On the graveyard shift, six gunshot victims is a quiet night

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The world's largest hospital, Chris Hani Baragwanath in South Africa, is ideal for learning about the management of gunshot wounds for two reasons. Firstly, because it is on the boundary between Johannesburg and its apartheid-era satellite suburbs, it has to cater to one of the most violent urban areas in the world – and it has to do so with ever scarcer resources as health services deteriorate.

Every night the graveyard shift at "Bara" braces itself for the stream of knifing and gunshot victims brought in by world-weary ambulance staff who have seen it all. They dump their patients outside the casualty ward, where they have two benches to lie on, and a line of red metal gurneys. On the rare occasions that the patients have mattresses, these are blotched with blood. The floor is often slippery with blood – the trauma teams are too busy to clean it.

A doctor who fled from the civil war in the Democratic Republic of the Congo says he saw only one gunshot wound when he was in medical school there eight years ago. Now he would consider six gunshot victims in one night unusually low. On weekend nights, when the wards overflow with drunken and drugged patients, the number easily climbs to 20. Doctors here saw nearly 3,000 patients with gunshot wounds last year.

Illegal guns can be bought for as little as $30 (£20) in Soweto. Last year, 29,694 guns were reported stolen. Guns also make their way into the country from neighbouring African countries, Eastern Europe, China and the United States. Recent burglaries of South African armouries have added to the supply. The situation is worsened by the lack of safety for staff. Some doctors avoid entering the surrounding community. Most avoid travelling at night.

Aids is a life-threatening problem, with doctors estimating that half of all patients entering the casualty ward are HIV-positive. Treating them for knife wounds means doctors risk being infected.

In post-apartheid South Africa, health services have deteriorated in formerly black areas. A report last year by the Ethics Institute found that 40 per cent of staff wanted to leave, and that morale was so low that patients resorted to bribing nurses to get proper care. "The hospital does not have the most basic of things, such as linen. Patients have to use their own, which the hospital cannot wash when soiled, because it is not its property," said Sister Irene Maesela.

Nevertheless, Baragwanath has a proud tradition for training staff who have gone to the furthest reaches of Africa. "As a civilian hospital, it's main contribution has been towards training of health professionals," a spokesman said. "Since 1948, doctors graduating from the University of the Witwatersrand have benefited significantly from the experience gained here."

Likewise, as a training school for nurses, the hospital has contributed widely. Graduate nurses not only fulfil an important task at Baragwanath, but also across Africa. Baragwanath-trained staff work in many areas of the world today. The hospital also contributes to research. Its doctors claim that, despite the obstacle, Baragwanath gives guidance for those in similar situations, worldwide.

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