Hanneke Brits

Pediatric pain management in palliative care.

The management of pain in pediatric palliative care (PPC) is essential. Whilst the field of pain management has developed over the years, much of what is done in PPC is based on anecdotal evidence or adult studies. This review explores recent developments in pain management in PPC, in particular the WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. Key issues discussed include the definition, assessment, pharmacological and integrative management of pain, availability of medications, education and research. Whilst advances have been made, including publication of the guidelines, significant gaps exist in terms of the evidence base, education and access to essential medications and both interdisciplinary and international collaboration are required to meet these gaps.

The effectiveness of the implementation of the Cape Triage Score at the emergency department of the National District Hospital, Bloemfontein

Background: The need for an appropriate South African triage system led to the development of the Cape Triage Score (CTS), a system to prioritise emergency departments’ workloads. This study evaluated the effectiveness of the CTS at the National District Hospital emergency department, Bloemfontein. Methods: In this retrospective, descriptive, observational study, files of adult patients triaged at the emergency department during February 2013 were randomly selected. Inclusion was subject to the availability of the files. Physiological parameter results were used to calculate the Triage Early Warning Score (TEWS). The side-room investigations and South African Triage Score (SATS) were recorded. Other information gathered included diagnosis, outcome, and times the patient was triaged and seen by the doctor. Results: A total of 396 files were included in the study. Patients, of whom 57.8% were women, were between the ages of 16–89 years. More than half (52%) of side-room investigations were omitted or inappropriate. The adjustment of the TEWS to the SATS was done incorrectly in 52% of cases. The majority of patients (69.9%) were discharged home after treatment, although 88% were SATS orange coded. Over-triage occurred in 8.1% of TEWS and 67.8% of SATS cases. The mean waiting time from triage until patient was seen by the doctor was 2 hours. Conclusions: The TEWS proved to predict outcome better than the SATS. Due to inaccurate triage, only 8% of patients were seen within the recommended waiting times. The CTS has not been effectively implemented at the National District Hospital emergency department.

Illegible handwriting and other prescription errors on prescriptions at National District Hospital, Bloemfontein

Background: It is generally accepted that doctors have illegible handwriting. The writer usually knows what is written, but other parties often have problems reading and interpreting. Aim: The aim of the study was to determine whether illegible doctors’ handwriting and other factors that can lead to dispensing errors occur on prescriptions at National District Hospital. Method: In part one the prescriptions of 20 doctors were read by five doctors, nurses and pharmacists to detect who could read it most accurately. In part two, these doctors were asked to write a prescription with an IntelliPen®. Results: From the 300 measurements, 88% of the doctors read the prescriptions correctly, compared with 82% of the nurses and 75% of the pharmacists. A potential fatal error was lorazepam injection 4 mg, which was read as 40 mg (lethal dose) by 20% of healthcare workers (HCWs). With the IntelliPen® only 39% of the prescriptions were readable. Only 65% of prescribers could be identified from their handwriting or the name stamp used. Conclusion: Pharmacists read the prescriptions worst and they are the people who must dispense the prescriptions. Some of the reading mistakes were critical and could be lethal. Many of the prescriptions did not meet the legal requirement for prescriptions.

Causes of prematurity in the Bloemfontein Academic Complex

Background: Prematurity is globally the leading cause of neonatal mortality, morbidity and long-term disability. The Millennium Development Goals (MDG) of the United Nations, and specifically MDG 4, address child mortality. Neonatal mortality rates contribute to 37% of all under-five mortality, with the largest proportion (30%) due to prematurity. The overall purpose of this study was to determine factors associated with prematurity and to identify treatable and preventable causes at the Bloemfontein Academic Complex in order to decrease the morbidity and mortality associated with prematurity in line with MDG. Methods: A case control study design was used including all premature babies referred to the Kangaroo Care Unit of the National District Hospital between December 2010 and March 2011. Each baby was included with his/her mother as a pair. For each premature baby and mother pair a term baby and mother pair was included as a control. Data were collected on a data sheet from the mothers’ antenatal records, and from maternal notes as well as the neonatal follow-up and discharge notes. Data gathered included baseline characteristics, habits, diseases and medication of the mother during the antenatal period and delivery as well as baseline demographics of the babies. Results: A total of 194 mothers and 198 babies were included in the study with 109 case mothers and 85 control mothers. Pre-existing medical conditions were more prevalent in the premature group (69%) compared with the control group (27%) with p < 0.0001. These conditions included hypertension, HIV disease and syphilis. Possible causes for prematurity identified in this study included teenage mothers and premature rupture of membranes. Conclusion: Risk factors identified for prematurity were: teenage mothers, pre-existing medical conditions in the mother, and preterm rupture of membranes. Smoking and alcohol consumption during pregnancy could not be identified as risk factors for prematurity. It is recommended that patients with any of the above-mentioned identified risk factors be classified as high risk for the development of prematurity and shorter follow-up intervals and more aggressive management of pre-existing medical conditions should be practised.

