According to The Lancet Commission on Global Surgery, about 5 billion people around the world lack access to decent surgical care. These inadequacies clearly impact the overall health of the world’s population. In the last several years, the overall interest in global surgery has increased significantly.
Groote Schuur is one of Cape Town’s premier tertiary academic hospitals. It is a very large, government-funded, teaching hospital with close to 1000 beds, situated on the beautiful slopes of Devil’s Peak in the city of Cape Town. This hospital was officially opened in 1938 and underwent major extension with the building of a new hospital in 1984. Groote Schuur is internationally renowned as the training ground for some of South Africa’s best doctors, surgeons and nurses. It also serves as an international training center for doctors from several African and European countries. The first human heart transplant was done at Groote Schuur by Dr. Christian Barnard on December 3rd 1967.
In 2018, the University of Arizona, Surgery Residency Program established a partnership with the Surgery Department of the University of Cape Town to have our PGY 4 residents do an away rotation at Groote Schuur. So far, all of our PGY4 residents except one has spent six to seven weeks at Groote Schuur. This has been a phenomenal and well received rotation where the residents do an average of 50 cases with significant autonomy and learn to provide quality care to patients with limited resources.
As I rounded on the more than 30 patients on the colorectal service, the unit that really caught my attention was the Intestinal Failure unit. This unit is run by Dr. Adam Boutall, one of the handful of colorectal surgeons by training in South Africa. Typically, the patients in this unit are transferred from the smaller regional hospitals for a higher level of care. These patients all had complex fistulae, open abdomen and multiple stomas. The number one cause of intestinal failure was trauma, more penetrating. Surprisingly, however, I learnt that the number two cause was appendicitis. Yes, Appendicitis!
So why this phenomenon? Why would appendicitis be the cause of such significant number of intestinal failure? The most common reason is delay in presentation to the hospital. Most of the patients present with peritonitis from festering perforated appendicitis and typically are treated with exploratory laparotomy and a right hemicolectomy with subsequent anastomotic leaks that require several re-exploration and an ultimate stoma with resultant fistulae from enterotomies. A less common reason is the delay in surgical management due to lack of OR time. The patient might be admitted and treated with antibiotics for several days while waiting for OR time until they perforate and then it becomes an emergency. The third plausible cause of these multiple intestinal failures could be that the smaller satellite hospitals are typically staffed by less experienced trainees or Junior consultants. This is however, speculative. The very high trauma volume could also be a contributing factor to the high number of intestinal failure.
The management of intestinal failure in a limited resource environment is complex, innovative and very expensive. There is a very long hospital stay, prolonged TPN use and challenges with availability of OR time. There is also an insurmountable problem of social factors, since most of these patients live far away with minimal financial resources. Coupled with all of these is the limited funding from the government which leads to rationing of resources.
Despite all these challenges, I was so impressed by the dedication and high quality of care provided by the surgeons, nurses (called sisters, even if you are a male) and other medical staff. They have come up with all kinds of innovative ways to treat the patients and lower cost, including refeeding the distal ileostomy with enteric content from a high output proximal stoma to reduce the amount of TPN used. Reflecting on my experience, I would say there is always room for quality improvement which includes having a standing Morbidity and Mortality conference, creating a good functional database, establishing defined quality measures and population awareness campaign.
As I left Groote Schuur, I will always have in my mind the 53 y/o male who was transferred from one of the satellite hospital to the Intestinal failure unit. He has sustained multiple GSW and was POD 10 from multiple abdominal operations. He now has multiple stomas and an open belly with stool leaking out of the wound, definitely a fistula. As we rounded, the surgeons told him “this is the beginning of a long road”. The look in his eyes told me he accepted his fate with calm confidence knowing he will get the best care at Groote Schuur. I am glad my residents are rotating here. This experience also made me reflect on merits and demerits of the concept of government funded healthcare.
Acknowledgment
I would like to thank Professors Elmi Muller, Eugenio Panieri and Adam Boutall for making it possible for our residents to rotate at Groote Schuur and for providing such a welcoming and conducive environment for them to learn.