Daniël J. van Hoving

Haiti Disaster Tourism-A Medical Shame

The devastating Haiti earthquake rightly resulted in an outpouring of international aid. Relief teams can be of tremendous value during disasters due to natural hazards. Although nobly motivated to help, all emergency interventions have unintended consequences. In the immediate aftermath of the earthquake, many selfless individuals committed to help, but was this really all in the name of reaching out a helping hand? This case report illustrates that medical disaster tourism is alive and well.

Haiti: the South African perspective

UNLABELLED BACKGROUND AND PROBLEM STATEMENT: The South African response to the Haitian earthquake consisted of two independent non-government organisations (NGOs) working separately with minimal contact. Both teams experienced problems during the deployment, mainly owing to not following the International Search and Rescue Advisory Group (INSARAG) guidelines. CRITICAL AREAS IDENTIFIED To improve future South African disaster responses, three functional deployment categories were identified: urban search and rescue, triage and initial stabilisation, and definitive care. To best achieve this, four critical components need to be taken into account: rapid deployment, intelligence from the site, government facilitation, and working under the auspices of recognised organisations such as the United Nations and the World Health Organization. CONCLUSION The proposed way forward for South African medical teams responding to disasters is to be unified under a leading academic body, to have an up-to-date volunteer database, and for volunteers to be current with the international search and rescue course currently being developed by the Medical Working Group of INSARAG. An additional consideration is that South African rescue and relief personnel have a primary responsibility to the citizens of South Africa, then the Southern African Development Community region, then the rest of the African continent and finally further afield. The commitment of government, private and military health services as well as NGOs is paramount for a unified response.

The influence of the 2010 World Cup on the Tygerberg Poison Information Centre

Introduction. The soccer World Cup is one of the biggest sporting events in the world, but data on the effect of sporting events of such a magnitude on the service demand on Poison Information Centres (PICs) are limited. Objective. The aim of this study was to determine the influence of the 2010 World Cup on the workload of the Tygerberg Poison Information Centre (TPIC). Methods. Data were collected prospectively for three time periods during 2010: (1) 31 days preceding the World Cup (10 May–10 June); (2) 31 days during the World Cup (11 June–11 July); and (3) 31 days after the World Cup (12 July–11 August). The calls received during 2010 were compared to calls received during corresponding time periods in 2008 and 2009. Collected data included date and time, callers location and medical background, patients age and gender, intent of exposure, route of exposure and specific toxin class. Results. During the study, 3888 calls related to human poisoning were received (1162 in 2010, 1412 in 2009 and 996 in 2008). The mean daily call volume between 2010 (12.49; 95% CI 11.57–13.42) and 2009 (13.23; 95% CI 12.30–14.15) did not differ significantly (p = 0.25). The mean daily call volume during the World Cup was 11.13 (95% CI 9.59–12.67; n = 345) compared to 14.26 (95% CI 12.71–15.80; n = 442) for the similar period in 2009 (p = 0.08). The mean daily call volume before and after the World Cup was 12.74 (95% CI 11.20–14.29; n = 395) and 13.61 (95% CI 12.07–15.16; n = 422); p = 1.00 and p = 0.39, respectively, when compared with the World Cup period. Discussion. An unexpected finding of this study was that the hosting of the 2010 World Cup resulted in fewer calls to the TPIC. This decrease could be attributed to the high visibility of policing, an extended school holiday and the positive attitudes of South Africans towards making the World Cup a success. Conclusion. PICs should be consulted during the planning stages of major sporting events. Contingency plans should still be in place to overcome any unexpected rise in call volume.

Poor return on investment: investigating the barriers that cause low credentialing yields in a resource-limited clinical ultrasound training programme

BackgroundClinical ultrasound is commonly used in medical practices worldwide due to the multiple benefits the modality offers clinicians. Rigorous credentialing standards are necessary to safeguard patients against operator errors. The purpose of the study was to establish and analyse the barriers that specifically lead to poor credentialing success within a resource-limited clinical ultrasound training programme.MethodsAn electronic cross-sectional survey was e-mailed to all trainees who attended the introductory clinical ultrasound courses held in Cape Town since its inception in 2009 to 2013. All trainees were followed until they completed their training programme in 2015.ResultsOnly one fifth of trainees (n = 43, 19.7%), who entered the Cape Town training programme, credentialed successfully. Ninety (n = 90, 41.3%) trainees responded to the survey. Eighty-six (n = 86) surveys were included for analysis. Time constraints were the highest ranked barrier amongst all trainees. Access barriers (to trainers and ultrasound machines) were the second highest ranked amongst the non-credentialed group. A combination between access and logistical barriers (e.g. difficulty in finding patients with pathology to scan) were the second highest ranked in the credentialed group.ConclusionsAccess barriers conspire to burden the Cape Town clinical ultrasound training programme. Novel solutions are necessary to overcome these access barriers to improve future credentialing success.

