Key Words:South Africa , vascular , injury , hemostasis , endovascular , shunts
South Africa is a large country (1,200,000 sq km 2 ), with a population of about 50 million. Of these, half live in the urban environment and half live in the rural environment. There is inevitably a wide difference in the availability of general and specialized medical care as a result.
For many years, South Africa has had a background of violence. Some of this can be attributed to the political and other difficulties of the Apartheid era, but a significant proportion was both criminal and tribal in origin. The trauma registry at Johannesburg hospital, which has been in existence since 1984, reflects that in 1984 of the 1000 major resuscitations per annum (injury severity score [ISS] >15) some 300 injuries were penetrating in nature. In the 1980s, these were predominantly due to stab wounds and usually associated with alcohol.
Around the time of the advent of full democracy in 1994, there was initially an upsurge in interpersonal violence, partly due to the relatively free availability of firearms and partly due to some initial instability in the political system before the democratic elections. At that time, not only was there an upsurge in the number of gunshot wounds; but also a significant proportion in both rural and urban environments were due to wounds from assault-rifle (AK-47) ammunition. By 1994, of the 2000 resuscitations at Johannesburg hospital, 1000 were penetrating; and, by 1999, there were 2500 resuscitations of which 2000 were penetrating, the majority of which were gunshots. By 1999, at the two major teaching hospitals in Johannesburg (Chris Hani Baragwanath Hospital in Soweto and Johannesburg Hospital in central Johannesburg [ Fig. 32-1 ]), the incidence of penetrating trauma was approximately 85% of all trauma victims. Of these, 70% were secondary to gunshot injuries. The majority of the remaining injuries were due to stabbing.
Since 1994, government focus has been on bringing primary health care to poorer people, especially in rural areas. The money has had to come from somewhere; and, despite dramatic increases in total budget, famous urban hospitals like Baragwanath, and Groote Schuur in Cape Town fell into neglect while hundreds and thousands of rural dwellers received some medical attention, many for the first time in their lives.
The last 10 years has seen a decline in the homicide rate across the country, and stringent firearm laws have seen a significant reduction in the use of firearms. There has been a slight increase in the number of stabbings; but overall, particularly in the Johannesburg area, both the homicide rate and the incidence of penetrating injury has dropped in some cases by up to half. In 2011, the same trauma registry showed 1700 cases, of which 800 were penetrating. The incidence of gunshot injuries in the Cape Town area has not shown such a dramatic falloff, but this may be partly due to increased use of firearms secondary to an increased gang culture and drug culture.
A substantial number of vascular injuries seen in the South African context present late, with other competing injuries; and patients are in hypovolemic shock. The patients’ outcome may also be compromised by the high prevalence of AIDS.
The common mechanisms of injury in blunt trauma are similar to other countries and are related to long bone fractures, direct blows to the neck, and compression injuries. South Africa has a very high incidence of pedestrian injuries from motor vehicles, with associated pelvic, femoral, and lower limb fractures, many of which are associated with vascular injury as well.
Other injuries seen include strangulation, animal bites (beyond the area of penetrating injury), ejection from motor vehicles, and an association between high cervical fractures and fractures involving the foramen transversarium, associated with blunt internal carotid artery injury.
In penetrating trauma, currently 50% of vascular injuries are gunshot-wound related and are particularly common in the torso, with transmediastinal injury, transabdominal injury, and injury to the femoral vessels. The bulk of stab wounds causing vascular injury are to be found in the neck, particularly zone I and zone II (in association with aerodigestive injuries).
A relatively large number of patients with stab wounds to the heart survive to reach the hospital; and our experience, like similar series from elsewhere, has been that, if they survive to reach hospital alive, they are likely to leave the hospital alive ( Fig. 32-2 ).
Finally, South Africa has a significant gold and coal mining industry. The deepest mines are found about 50 miles (80 kilometers) to the west of Johannesburg in the West Wits Goldfield (Tau Tona and Mponeng mine). Active mining takes place at up to 17,000 feet (about 5000 miles) below ground level. At this depth, the uncooled temperature of the rock can reach 60° C, and the air pressure can reach more than twice that at sea level. Rock movement is common. The mining industry has an excellent safety record, but the challenges of the injuries caused include rock falls causing crush and compartment syndromes, often complicated by the long periods (up to 2 hours) to reach the surface.
