Browsing by Author "Clarke, Damian Luiz."

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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.
Developing a multi-faceted approach to improving and uplifting trauma care in the periphery.
(2013) Clarke, Damian Luiz.; Thomson, Sandie Rutherford.
Introduction Rural trauma care in South Africa is under resourced and the quality of rural trauma care appears to be uneven. This project aimed to assess the quality of rural trauma care in Sisonke Health District and to develop targeted quality improvement programmes to improve it. Methodology A strategic planning methodology consisting of a situational analysis, planning synthesis and implementation was used in the project and was integrated with a health system’s model of inputs, process and outcome to provide a structured overview of the whole process. A number of academic constructs from fields outside of health care were used to analyse the quality of care and to develop targeted quality improvement programmes. Results The table below summarises the results of this project by placing each of the published papers in this thesis into the integrated grid. The various tools that were adopted to assist with the project included error theory and quality metrics for trauma and acute surgery. These are also situated within the grid. Analysis of the inputs of rural trauma care revealed that there were major deficits in terms of the human resources available to manage the large burden of trauma seen in rural hospitals. Analysis of the process revealed deficits in the transfer process and the quality of documentation and observation of trauma patients in our system. Analysis of the outcomes revealed a high incidence of error associated with rural trauma care and poor outcomes for a number of conditions such as burns. Synthesis and Implementation involved the development of a number of strategies and a review of their efficacy. These included a surgical outreach programme, restructured morbidity and mortality meetings, error-awareness training and the use of tick-box clerking sheets. The impact of these various programmes was mixed. The surgical outreach programme was successful at delivering surgical care in the districts but less successful at transferring surgical skills to rural staff. The morbidity and mortality meetings, and the errorawareness training changed the culture of the institution and increased the understanding of the danger of error. The tick-box initiative revealed how difficult it is to change human behaviour. A number of audits have suggested that there is a general improvement in the quality of care. This has resulted in improved outcomes for the management of penetrating abdominal trauma and burns care. Conclusion Rural trauma care has many deficits and these translate into poor outcomes. Addressing these deficits is difficult and requires a multi -faceted approach. Undertaking quality improvement programmes in an ad hoc manner may be counter-productive and using a structured systematic approach may allow planners to contextualise their interventions. Currently trying to increase the inputs and resources available for rural trauma care is difficult and most of the intervention should aim at refining and improving the process of care. A number of projects have emerged from this thesis.
Laser doppler assessment of gastric mucosal blood flow in normals and its relationship to the systemic activity of growth peptides in healing and non healing gastric ulcers.
(1999) Clarke, Damian Luiz.; Thomson, Sandie Rutherford.
The pattern of mucosal blood flow in normal human stomachs, and benign gastric ulcers was assesed with laser Doppler flowmetry and the relationship between a single determination of ulcer blood flow and the systemic level of growth factors was investigated. A significant ascending gradient in mucosal blood flow from the antrum to fundus was demonstrated. Different levels of cellular activity in the regions of the stomach may explain this gradient. In the gastric ulcers that healed on standard medical therapy mucosal blood flow was significantly increased in comparison to normal stomachs. In the ulcers that were refractory to standard medical therapy mucosal blood flow was significantly lower than in normal stomachs and healing ulcers. Higher systemic levels of the growth factor bFGF were demonstrated in healing ulcers compared to non-healing ulcers. Gastric mucosal blood flow can increase in response to the increased metabolic demands of healing, however impairment of this response may be an important factor preventing healing of benign gastric ulcers. It would appear that non-healing of gastric ulcers can be predicted at initial diagnosis by reduced peri-ulcer gastric mucosal blood flow and low blood levels of bFGF.
Oesophageal cancer in rural South Africa: challenges in diagnosis and an alternate technique of stent placement for timely palliation in a resource-constrained environment.
(2016) Govender, Morganayagi.; Clarke, Damian Luiz.
Abstract available in PDF.
A prospective audit of the use of diagnostic laparoscopy to establish the diagnosis of abdominal tuberculosis.
(2011) Islam, Jahangirul.; Wilson, Douglas Paul Kinghurst.; Dawood, Halima.; Thomson, Sandie Rutherford.; Clarke, Damian Luiz.
