Dom in South Africa: CHOPPER.

Something rather exciting happened yesterday. I gave a presentation on the recently updated WHO (World Health Organisation) tuberculosis management guidelines. After the presentation I went to theatre to perform my 90^th (documented) spinal anaesthetic since I have arrived. That is almost 100. Maybe I’ll celebrate by giving my patient something a little something special on the centenary, such as a sticker congratulating my one hundredth patient or a little intravenous shot of fentanyl (an analogue of morphine – don’t worry, I’m not going to do that). Nope, as thrilling as that all sounds, this is not what I want to talk about. What I want to mention is something that my paediatric nurses were trying to call me about just before I walked into theatre Thursday morning to perform spinal anaesthetic number ninety. There was a seven month old infant admitted in Calloway (the paediatric unit) having suffered a gunshot.

When I was informed of the news, two things surprised me. It wasn’t that the baby had been shot whilst in her mother’s arms, who was killed alongside the aunty. What surprised me the most was that the infant had been admitted to my ward (the usual protocol is that ANY gunshot victim should be stabilised and transferred to a surgical unit – bullets can be very unpredictable) and secondly that she was still alive.

A brief assessment revealed that the baby was pretty stable. She had an entry wound in the top left corner of her chest and the bullet had ended up in her abdomen. There was bleeding around the lung (a haemothorax) and, I expect, a whole load of punctured bowel. Kids can be very deceptive – one minute they are fine, even if a large bullet has made a small journey through some of their vital organs – and suddenly, they will decompensate and die very quickly if not managed appropriately. Quite frankly, I have had enough of children dying from traumatic injuries and it feels like it has happened far too often recently – such as the five year old who suffered severe internal bleeding after being struck by a car a few weeks ago. If only he could have got to a surgical facility in time. We waited for five hours until the ambulance never arrived and he said goodbye to this world.

As mentioned before, the ambulance service is pretty dismal here (I guess the flip side of the argument is at least we have one). However, there is one exception: Did I ever mention Holy Cross has a helicopter pad?

Once the infant was stabilised I called Metro (the ambulance control board) and explained my case; I asked for air support as I was worried the infant would suddenly turn. The response I got was: “You want a chopper? Ok, I’ll call you back.” Four brief phone calls later I spoke to a lovely paramedic in East London, where the chopper is based – about 6 hours drive from here. I was expecting to be let down, instead her final words were: “OK then, we’ll be with you in about an hour.” Eureka! The adrenaline started flowing through my veins – I can’t explain why – I was teaming with excitement. However, I didn’t let this show – I wanted to remain composed in this delicate situation. The response of my nurses when I told them was of sheer joy – so, I let them do the singing and dancing whilst I nervously waited and checked on the baby every fifteen minutes whilst I continued with ward rounds as usual.

After a slight detour from being given the wrong coordinates, the pilot called me from the aircraft for directions – a lot easier than you would expect: “Just follow the tar road and look for me waving.” The plan worked very well. It was a magnificent site to see the chopper circle round the hospital and land on what the pilot described as: “The best chopper pad I have had pleasure of landing on in the Transkei. We’ll happily return.”

The infant made it to the referral unit: I am eagerly waiting to hear of her outcome. News on the grape vine is that she was transferred onto an even higher level of care.

This is a supine xray of the baby - the bullet went in just by the "L" mark in the top right hand corner of the image and ended up in her abdomen where you can see it. Notice the opacification in the left side of the chest - that's a haemothorax (blood on the chest - the infant is lying flat, so there's no fluid level)