted other medical students, one of which perform an excision of a keloid scar. The operation was not fully explained to the student and he tried to perform the operation anyway against my wish's to seek further assistance. This resulted in sub-standard care for this patient, and the person operating was not acting in the patients best interest. From witnessing this I have learnt that if I ever was to find myself in a similar situation where I was unsure or uncertain then it is in the patients' and also my best interest to seek assistance or more senior help. If this had been done then patient would have received a better outcome from the operation and the patient would not have returned to hospital the following week to have the incision re-sutured.

During my time with Professor Bass I noticed that things are often done a little differently in South Africa, such as aseptic technique for hand washing was not strictly adhered to, and for example on more than one occasion members of the surgical team whom where scrubbed into the operation would removed their mobile telephone from their pocket, answer it, and then proceed with the operation with out re-gloving or re-washing their hands!

From my time in Tygerberg I have realised that it is of a high importance to have a deep understanding of anatomy to make a very good plastic surgeon. This in-depth anatomy knowledge of the operating surgeons in Tygerberg allowed them to fully think through all presenting surgical patients and suggest the best possible procedure for such problems.

Whilst I was in Tygerberg I managed to integrate into surgical team and provide a great deal of assistance to the other doctors in the team. I would be allowed to go to the accident and emergency department to initially asses the patients for the doctors and would make decisions on what the best line of initial treatment of these patients would be and then discuss this with the surgeons and then implement it. If I was not there then these patients would have to sit in the accident and emergency rooms for hours waiting for the doctors to finish there surgery and come down to see them. This meant that these patients got earlier treatment, which all too often meant early pain relief. I also learnt how important wearing a seat belt in a car is, following seeing so many horrific road traffic accidents!

The team also trusted me to be responsible for all of the patients that presented with mandible fractures to the clinics. As clinics where so busy and the fractured mandible cases tended to be rather numerous this allowed more time for the doctors to see the other patients, and it also mean the patients received a level of care higher than they would have otherwise received.

I was permitted to manage the mandible fracture cases from first presentation to discharge (initially under supervision until I became competent in dealing with these patients). I would initially take a history for the patient, (which could sometimes be difficult for a number of reasons, e.g. language barrier, or the patient being part of a gang); following this I would examine the patient mandible, and mouth. I would then request a panorex radiograph of the mandible, if one had not already been taken, and then assess the fracture. I would then follow a protocol explained to me by the consultant as to how to treat these patients. A lot of them would have maxillomandibular fixation (MMF) with wires or cable ties (see below under research), or would receive conservative treatment.

All the mandible fracture patients would have the importance of oral hygiene explained to them and would be consented to the MMF. They would then be treated as appropriate and told return in two weeks to clinic for a check up, then again on week four.

Prior to my arrival many of the patients where sent home from clinic and told to return to clinic on a different day as there wasn't enough time to deal with them. The most severe would receive MMF and the rest would receive conservative treatment. Those that complained following the conservative treatment would then be called back for open reduction internal fixation of the fracture as it would have set in the wrong position by that point.

Hopefully this should now change as when I left, the department where in discussions with the University of Stellenbosch to have medical students rotate through plastic surgery as they would be able to perform these tasks.

Language

South Africa has 14 native languages, all of which are present in the Western Cape, with most people speaking Africaans or English. The plastic surgery team could speak only English, Africaans, and two of the doctors spoke German also. As many of the patients spoke different languages such as Xhosa, it often proved rather difficult to communicate with the patients and required a lot of patience, diagrams, and hand signals. It was challenging to find translators for these patients as there was not enough funding in the hospital so there was only ever one translator for the entire hospital. This meant that we often had to communicate through nursing staff to the patients. This also proved difficult as the male population from some areas believe that admitting to pain makes you a weaker man, therefore when asked if they can feel anything when they have been given a local anaesthetic they would say the couldn't feel any pain, even when sometimes they would be in pain.

Finally...

At the Tygerberg Hospital there were many brutal and barbaric acts on there that would rarely be seen in England. For example, being thrown off a train. All these things happen on a day to day basics in South Africa and there are some real issues associated to violence especially with so much of the population living in the townships and the associated informal settlements along side the townships. In the evening the young residents of these settlements get drunk and are very violent. A large amount of incidents happen in the evening and the accident and emergency department is where they all come.

The time I spent on accident and emergency was a real eye opener and really enjoyable. The patients respect the staff and rarely cause trouble, or abuse the staff. This is partly because they know that if they do they will be put into prison and will also be refused medical treatment, and this is the only place from which they can get treatment.