The prevalence of multiple losses experienced by children from birth to 18 years in the National District Hospital in Bloemfontein

Background: Multiple losses experienced by children is a topic on which little research has previously been completed. Therefore, a specific definition of multiple losses is unavailable. Multiple losses are traumatic for children and result in the need for intervention and support with respect to grief, loss and bereavement issues. The main goal of this study was to determine the prevalence of multiple losses children who had experienced this from birth to 18 years of age in the National District Hospital in Bloemfontein. Method: A literature search was carried out to define the concept of multiple losses experienced by children appropriate to the South African context. Thereafter, a descriptive study with an analytical component was used to gather information on multiple losses. Structured interviews with the parents or caretakers of the children at the National District Hospital were conducted by the researchers by means of a questionnaire. The interviews were conducted in English or Afrikaans. Results: A total of 62 interviews were performed with the parents or caregivers. Multiple losses, defined here as the loss of three or more personal, interpersonal or environmental assets, were experienced by 69% of these children (95% confidence interval: 57–79%). The majority of losses experienced occurred in the interpersonal (87%) and environmental (82%) categories. The death of a family member took place in 61% of cases. Unemployment of a parent, with its consequences, was reported in 63% of cases. Conclusion: The criteria used to define multiple losses in this study were adequate and appropriate for this study population. The prevalence of multiple losses in children in the National District Hospital in Bloemfontein was 69.4%. This figure warrants the need for support and bereavement counselling for children to prevent long-term problems with relationships and adaptation within society.

Do we miss half of the injuries sustained during rape because we cannot see them? An overview of the use of toluidine blue tissue stain in the medical assessment of rape cases

Abstract The prosecution of rape cases is difficult due to the absence of eyewitnesses. McCauley found that the detection of vaginal lacerations increased from one in 24 to 14 in 24 in reported adult rape cases when toluidine blue was used. Proof of injuries consistent with sexual penetration adds significantly to the evidentiary value of the medico-legal testimony. Although rape is not a clinical diagnosis and there are no diagnostic criteria to confirm rape, the possibility of genital injury during rape far exceeds the possibility of injury with consensual intercourse. If a complete examination, including the use of toluidine blue, is not used a rapist may walk away to rape again, while the victims remain with the stigma that they may have made a false allegation. Toluidine blue is a basic thiazine metachromatic dye. It has a high affinity for acidic tissue components, thereby staining tissues rich in DNA and RNA. The epithelium of the external genitalia does not have nucleated cells and prevents contact of stain with nuclei. Where the epithelium is damaged and the underlying nucleated cells are exposed, the nuclei stain blue. Injuries sustained during genital penetration show a distinctive distribution. Toluidine blue stain is easy and safe to use, available, inexpensive and does not interfere with other medico-legal evidence, therefore it is recommended to be used in the examination of all cases of alleged rape.

