Author: Dr Victor Kong, MD, PhD, ChM, MSc, DRCPSC, MRCS, FRACS
Trauma surgeon

Earlier in my surgical career, I sought and underwent training in South Africa that would profoundly influence my work as a trauma surgeon. I had been in South Africa for two weeks and had been working in a trauma unit for the past 10 days. The unit was almost always full, with an endless stream of patients being treated for all types of injury daily, especially penetrating injuries. Under the guidance of my senior registrar, I managed a handful of patients with stab wounds to the neck—what was referred to colloquially in our unit as ‘stab necks’. I treated one such patient, whom I will call Joe, who—in the years that followed—would ultimately cement my belief in keeping things simple.

Another stab neck
It was a payday weekend; a time when the trauma volume is the highest of the month. The advanced paramedics brought in a young man from the nearby township (informal settlement) who was involved in an altercation and had been stabbed in the neck. The patient was restless en route and was promptly sedated and intubated. The paramedic was frantically pressing on his neck wound under a pile of gauze, all of which had been soaked bright red. There was a flurry of activity in the trauma bay, where everything followed Advanced Trauma Life Support (ATLS) to the letter and everyone was trying to do their part—obtaining IV access, giving blood, etc.

I took one look at the wound; it was actively bleeding. Not just any bleeding that one could see; it was almost as if one could hear it. It was spurting like a fountain, and jets of blood were spraying onto everything in the vicinity. Not only had the blood soaked though the poor paramedic’s sleeves, but the entire sheet on the trauma bay was also soaked. And within seconds, before I had the chance to take another glance at the patient, two more stacks of gauze were soaked, and I could still see fresh blood welling up between the paramedic’s compressing fingers. The patient’s blood pressure was dropping extremely fast; and he probably had a few more minutes before he suffered a cardiac arrest.

A Foley’s in time
This patient was obviously in serious trouble. It almost sounded too obvious. An actively bleeding wound: any textbook would say that you should apply pressure first. He also had the classic hard signs of vascular injury, and it was obvious that he needed to be sent to the operating theatre immediately to deal with bleeding, probably from a severed artery. Although the operating theatre was close by, I doubted whether he would survive getting there in the first place. How could I get him there safely?

Dr A, my very experienced senior registrar (who had recently completed his training), tapped me on the shoulder and said calmly: “Kong, go put a Foley’s catheter through the wound, blow it up and then we go to theatre and sort the rest out.”

I was a little taken aback and before I had a chance to say anything that sounded remotely intelligent, he motioned me towards the patient and told me not to worry.

“I will do it with you, don’t worry. I know what you’re thinking. You obviously don’t know that’s how we do things here. We only do what works and I can tell you it works like a charm.”

Dr A had the suction in his hand to clear the blood and in one swift motion, I pushed the Foley’s catheter through the wound that was pulsating with fresh blood and slowly inflated the balloon. The next thing I saw was blood streaming through the catheter and coming out the other end.

"Make sure you clamp the end!” Dr A said.

After I applied the clamp, the bleeding did slow down, but it didn’t stop. I was beginning to question my own sanity in performing what I thought was a rather unorthodox technique.

Dr A must have seen my hesitation, but he simply smiled and handed me another Foley’s catheter.  

”Just put another one in; that should do the trick.”

As sceptical as I was, I did exactly what I was told. Lo and behold, by the time the second one was inflated, the bleeding had stopped completely. I was shocked. It actually worked, all within a few minutes.

Dr A and I got the patient to the operating theatre swiftly, where a formal neck exploration was undertaken. During the professorial round the following day, Dr A presented the patient, Joe, whom I knew had already been extubated. Joe gave me a thumbs up when he saw me and asked when he could go home, as if nothing had happened. Dr A chuckled and told him, pointing his finger at me, “This doctor saved your life. He will tell you when you can go home”.

I knew it was not exactly true, but I also know that the Foley’s catheter worked, and it worked very well.

My inquisitive mind drove me to look much deeper into this rather new technique, which I had never seen, let alone perform. I searched through all the literature and every trauma book I could find. Giving credit where it is due, I would eventually find out that the notion of using a balloon tamponade in trauma is not new. Foley’s Balloon Catherter Tamponade (FBCT) was first described by trauma surgeons at Baragwanath Hospital in Johannesburg in the 1990s. It was subsequently re-popularised by the group at Groote Schurr Hospital in Cape Town. All in all, a very South African form of ingenuity. In the ensuing years during my training in South Africa, I was fortunate to have been able to continue to build on this and publish my personal experience with this technique.

Final thoughts
As it happens, many years after I left South Africa, I encountered another patient who was remarkably similar to Joe. Though a few eyebrows were raised, and several confused looks were present on the faces of some of my colleagues, I applied the same technique with equally successful results. As I reflect on my early years of training, I feel ever so grateful to my South African colleagues for so generously teaching me and sharing their wisdom in a distinctly South African style.