Sleep-deprived, mentally exhausted and overwhelmed. This is the reality of the country’s community service and intern doctors. As the battle for safe-working conditions for junior doctors continues, The Saturday Star recently spent a gruelling 12-hour shift at Charlotte Maxeke Academic Hospital with a young medical professional to witness first-hand their treatment of the sick and injured while fighting physical and mental fatigue. Reporter Noni Mokati followed intern doctor, Natasha Naidoo, on the ‘graveyard’ shift.
It is Saturday afternoon, 4.30pm. For many a day of rest after a working week. In reception area 160 at Charlotte Maxeke, the silence is eerie. There are a few people around; those in the sturdy chrome seats are there for a reason. There is a system. Open a folder before you can be examined by a doctor. Those are the rules. This handful of people are doing just that.
It’s quiet everywhere – even in the porter and triage areas.
The stench of urine in the reception area is unmistakable.
But Glen Maluleke’s friends are oblivious. They anxiously stand outside the casualty unit entrance waiting for news. He was transferred from a clinic in Hillbrow, having been stabbed several times.
The air feels warm now, but as the sun retires, a cold winter wind sails slowly through the corridors of the hospital.
An ambulance driver stands idle outside. He is waiting for patients who need to be transferred. He explains the smell.
“You see, different smells come with different patients. Some are homeless people from the streets and others come in with illnesses such as diarrhoea. It’s become the norm. We are used to it,” he says.
Through the main door, a man emerges from the trauma unit area.
His hospital gown is covered in blood. He uses one hand to hold it tight in a bid to cover his private parts. He holds a drip in the other hand.
Dr Natasha Naidoo, 24, is an intern doctor. She recently graduated from the University of Cape Town. Her 12-hour shift is about to begin.
While we wait for her, we are led to the doctors’ resting quarters. There, Dr Steve Moeng, head of the trauma unit, prepares us for what we are about to witness.
He says the unit is the busiest in the hospital and often deals with alcohol-related cases, especially at the end of the month. And today is the last day of May.
“Many of our cases involve young people between the ages of 19 and 36. While we have other wards in the unit, we mostly deal with chest and abdomen areas, attending to 50 major cases a week,” he says, pointing out they have two interns who work on a rotational basis.
“I am leaving in five minutes – I have to head down to ICU,” he says, suddenly hurrying his sentences.
He has to go. It is a mad dash.
Moeng changes into his scrubs and heads for the door.
The hospital’s winding corridors are a confusing maze but Moeng knows them like the back of his hand. He slips into the resuscitation room and begins work on a patient.
But it’s too late. The young white boy lying on the bed dies. A stretcher standing forlorn in the passage bears witness. So do the droplets of blood on the floor.
An hour passes and Naidoo emerges from a handing-over session. Her hair is neatly combed and she is dressed in dark blue scrubs and takkies.
And so the shift starts.
It is 8.55pm. Paramedics haul in a young boy on a stretcher.
He is badly hurt, a PVA (passenger vehicle accident) case. Paramedics inform a registrar that the boy was sitting on the back of a bakkie. He is taken into a room where his head and chest is scanned.
Suddenly everybody is busy. No one is sitting down. Naidoo walks from one bed to another, examining patients, reading files.
In a stitching room she tends to a man who had been assaulted. He tosses, turns and grunts with every painful stitch. He is not happy. He is also obviously drunk. His naked body is covered with a sheet.
The man has several lacerations above his right eye, below the eye and several cuts on his body. He gives the young doctor a tough time. She tries to restrain him, but the man is relentless. Earlier he had jumped off the bed and urinated on the floor. It took two male doctors to calm him down.
Naidoo and her assistant, Dean Sevel, a fifth-year medical student, decide to sedate him first.
“Sorry sir! Wait one second. Please sit still, sir,” she pleads.
The patient will not co-operate. He clutches the sheet and covers his head. He moves his legs, forcing Sevel to cover his private parts several times. Then Naidoo takes a chance and finely places a needle in his abdomen. A few minutes later he is sedated and the stitching begins.
Naidoo’s nights at the hospital are not easy, but her daily routine is a simple one.
When she gets home, she eats, sleeps and wakes up ready for her next 12-hour shift. She is still exhausted, but she gets on with it.
“When I’m tired, I grab whatever I can to eat at home. I do go to gym but it’s not easy. I’m always tired. All I want is to sleep.
“It’s not all that bad when you’re used to it,” she admits. “We do get a few days off.”
Only six months from graduating, Naidoo knows she still has a lot to learn. Her one passion is helping patients get better.
“It’s rewarding when you see a patient come in and you don’t think they are going to make it, but in the end they wake up and are strong again,” she says.
Naidoo raises an eyebrow, as if to think. She explains how busy she was the day before.
“Ninety percent of the cases we saw were assaults. It’s frustrating because the incidents are all avoidable.”
It’s 11pm and the trauma unit is quiet again. For now, anyway.
“Wait. You’ll see. We are busiest between midnight and 2am. That is when people go home from the pubs and taverns,” a nurse says.
Meanwhile, Naidoo takes a patient to another room for a scan.
The corridors of hospital are quiet. Outside, the sky is pitch dark. Two cleaners mop the long corridor.
Then the clock strikes midnight – it’s June 1. And, as predicted, drama in the trauma unit starts up again.
Naidoo’s neatly combed hair is slightly dishevelled and her eyes are bloodshot. She is yet to eat anything. “I’m starving but will grab something later.”