Estimated injury-associated blood loss versus availability of emergency blood products at a district-level public hospital in Cape Town, South Africa

Introduction International guidance suggests that injury-associated haemorrhagic shock should be resuscitated using blood products. However, in low- and middle-income countries resuscitation emphasises the use of crystalloids – mainly due to poor access to blood products. This study aimed to estimate the amount of blood loss from serious injury in relation to available emergency blood products at a secondary-level, public Cape Town hospital. Methods This retrospective, cross-sectional study included all injured patients cared for in the resuscitation area of Khayelitsha Hospital’s emergency centre over a fourteen-week period. Injuries were coded using the Abbreviated Injury Scale, which was then used to estimate blood loss for each patient using an algorithm from the Trauma Audit Research Network. Descriptive statistics were used to describe blood volume lost and blood units required to replace losses greater than 15% circulating blood volume. Four units of emergency blood are stored in a dedicated blood fridge in the emergency centre. Platelets and fresh plasma are not available. Results A total of 389 injury events were enrolled of which 93 were excluded due to absent clinic data. The mean age was 29 (±10) years. We estimated a median of one unit of blood requirement per week or weekend, up to a maximum of eight or six units, respectively. Most patients (n = 275, 94%) did not have sufficient injury to warrant transfusion. Overall, one person would require a transfusion for every 15 persons with a moderate to serious injury. Conclusion The volume of available emergency blood appears inadequate for injury care, and doesn’t consider the need for other causes of acute haemorrhage (e.g. gastric, gynaecological, etc.). Furthermore, lack of other blood components (i.e. plasma and platelets) presents a challenge in this low-resourced setting. Further research is required to determine the appropriate management of injury-associated haemorrhage from a resource and budget perspective.

Abdominal ultrasound for diagnosing abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV-positive adults

CITATION: Van Hoving, D. J., et al. 2017. Abdominal ultrasound for diagnosing abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV-positive adults. Cochrane Database of Systematic Reviews, 8:1-15, Art. CD012777, doi:10.1002/14651858.CD012777.

Poor adherence to Tranexamic acid guidelines for adult, injured patients presenting to a district, public, South African hospital

Introduction In South Africa’s high injury prevalent setting, it is imperative that injury mortality is kept to a minimum. The CRASH-2 trial showed that Tranexamic acid (TXA) in severe injury reduces mortality. Implementation of this into injury protocols has been slow despite the evidence. The 2013 Western Cape Emergency Medicine Guidelines adopted the use of TXA. This study aims to describe compliance. Methods A retrospective study of TXA use in adult injury patients presenting to Khayelitsha Hospital was done. A sample of 301 patients was randomly selected from Khayelitsha’s resuscitation database and data were supplemented through chart review. The primary endpoint was compliance with local guidance: systolic blood pressure <90 or heart rate >110 or a significant risk of haemorrhage. Injury Severity Score (ISS) was used as a proxy for the latter. ISS >16 was interpreted as high risk of haemorrhage and ISS <8 as low risk. Linear regression and Fischer’s Exact test were used to explore assumptions. Results Overall compliance was 58% (172 of 295). For those without an indication, this was 96% (172 of 180). Of the 115 patients who had an indication, only eight (18%) received the first dose of TXA and none received a follow-up infusion. Compliance with the protocol was significantly better if an indication for TXA did not exist, compared to when one did (p < 0.001). Increased TXA use was associated only with ISS >15 (p < 0.001). Discussion TXA is not used in accordance with local guidelines. It was as likely not to be used when indicated than when not indicated. Reasons for this are multifactorial and likely include stock levels, lack of administration equipment, time to reach definitive care, poor documentation and hesitancy to use. Further investigation is needed to understand the barriers to administration.