In August 1979 a photograph appeared in a local newspaper of a four-year-old pretending to listen to a fellow pre-schooler’s heart. In the accompanying text, the little boy was identified as “doctor” Charl Carstens. Prophesy or destiny? You decide – because the same Dr Charl Carstens now heads up the emergency department of a large private hospital with a picture postcard view of one of the seven wonders of nature.
Netcare Blaauwberg Hospital is located in Bloubergstrand, a seaside suburb of the city of Cape Town that is famous for its classic view of Table Mountain. When it opened in 2007, it instantly made history because its emergency unit was the first in South Africa to be created by emergency medicine specialists.
Emergency medicine as a specialty was introduced in South Africa in 2003 by Dr Clive Balfour. Charl had met Dr Balfour by chance, during a rotation at a hospital in England’s Lake District and was encouraged to return to South Africa and become one of the first group of 10 South African doctors to complete the four-year course. A fellow resident established the emergency department at Netcare Blaauwberg and Charl, after working there part-time during 2007, joined as a consultant full time in 2008.
On his watch the hospital was recognized by the Trauma Society of South Africa (TSSA) as a level III trauma centre in 2018, then pulled out all the stops to attain level II trauma centre certification in 2023.
When the precursor to the Angels Initiative began operating in South Africa in 2014, Netcare Blaauwberg was among the first hospitals to gain stroke-ready status. In 2018 an Angels consultant conducted a simulation at the hospital, and the Angels stroke kit and checklists became part of the stroke protocol. Enthusiasm for the stroke program however flagged after Covid disrupted the healthcare system and the hospital lost its neurologist and stroke champion to illness. But all that was about to change.
Sr Claudette Lotz never considered a career in any field other than nursing. “You just know,” she says. She earned her first degree at what is now the University of Johannesburg, and after a year in the ICU joined the Netcare group as a trauma nurse. A dislike of routine kept her in the emergency department. “I have never worked on a ward,” she says.
When her children became provincial swimmers, her career took a backseat. For almost two decades she worked only occasional shifts but in 2019 she moved to Cape Town and prepared to return to fulltime nursing. That same year she obtained a post-grad qualification in nursing education at the University of Stellenbosch; during the pandemic the following year she embarked on post-grad studies in public health, and this past December she graduated with a master’s degree in nursing science. In September 2022 she became unit manager of the ED department at Netcare Blaauwberg and less than a year later the hospital won its first gold WSO Angels Award.
A stroke care system was already in place when she arrived, and Dr Carstens was immediately on board, she says. Recognizing that quality monitoring was the key to improvement, Claudette met with Sr Zasskia Wiese, the national stroke coordinator for the Netcare group, to learn how to load patient data into the stroke care quality improvement registry, RES-Q.
“In the beginning it looked impossible,” she says. “But once you get started, you see it can be done.” She and ED clinical nurse specialist Michelle Cronje started the practice of making loading their stroke care data their first priority every morning. When the numbers showed that their door-to-needle times could be faster, Angels consultant Bernise Schubert facilitated training about the hyperacute phase. When the time to reach radiology presented a challenge, they asked the EMS to bring stroke patients directly to the CT and carried out tests on the run. A whatsapp group connecting the key players has proved immensely valuable and supports prenotification so they’re aware of the patient from the moment they summon the ambulance until they arrive at CT.
The result of these efforts was a second gold award in the third quarter of 2023 followed by their first platinum award in quarter four. Now they are about to receive their second diamond award, recognizing them as a beacon of stroke care excellence.
There has been a shift in attitude among doctors in the ED, Charl says. They actively look for reasons to treat ischemic stroke with thrombolysis and make every effort to gain family consent for this life-altering treatment. The enthusiasm of a younger generation of nurses and their excitement when they witness the impact of the treatment are likewise infectious.
“Just start loading your data, just start by taking the first basic step,” is Claudette’s response when you ask what advice she has for hospitals that have yet to commit to stroke care improvement.
“Taking that first step can be hard,” Charl adds. “But you need that person who is prepared to light the fire. Then everything falls into place.”
They are both that person albeit in different ways. Charl has the cool head which he says is a necessary characteristic for an emergency doctor. “The ED is no place for a cowboy; you need a cool head to manage chaotic stress situations and create order to have a good outcome.” He’s a young dad who juggles work and family life and still tries to get in a game of golf.
In a different life stage and having regalvanised her career in a field she loves, Claudette finds it difficult to tear herself away from work. She is likely to work until 10 or 11 at night, especially if the unit is busy and her team has their hands full. “I cannot stand by and watch someone else struggle, she says. “A leader has to be part of her team.”
Driven to succeed and immensely proud of their hospital, Charl and Claudette are now exploring ways to make their diamond shine even brighter. They are talking to the radiology team about using DWI-FLAIR Mismatch, an MRI technique to determine which patients with unknown stroke onset times are candidates for thrombolysis.
A stroke protocol for wake-up strokes and late arriving patients will save many more lives. It might even have saved that of Charl’s uncle who’d arrived too late after suffering a severe stroke. Back then nothing could be done for him, Charl says. “Perhaps we could have done something now.”
