The overpass is a good 20 or 25 metres high. No wonder the patient is groaning in agony. I’m surprised he’s even conscious.
Behind me The Leopard approaches with our gear. Seems the case has inspired him to show me what he’s made of. Or maybe the siren of our back-up ambulance wailing towards us has compelled him to act.
The policeman helps by manually stabilising the patient’s head. Calmly the Leopard scissors off the man’s shorts and T-shirt to expose him for a better examination. He slips a wide-bore IV into the cubital fossa without blinking and throws me a bag of Hartmann’s solution.
‘Five minutes on scene or we get docked,’ scoffs The Leopard. ‘Patient’s got an open-book pelvis with jelly legs, but it’s all about those five bloody minutes.’ He shakes his head and I know what he means. Time to hospital is the essence in trauma, but proper immobilisation, effective analgesia, cautious extrication and transport strategies will all, in the long run, reduce morbidity. Only by working the road can one truly appreciate ‘time’ as but one factor among many upon which an ambulance service should be judged.
Once the line is clear of air I connect and open it for a bolus. The Leopard double-checks the blood pressure, palpating seventy systolic. Falls from great heights often cause serious pelvic fractures like this, lacerating vessels internally and resulting in massive blood loss filling body cavities. This, in turn, can lead to absolute hypovolaemia – a condition of low blood volume – that could prove fatal.
‘Keep the fluids going wide open, we’ll shut it off at ninety systolic. Don’t go over ninety, got it?’
I nod.
Three paramedics from a Basic Life Support (BLS) ambulance arrive. They too comment on how lucky it is the Mercedes escaped damage. Two of them help with patient care, while the third, a stern-looking African man with spectacles on the end of his nose and epaulettes studded with shiny stars, stands to one side and starts a stopwatch hanging round his neck.
The Leopard looks over at me and rolls his eyes. ‘What did I tell you? Five minutes, let’s go!’ Maybe The Leopard is burnt out but tonight he’s playing the game. We’re being timed like athletes, timed by a stoney-faced supervisor with a digital stopwatch. Crazy.
Medics from the ambulance drag over a flat spine-board onto which we lay some pelvic sheeting. Once the patient is rolled over, we use this to stabilise him from the waist down, wrapped and clamped. Any unnecessary movement in pelvic fractures, even multiple examinations springing the iliac crests, increases internal bleeding and risk of death.
‘One, two, three, lift!’ The stretcher legs lock down and the trolley is wheeled to the ambulance. As the supervisor gets in the front seat he glances over at us and laughs.
‘Hey Rucker, four minutes, thirty-three. Close shave!’
The Leopard grunts and lights a cigarette.
From Netcare’s depot at Milpark we watch a retrieval helicopter descend onto a landing pad at the doorstep of the company’s very own fully equipped trauma hospital.
‘Heard it on the radio,’ The Leopard tells me. ‘Some lion safari gone wrong, a 4x4 rollover.’
Running parallel to public medical services, Netcare has fifty-three private hospitals like this throughout South Africa and Swaziland. Milpark alone employs some of the country’s brightest doctors, offering every imaginable specialty and a staggering ninety intensive care beds. For those who can afford private health cover the company has become South Africa’s provider of choice. But as an act of goodwill to the poorer people of South Africa, Netcare offers its ambulance services free to those who earn below a certain income threshold. Nowadays, the vast majority of emergency calls are made by non-subscribers. These patients are, however, always conveyed to public hospitals. Although it is currently common practice in South Africa to dial 911 – Netcare’s clever exploitation of the widely known US emergency number – bystanders will also ring the government’s metro ambulance service at the same time. In a crisis people will take whatever ambulance comes first.
As a consequence, driving to emergencies has become a frantic race between the public and private services. This ‘healthy competition’ has only improved response times in Johannesburg, according to Netcare medics. Relationships between crews from both systems generally remain harmonious despite this challenge. Stress comes instead from pressure placed on them by management to reach the scene first in order to uphold the service’s image as the quickest.
While good for the public, it’s a dangerous game for medics. In 2002, nineteen ambulances were written-off in the city of Johannesburg, mostly by Metro Ambulance Service drivers. Netcare are not so worried. Official figures show their average response times are five minutes faster than the government service.
‘Sometimes on the way to hospital with the patient we pass the Metro ambulance still heading to the scene,’ chuckles The Leopard. ‘We always give a little wave, of course.’
As we prowl for work in those raw, bloodstained streets of central Johannesburg, I have become The Leopard’s cub, learning to hunt with the master.
‘Are you ever afraid?’ I ask him. Stories of gun battles with drug gangs, resuscitations at knifepoint and snipers taking shots at reflective vests have kept me on the edge of my seat all night.
‘Ja, sure I get afraid.’
‘Of what?’
‘HIV.’
It isn’t what I expected him to say.
‘Average sixty people are shot every day here, ten thousand people die on the roads each year, 90 per cent of our calls are trauma, but HIV is the leading cause of death. At least 20 per cent of sub-Saharan Africa is HIV positive. Just do the math. If you consider 90 per cent of our work is trauma with active bleeding and 20 per cent of these patients are HIV positive, you will understand what we’re really afraid of. Get blood on you in Australia, England, America and you don’t sweat much. Get blood on you here and you don’t sleep till the results come back.’
The Leopard plans to enrol in a paramedic research degree, a doctorate perhaps. ‘I need to get off the road. I have children now, they live with my wife but I want to see more of them. You know, I have a responsibility to them, a responsibility to stay alive.’
The streets of Johannesburg seem eons away from the immense beauty of South Africa’s wilderness. The contrast is extreme. But then, some of the most stunning places in the world have a dark underbelly, a place shared by the poor, the sad, the criminal, the beggar, the victim and the paramedic.
‘Zero zero three?’
Reluctantly The Leopard picks up the handset and replies. Our lights and siren ignite the dark road ahead.
‘It’s not a bad neighbourhood, this,’ says The Leopard. ‘We’re less than a kilometre from Hillbrow, I have a drink here sometimes, you know, during the daytime.’
But descending a steep hill we are first on the scene of a chaos like none I’ve encountered.
From what I can make out, a fully laden semitrailer lost control, veered to the opposite side of the road, crushed five cars and continued on to plough through a restaurant packed with diners, finally coming to rest deep within the building.
The carnage is widespread and horrific.
Bodies