HIV epidemic is one of the major challenges to the South Africa’s socio-economic development. The incidence of tuberculosis is rising in sub-Saharan Africa, and in 2009 South Africa had the second highest incidence of tuberculosis in the world. Approximately 80% of incident tuberculosis cases in South Africa are HIV positive. In HIV positive individual, abdominal tuberculosis has been reported as the most common form of extra-pulmonary tuberculosis. HIV/AIDS has resulted in a resurgence of abdominal tuberculosis in South Africa. Making the diagnosis of abdominal tuberculosis is still difficult, though the condition is common. The role of laparoscopy in making the diagnosis is undefined. Method: All patients with clinically and radiologically suspected but histologically or microbiologically unconfirmed abdominal tuberculosis were referred to the investigating team and laparoscopy was performed to diagnose abdominal tuberculosis. Histology was performed on tissue biopsy specimens and TB culture on ascitic fluid and peripheral blood specimens. Results: From January 2008 to June 2010 a total of 190 patients were referred to us. No surgical intervention was taken in 60 patients; all of them were HIV positive. Twenty six of them died (43%) in the hospital during the evaluation period before the diagnostic laparoscopy, and the rest (57%) were unfit for anaesthesia. Forty nine patients required emergency laparotomy either for bowel obstruction or peritonitis and 39% of them died. Eighty one patients underwent diagnostic laparoscopy and 77% of them were HIV positive, in 16% the HIV status was unknown. Two percent had clinical ascites. Laparoscopic findings included intra-abdominal lymphadenopathy in 56, minimal ascitic fluid in 46, intra-abdominal mass in 17, and deposits on bowel wall, peritoneum or omentum in 20 patients. Fifty five patients (68%) had positive histology for tuberculosis. In 15 patients (19%) histology revealed non-specific inflammation, no pathology was found in one patient and no specimen was taken from one patient. Eighty percent of peritoneal deposits and 77% of lymph nodes were positive for tuberculosis, whereas 35% ascitic fluid culture was positive. In nine patients (11%) an alternative diagnosis was found (appendicitis, adenocarcinoma, lymphoma). Conclusion: Laparoscopy was feasible and showed a high yield to establish the diagnosis of abdominal tuberculosis and to provide an alternate diagnosis. Laparoscopy was useful to establish the gross features of abdominal tuberculosis and to provide the adequate specimens for examinations. Very poor follow negated the evaluation of the clinical response to anti tuberculosis therapy.
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.
Spectrum and cost of road traffic crashes : data from a regional South African hospital.
(2014) Parkinson, Frances.; Clarke, Damian Luiz.; Aldous, Colleen Michelle.
Road traffic crashes (RTCs) are a worldwide phenomenon, but a disproportionate number of deaths and injuries caused by RTCs occur in developing countries. A number of international organisations have drawn attention to the problem and called for a comprehensive public health response. Such a programme needs to be multi-faceted and use preventative and therapeutic strategies and also involve a wide range of stakeholders from government and civil society. In South Africa, the Province of KwaZulu-Natal (KZN) has the worst record for the number of deaths and injuries sustained on the roads. Despite the urgent need for such programmes in the Province there is a paucity of local research on the problem. This project sees itself as part of an ongoing systematic comprehensive quality improvement initiative. The objectives of this single-centre study are to determine common patterns of injury associated with road traffic crashes in KZN, to identify risk factors which may be targeted by specific injury prevention programmes and to establish the in-hospital cost of RTCs. This will be done by identifying a cohort of patients with injuries sustained in RTCs, gathering data on their injuries and circumstances of the crash, and costing their inpatient stay using micro-costing methods. It is hoped that this information on the burden of disease (including cost) will be incentive for investment in local healthcare and risk-reducing measures (relevant to local risk factors). The costs may also serve as a baseline for larger province-wide costing studies.
The spectrum, outcomes and costs of acute appendicitis at Edendale Hospital and its related catchment areas.
(2014) Kong, Victor.; Aldous, Colleen Michelle.; Clarke, Damian Luiz.
Abstract available in PDF file.