A descriptive study of trends in the pictures drawn by primary school learners in South Africa

BACKGROUND Illness, lack of vocabulary and unwillingness to discuss emotional distress may contribute to poor communication with children. Drawings may play a crucial role in enhancing communication with this patient group. AIM This study aimed to describe the pictures drawn by primary school learners in the childrens palliative care programme in Bloemfontein, South Africa, and to evaluate whether drawings can be used to assess emotional wellbeing. METHODS Drawings were assessed according to standardised human figure drawing guidelines and emotional indicator (EI) scales. Pictures were discussed with the child and compared with the clinical presence of depression or emotional discomfort. RESULTS A total of 29 pictures drawn by 20 children were assessed. Of the 20 participants, 18 were boys, with a mean age of 10.2 years, and 12 children were assessed as having clinical depression. CONCLUSIONS The presence of two or more EIs, small pictures or pictures in dark colours may indicate clinical depression. Health professionals are advised not to try to interpret the picture, but to use the picture to enhance communication. Let the child explain the picture, rather than relying only on the assessment tool.

Bereavement overload and its effects on, and related coping mechanisms of health care providers and ward administrators at National District Hospital in Bloemfontein, Free State

Background Patient death is an event that all health care workers will face at some point. Beyond the family, the greatest emotional strain is on people who work directly with the patient and family. Bereavement overload occurs after multiple losses without time for normal grief in between. Aim To investigate bereavement overload, its effects and related coping mechanisms of personnel working in adult medical wards. Setting Four adult medical wards at National District Hospital, Bloemfontein. Methods An analytical cross-sectional study design was performed with the aid of an interviewer-administered questionnaire. The target population included health care providers (13 doctors and 20 nurses), eight final-year medical students, and four administrative staff working in the four adult medical wards at National District Hospital, during August to October 2016. Results Half (48.9%) of the 45 participants reported bereavement overload. None of the medical students reported bereavement overload compared to 60.0% of nurses, 75.0% of administrative staff and 53.9% of doctors. Nearly two-thirds (64.5%, n = 29) stated that they suffered from compassion fatigue. The majority of participants (62.2%) used only positive coping mechanisms. The use of negative coping mechanisms correlated directly with a longer duration in the medical field. Conclusion With a 49% prevalence of bereavement overload, it is important that support systems are in place to prevent the effects of negative coping mechanisms. The desirable outcome is that health care providers, who suffer from bereavement overload, experience compassion satisfaction and become more dedicated to the patients’ well-being without expense to themselves.

The prevalence of neonatal jaundice and risk factors in healthy term neonates at National District Hospital in Bloemfontein

Background Neonatal jaundice affects one in two infants globally. The jaundice is the result of an accumulation of bilirubin as foetal haemoglobin is metabolised by the immature liver. High serum levels of bilirubin result in lethargy, poor feeding and kernicterus of the infant. Aim The main aim of this article was to determine the prevalence of neonatal jaundice and secondly to explore its risk factors in healthy term neonates. Setting Maternity ward, National District Hospital, Bloemfontein, South Africa. Methods In this cross-sectional study, mothers and infants were conveniently sampled after delivery and before discharge. The mothers were interviewed and their case records were reviewed for risk factors for neonatal jaundice and the clinical appearance and bilirubin levels of the infants were measured with a non-invasive transcutaneous bilirubin meter. Results A total of 96 mother-infant pairs were included in the study. The prevalence of neonatal jaundice was 55.2%; however, only 10% of black babies who were diagnosed with jaundice appeared clinically jaundiced. Normal vaginal delivery was the only risk factor associated with neonatal jaundice. Black race and maternal smoking were not protective against neonatal jaundice as in some other studies. Conclusion More than half (55.2%) of healthy term neonates developed neonatal jaundice. As it is difficult to clinically diagnose neonatal jaundice in darker pigmented babies, it is recommended that the bilirubin level of all babies should be checked with a non-invasive bilirubin meter before discharge from hospital or maternity unit as well as during the first clinic visit on day 3 after birth.

The emergency management of a rape case in a nutshell: adolescent and adult cases

The management of a rape case in the emergency department is shrouded in an unacceptable level of lack of confidence. Since South Africa has a high incidence of rape, the contribution of health practitioners in addressing the crime successfully is essential. The medical management of such cases carries a high level of uncertainty with an accompanying element of not feeling in control. The intimidation associated with the responsibility of being an expert witness complicates the matter further. This article attempts to address the reluctance to get involved in medico-legal cases and emphasises the holistic management of survivors of rape.