Reliable follow-up is often difficult in South Africa, and treating minimal injury conservatively (nonoperatively) is not always either feasible or possible. There is an associated shortage of high-care beds, so many injuries that would no longer be operated on elsewhere are dealt with surgically, including with the use of endovascular techniques. Long-term follow-up is difficult in institutions in South Africa, particularly after trauma, mainly because of socioeconomic factors. It is expected that only approximately one third of patients will return to clinic visits within 2 months of discharge.
Region-Specific Systems of Care
There is approximately 1 physician for 25,000 patients in the rural areas, and 1 physician per 700 patients in the urban areas of South Africa. There are 43 registered subspecialist vascular surgeons and 25 registered subspecialist trauma surgeons for the country, almost all concentrated in the urban areas, and most in Academic centers. There are some 800 practicing general surgeons nationwide, mostly in the major centers; and it is they who bear the brunt of the vascular trauma load.
Currently there are 8 medical schools in South Africa, producing 1500 graduates per annum. Unfortunately 700 doctors leave the country each year primarily to Canada and Australia, many of whom have already trained as specialists, including surgery. Thus, there is a significant shortfall of medical practitioners in general and a shortfall of surgeons, in particular. While qualified general surgeons provide the full range of trauma care in most instances, select cases requiring subspecialty care or techniques (e.g., endovascular stent-grafts) may be referred to subspecialty vascular or trauma centers. By its very nature and urgency, a good deal of trauma is dealt with by general surgeons in regional or district hospitals.
There is a thriving private health sector, which inevitably spends considerably more of the national health dollar per patient than the state sector. In general, private facilities are better equipped and staffed; and many centers are capable of advanced surgery (e.g., stereotactic neurosurgery, cardiac and lung transplantation). Diagnostic imaging is usually far superior and more accessible at these private facilities, as is endovascular and minimally invasive surgery. A substantial proportion of the population (up to one third) are covered by private health insurance, by a gasoline tax if the victim is injured in an automobile accident, and by a workman’s compensation insurance scheme. Thus a significant amount of trauma will be dealt with by the private sector; and, indeed, the first two Level I trauma centers accredited by the Trauma Society of South Africa are fully privately funded.
Much rural surgery, both basic surgery and obstetric surgery, is performed by general practitioners. Although there is a mix of public and private facilities across the country, the reality is that most trauma, particularly outside the major city centers, is dealt with in the public sector hospitals by government-employed doctors, many of whom are quite junior and lack senior backup, adequate infrastructure, and appropriate training.
As with many other developing countries, prehospital care in the major cities is good in parts, with a combination of public and private ambulance services, paramedics, linked road and air ambulances, and an integrated system of care; however in the rural areas, the level of training is often poor, the vehicles are ill equipped, and the distances long, resulting in interhospital transport times of up to 8 hours. Similar to Australia, many parts of the country are served by a rural flying doctor service, though sometimes during daylight hours only.
Techniques of Care
There is considerable emphasis on short courses to upgrade trauma care and the recognition of vascular injury. The Advanced Trauma Life Support program (ATLS) of the American College of Surgeons has been in place for 20 years, and over 30,000 physicians have been trained. In addition to the specialist fellowships such as surgery, and subspecialty fellowships such as vascular surgery, and trauma surgery, with trauma critical care, the College of Medicine of South Africa also offers a 2-year Higher Surgical Diploma to provide extra preparation and support for rural doctors involved in basic general surgery, including life-saving surgery such as damage control surgery.
The Definitive Surgical Trauma Care (DSTC) Course of the International Association for Trauma Surgery and Intensive Care (IATSIC) has been very popular, with some 500 surgeons and surgical medical officers now trained in advanced emergency surgical life and limb-saving techniques, including damage control, vascular shunting, and basic vascular repair.
Management of Acute Vascular Hemorrhage
There is emphasis on arresting hemorrhage with conventional techniques and sometimes with tamponade, using adjuncts such as the Foley catheter. This technique has proven useful especially in stab wounds of zone I of the neck, allowing transfer to a more appropriate center. The surgical tourniquet (perhaps because South Africa does not have the recent combat experience of the Middle East and Afghanistan) is not in frequent use. The penetrating wounds are generally low-energy gunshot wounds or stab wounds, and almost all can be controlled by direct pressure or by the use of a blood pressure cuff ( Fig. 32-3 ).