The Golden Day – PhD submission

Oh the joy of finally submitting the bound, accepted thesis. Thank you! ‪#‎love‬ ‪#‎gratitude‬ ‪#‎PhD #ANU #perseverance

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“Improving the medical management of organophosphorus pesticide poisoning through health services research and training” – Bishan N. Rajapakse, PhD , Australian National University, February 2015.

Abstract

Organophosphorus (OP) self-poisoning is a major global public health problem resulting in over 200,000 deaths each year with a case fatality of 15-30%. Early medical management consists of effective resuscitation and targeted antidote therapy.

This thesis argued that health services research and rural doctor training could be used to improve the medical management of OP poisoning in a resource limited rural Sri Lankan setting, where the delivery of critical care is limited by a lack of diagnostic tests and resuscitation skills. Research investigating the use of AChE in guiding clinical management, and research that measured the effectiveness of rural resuscitation training, were the two streams of research that were the founding pillars of the thesis. These two elements were linked together through a conceptual framework of knowledge translation, each operating at different points in the continuum of evidence being translated into practice.

An AChE point-of-care test (Test-mate ChE) was demonstrated to provide accurate and reliable results in acute OP poisoning when compared with a reference laboratory. A survey based analysis of clinician’s knowledge, attitudes and practices found that most doctors valued the test, but also surprisingly found that doctors who were more experienced with AChE valued the test less. Low proportions valued the test in guidance of acute poisoning management (e.g. to direct oxime therapy and early discharge).

A systematic review highlighted a lack of supporting primary evidence for the use of AChE in relation to oxime use and discharge decisions. Advice on interpretation of AChE and caution about pitfalls in measurement were also lacking. These areas need to be addressed to optimise provision of AChE POC devices.

A train-the-trainer (TTT) model of resuscitation education was effective in improving resuscitation knowledge and skills in rural peripheral hospital doctors, and improvements in most components were sustained for 12 weeks. This demonstrated the effectiveness of using non-specialist doctors to conduct peer-led advanced life support (ALS) training in a low resource peripheral hospital setting, using objective knowledge and skills endpoints according to standardized metrics.

A systematic review of resuscitation of OP poisoning found no texts solely focused on acute initial management. An ‘OP specific’ ALS guideline was proposed based on consistent literature recommendations highlighting the importance of rapid atropinisation (doubling dose regimen) to be delivered simultaneous with immediate airway, breathing and circulation management. Other antidotes such as oximes should not be in the ALS guidelines.

A participatory action research approach was used to address practical problems through close engagement with health services and local training systems. The experience from both streams of research showed that such strategies were integral to the completion of the studies employed in the low resource rural setting. The thesis demonstrated health services research and training could be used to close the evidence-practice gap, and may have a role in the improvement of the medical management of OP poisoning. Future research should investigate clinical endpoints associated with the use of AChE in guiding OP poisoning management, the development of decision rules offering practical guidance in measurement and interpretation of AChE, the evaluation of OP specific ALS guidelines, and the sustainability rural resuscitation training programs.

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Reflections of the Boxing Day Tsunami in 2004

In light of the tragedies occuring after the recent Earthquakes in Nepal Arjuna Mohottala shares his memories of lessons learned from his first hand experience of another devastating disaster, in Sri Lanka, with vote of hope the best possible recovery for the Nepalese society.

My View of the World

A little over 48 hours ago, close to noon on Saturday April 25, 2015, the peaceful country of Nepal was rocked by a magnitude 7.8 earthquake and subsequent aftershocks. Many of you would have seen the effect of this earthquake, the aftermath and the ensuing agony of those who were affected by this natural disaster on media and through friends.

A decade ago, I too had a front-row seat to witness one of the greatest natural disasters in modern history; the Boxing Day tsunami of 2004. I still recall it as yesterday. My father being a meteorologist all his life and the Director of the Meteorological Department of Sri Lanka for over 12 years, I would have been one of a handful of Sri Lankans who knew the true meaning of the word tsunami prior to the unfolding of events on that fateful Sunday.  The first indication was when I felt…

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PhD Thesis – the story behind the questions..

I was once told that good writing is all about the narrative. When I started writing up my doctoral dissertation I soon learned that I was collating, and weaving together, a series of narratives into a cohesive story with some scientific value.

I also learned that the key to good research is having useful and relevant research questions. In my thesis some of the most important questions only came clear to me whilst I was already on the ground doing research in a rural hospital in Sri Lanka. Here, I remember vividly observing many critically ill patients who had intentionally consumed deadly pesticides, and wondering what their fate would be given and how we could improve the medical management in order to save lives. Thus, for me it made sense to try and provide a story about the “context” where I embodied the research questions that would culminate into the ensuing scientific narrative.

Below is a poem that never made it into the final thesis, but in perhaps captures the passion of enquiry that sustained me through the long journey of formulating hypothesises, collecting data, and publishing my final findings.

Too young to die

Side by side in the intensive care they lie,

Multiple family members hoping they won’t die,

I can’t help but ask myself why,

Surely this lady is too young to die?

.

Was this the result of frustration in the home,

Did she really want to leave this world for good?

Would her family and kids not worry and feel pain,

Everything seemed like it was all in vain,

.

Back to the room with the lights and the constant beeping,

Things are getting tense, she is more than sleeping,

Deep down I feel strongly that this lady should not go now,

I want to help, but the real question was “how”?

14/2/07 (21:24hrs)  The above poem was written whilst observing a 36 year old woman, from a rural town in the north central province of Sri Lanka, fight for her life whilst on an intensive care ventilator. She was the mother of 3 children, and took an organophosphorus pesticide poison following an argument with her husband. She died within 2 days of presentation to hospital.

My PhD research was dedicated to the countless patients, like this lady, and to the numerous health staff and researchers who who were all a part of the effort to save and improve these patients lives.

The following two PDF excerpts show the contextual story which lead to the eventual scientific document that comprised the final thesis.

A strategy for hope in the face of death…

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Download here (phd-thesis-preface )

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The table of contents

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The entire thesis can be downloaded from ANU digital thesis at this link  – however, I’m happy to be emailed (bishan.rajapakse@gmail.com) and send you a pdf copy if you would like to read it. I would also be delighted to hear any reflections or comments on this work that occupied my attention for the better part of a decade.