Clinical Medicine

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Adequate analgesia in caring for paediatric burns patients in a peri-urban setting in KZN.
(2020) Wall, Shelley Lynn.; Clarke, Damian Luiz.; Allorto, Nikki Leigh.
This PhD thesis centres on achieving adequate analgesia in caring for paediatric burn-injured patients in KwaZulu-Natal, South Africa. The burden of burn injuries in sub-Saharan Africa is huge. A large number of children in the under-five age group sustain burns in the region annually. Pain is virtually synonymous with burn injuries. All children with burns experience pain, regardless of the cause, size or depth of the burn. This PhD study aimed to improve the care offered to paediatric burns patients by addressing obstacles to adequate analgesia in paediatric burns patients; and to offer a practical, easy to use, locally applicable analgesia protocol which can be used at district, regional and tertiary hospitals alike. The objectives were to identify deficits in the knowledge of doctors in terms of prescribing procedural analgesia for children with burns; to evaluate the use of an alternative analgesic agent, Methoxyflurane, for pain management during dressing changes in an outpatient department; to compare the analgesic requirements of children presenting with acute versus chronic burns; to evaluate the use of an alternative analgesic agent, Methoxyflurane, for pain management during dressing changes for patients admitted to the burns ward; to evaluate obstacles to adequate analgesia in paediatric burns patients; and to develop an analgesia protocol applicable to KwaZulu-Natal and other low-middle-income countries (LMIC), through the consensus of experts in the field. The development of this protocol was conducted in three phases. The first phase involved assessing obstacles to adequate analgesia in paediatric burns patients. The second phase involved assessing Methoxyflurane as an alternative analgesia option in both the inpatient and the outpatient setting; and the final phase involved the addition of Methoxyflurane to our analgesia protocols and reaching an expert consensus that the elements included in the analgesia protocol were applicable to KwaZulu-Natal and other low-middle-income settings. The analgesia protocol for paediatric burns patients has been developed with the local setting and resources as a primary consideration. It was specifically designed to be easy to use, safe in novice hands and locally applicable. In order to ensure that theoretical findings from the study are translated into practices that benefit all burn-injured children, this research should be combined with advocacy efforts.
A cross-sectional descriptive study of pre-hospital care providers’ training, knowledge and skills in austere environments emergency medicine in South Africa: a framework for a consensus statement for Wilderness Emergency Medicine.
(2017) Matthew, Jaybalan Allan.; Maharaj, Roshen.; Clarke, Damian Luiz.
There is a lack of research into the resource capabilities and capacity for wilderness emergency medicine practice in South Africa (SA). This is despite SA having vast expanses of populated austere geography that remains difficult to access by conventional health care systems and the country increasingly becoming an attractive ecotourist destination. With increasing needs for skilled health care personnel to deal with medical emergencies in this environment, it is first necessary to determine the extent of the current resources present within SA. This research looked at the human resource potential to deal with medical emergencies in the wilderness emergency environment in SA. Chapter one considers the conceptual and contextual framework of this research in light of the above and a review of the available literature. Chapter two presents research from a study that determined the self-reported extent of training, knowledge and skills that capacitated Emergency Care Practitioners (ECP) registered with the Health Professions Council of South Africa (HPCSA) when operating in the wilderness environment and when dealing with medical emergencies. Chapter three examines data gained from a survey conducted among emergency medicine specialists regarding the competency in knowledge, training and skills that are ideally required in the practice of wilderness emergency medicine (WEM). Chapter four compares the self-reported knowledge, training and skills of ECPs in the wilderness emergency environment, with what is suggested by emergency medicine specialists as the expected level of knowledge, training and skills for practice in this field. Chapter five presents a published editorial that highlights the potential value of this specialised WEM practice in resource-limited countries. This editorial suggests that proper wilderness emergency medicine training, knowledge and skills could perhaps be an alternative solution for frugal innovation for resource-limited pre-hospital and inhospital practice. There is a need for further training and skills uptake in WEM. Additionally, a local framework for a consensus statement on the practice of WEM needs to be established.
Quantifying the clinical exposure required to adequately prepare surgeons for deployment to conflict zones and to manage mass casualty situations.
(2018) Uchino, Hayaki.; Kong, Victor.; Clarke, Damian Luiz.
Introduction: The ongoing state of global geo-political instability means that it is prudent, even in peaceful countries, to prepare civilian surgeons to manage major military-type trauma. However, preparing a modern surgeon to manage mass shooting or terrorist-related injuries remains an ongoing challenge in many countries. In addition, there is no consensus on the key skill set a modern trauma or military surgeon requires to competently manage major trauma patients. Chapter 1 of this thesis reviews the trauma workload and operative exposure in a major South African trauma center and provides a comparison with contemporary experience from major military conflicts. It would appear that a South African trauma center has a sufficient burden of trauma and academic capability to train both military and civilian trauma surgeons. Based on our trauma workload, a 6-month rotation through a major South African trauma center should be sufficient to provide exposure to almost all major injuries in appropriate volumes to prepare a military surgeon for combat deployment. Chapter 2 of this thesis reviews the state of trauma training and preparedness in Japan and the trauma workload of a major Japanese emergency medical center, and goes on to compare it with that of a major South African trauma center. The intention is to quantify and compare the time required to gain adequate exposure to major trauma at the two respective centers. It is apparent that trauma training in Japan is hampered by a lack of clinical material as well as by systematic factors. South Africa, in contrast, has a huge burden of trauma, sufficient academic infrastructure, and relatively modern facilities, which ensures that surgeons have adequate exposure to major trauma. Developing an academic exchange program between Japan and South Africa may allow for the transfer of trauma experience and skills between the two countries. Chapter 3 of this thesis is a structured survey designed to investigate the role of international trauma clinical electives in South Africa, and to assess the impact these have had on the career of the various foreign surgeons who have undertaken them. The data demonstrated that an international trauma clinical elective in South Africa provides unparalleled exposure to almost all forms of trauma in conjunction with a well-developed academic support program. The trainees who completed such an elective all felt that the trauma training with clinical exposure was of inestimable value and substantially enhanced their career. Conclusion: South Africa has a sufficient burden of trauma to train surgeons to manage military and major civilian trauma. In addition, South African major trauma centers have sufficient academic support and capacity to ensure such training is structured and academically sound. In contrast, trauma training in Japan is impeded by a lack of clinical material as well as by systematic factors. Training a trauma-competent military or civilian surgeon in such an environment is difficult. An international trauma clinical elective in South Africa provides an unparalleled exposure to almost all forms of trauma in conjunction with a well-developed academic support program. For peaceful countries such as Japan, developing academic exchange programs with countries such as South Africa, which can offer broader trauma experience, is essential and can be mutually beneficial.

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