It’s the end of a shift for two SAPS officers standing guard inside in the hospital. Two others take over.
A man bleeding profusely is wheeled in. He has been stabbed. His blood drips on the floor.
Then paramedics wheel in two more men. They are also badly injured.
A man shot in the abdomen is brought in. His friends insist on seeing him but the nurses ask them to wait outside.
My head is spinning. So much blood, so much violence.
2.30am. An elderly man strolls into the unit.
He is red-faced and angry, his pain visible. His hand is covered with a blood-soaked handkerchief. He came from Orange Grove.
He stares the nurses down. They stare at him. Before they can ask anything, he announces: “Fight with the wife.”
He says he was trying to lock his wife out of their home but she got the better of him, slamming the door with his fingers still inside.
The nurses giggle. A domestic dispute. They have seen it a thousand times.
Another man wheels in his wife. She fell after he pushed her. They were fighting. More senselessness.
Naidoo quickly opens a can of cooldrink and has a 10-minute “supper break”. But the familiar sound of a fire engine outside ends her break. Another patient. No rest.
4am. This wee hour of the cold, dark morning seems to stretch on for ever.
The nurses and doctors are a picture of exhaustion. But they keep going.
6.30am. The winter sun dawns. Naidoo places drips on several patients.
She is tired but doesn’t show it.
There are no longer ambulances outside. The staff for the next shift start filtering in.
An unexpected burst of energy ignites the faces of the night staff, including Naidoo’s. It is almost time to go home. She gathers her files, checks on her patients.
7.30am. It is time for the handover.
It was a busy night. Just another ordinary, bloody, busy night.
8am. Naidoo finally leaves. We walk out, barely able to keep awake – me more so me than her.
She loves her exhausting job. She will return later today for another graveyard shift.
Thanks to trauma unit nurses Emma Rapanyane, Tstatsi Lebea, Mpho Ketso and Susan Mojapelo and fifth-year medical student Dean Sevel.
SLAVES OF THE STATE
Nicolette Erasmus, a qualified attorney, was reading for a PhD in Corporate Law at the School of Law at the University of the Witwatersrand in 2012 when she published an article called “Slaves of the state – medical internship and community service in South Africa”.
She says that often the number of work hours expected of junior doctors, which could be as much as 200 hours of overtime a month, amounts to unfair labour practice and human rights abuse.
“For trainee doctors, overtime over 80 hours is unpaid, and rendered involuntarily under threat of not qualifying to practise medicine… As forced labour… it is outlawed in international law. No other professional group in the country is subjected to such levels of exploitation… by the state,” Erasmus’s paper was published in the South African Medical Journal.
She says the situation violates several international and South African laws. Forced labour is “all work or service which is exacted from any person under the menace of any penalty and for which the person has not offered himself voluntarily”.
Many jobs require extended work hours, which are permitted within the strict parameters of the Basic Conditions of Employment Act 75 of 1997 (BCEA), so why are the working hours of trainee doctors so excessive?
Erasmus said this situation continued because by “quirk of history, workers who earn more than R115 572 per annum are exempt from the working-hour protections of the BCEA”.
In January medical practitioner Dr Miguel Desroches instituted a constitutional court case against the Department of Health over the placement and treatment of doctors doing their community service work.
But the Constitutional Court dismissed the case, saying it was not in the interest of justice to hear the matter at that stage.
Now six months later a group of interns and community service doctors continue the fight. Doctors Elsie-Marie van Straten, Victoria van der Schyff, Koot Kotze and Helene-Mari van der Westhuizen have drawn up a petition calling on Health Minister Aaron Motsoaledi to review the working hours of junior doctors. The petition stipulates that shifts for junior doctors should not exceeed 24 hours. It also calls for an end to interns being unpaid for overtime. It has so far reached 1 892 signatures with 607 more needed.
Researcher and non-practising attorney Nicolette Erasmus, who took the Desroches case to court,
said despite the grim working hours in the medical profession, change was not only inevitable, but essential.
“The reasons it is going to change is in previous generations, doctors were not protected by the constitution.”
Erasmus has submitted the matter to the public protector and will lodge a complaint over the Desroches case with the African Human Rights Commission.
EFFECTS OF FATIGUE
Studies have shown the dangers associated with lack of proper sleep, suggesting that fatigue leads to a loss of alertness.
Research at the University of Pennsylvania in the US found that sleep loss might be responsible for injury to and loss of neurons which are essential for alertness and optimal intellect.
Researchers have also shown that after being awake for 24 hours, a person’s cognitive psychomotor performance decreases to a level similar to that of someone with a blood alcohol level double that of the South African legal driving limit.
Doctor Chloe* is sometimes on call for 16 to 26 hours.
She has been an intern at Tembisa Hospital for six months and did seven calls last month, the last three of which were done in six days.
She says it was her choice to intern at Tembisa as she was hoping to gain experience, but she says her department is understaffed, with two interns and one senior medical officer on call. She says the medical officer spends most of the night tackling the backlog of C-sections.
“I’m not one to complain but I would like to advocate for safe working hours for interns. After being awake for 24 hours you can barely think straight, never mind treat patients to the best of your ability,” she says.
Dr Vikash Makan, 26, is often on 30-hour calls at Tshepong Hospital in Klerksdorp. He says the biggest challenge is the shortage of doctors.
“Lack of sleep causes stress. I have experienced that. Some of my colleagues are on antidepressants. I haven’t reached a point where I have resorted to something,” he says.
*Not her real name