EDITORIAL

Paediatric emergencies in office practice—an overview Brig SK Jatana* MJAFI 2012;68:4–5

eventualities. A study was carried out in Chicago in United States to see how well the physicians are equipped to handle paediatric emergencies.2 The emergencies in this study were upper airway obstruction, significant trauma, acute severe asthma, seizures, shock, cardiac arrest, and endocrine emergencies, e.g. diabetes ketoacidosis. A survey of 280 family physicians and paediatricians was conducted and it showed that majority of them had received at least one child requiring emergency care in the previous three-months period. In the majority of these office practices, doctors/paramedics were not fully prepared and did not have proper equipment to manage childhood medical emergencies. Only 27% of the staff was certified in basic life support and 17% were certified in paediatric advanced life support. Emergency drugs like epinephrine, oxygen equipment, and disposables like intravenous catheters, bag-valve-mask devices and nebulisers were not available in many offices. Many reasons were cited by the physicians for the lack of preparedness. Their perception was that: 1. Paediatric emergencies were not frequently seen in the office though surveys point to the contrary. 2. Doctors and paramedics do not have the time to seek necessary training. 3. Adequate drugs and equipment were available to treat such eventualities though again evidence is to the contrary. 4. Emergency equipment was too costly to purchase.

Paediatric office emergencies occur very frequently though perception among general population is to the contrary. The most common emergencies encountered in paediatric office practice, especially in our country are dehydration, asthma, seizures, respiratory distress, shock, and trauma. Unfortunately no studies are available from our country, which review the emergency medical services (EMS) in children, office preparedness for the same, and the challenges faced by the care providers, especially the general practitioner, in handling these emergencies. Though all emergencies in the paediatric age group are not immediately life-threatening, yet adequate training and equipment are required to treat such emergencies. The concept of EMS in children has not taken roots in India and is still not considered important enough to merit a separate arm of EMS. However, there is much awareness in Western countries to this requirement and EMS in children is a concept. The family physicians provide initial, comprehensive, and continuing care right from educating the parents on prevention of emergencies till timely and optimal treatment on the occurrence. They participate in acquiring training of paediatric treatment, appropriate triage, transportation of patient to the appropriate Emergency Department of a hospital, hospital treatment, and the patient’s rehabilitation after discharge.1 Most injuries in paediatric age group are preventable. Similarly, many illnesses can be prevented from becoming emergencies by early recognition of the ailment and institution of prompt treatment by family physicians and first contact care providers in the office/clinic. Parents and guardians need to be educated on first aid treatment, recognition of signs and symptoms of serious illness, and when to seek medical help. This can go a long way in the prevention of an ailment requiring emergency care. General practitioners frequently see children in their office with medical conditions that may evolve into an emergency if not promptly attended to. Hence, they and their staff should have adequate training in such emergencies, appropriate equipment and treatment protocols in place to manage such

TRAINING OF OFFICE PERSONNEL This is a very important aspect in the management of childhood emergencies in office practice. All practising physicians should have personnel who are trained in various aspects of managing emergencies in children. They should be able to recognise the severity of the illness as soon as they come in contact with the child, may be in the waiting room or the examination room, or even as early as receiving information on the telephone from the child’s parent. All of them should be trained in basic life support and the physicians themselves should have training in paediatric advanced life support. Besides, preparation and confidence in managing emergencies can improve by scheduled ‘mock code’ exercises, where these health providers can prepare and ensure that emergency medications are available, equipment is functional and management protocols are in place and updated. Later unscheduled mock drills can be performed to assess the shortcomings and make improvements.3

*Deputy Commandant, Command Hospital (SC), Pune – 40. Correspondence: Brig SK Jatana, Deputy Commandant, Command Hospital (SC), Pune – 40. E-mail: [email protected] doi: 10.1016/S0377-1237(11)60144-5

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© 2012, AFMS

Paediatric Emergencies in Office Practice—An Overview

EMERGENCY AND RESUSCITATION EQUIPMENT

the following components (though EMS in children has not been specifically mentioned): • Ambulance: operations and maintenance • Call centre: for ambulance dispatch and control • Empanelled health facilities/hospitals: ensuring quality of care • Information system and knowledge management training: for emergency case management on-site, in-transit, and in hospitals • Health education: among general public • Legal framework: to define roles and liabilities of various stakeholders • Governance: for transparency and regulation To conclude EMS especially for children in pre-hospital/ office practice is the need of the hour especially in our country. The office of the primary paediatric healthcare provider will be the first stop for emergency medical care that consists of prevention of emergency by timely treatment of illnesses, management of emergency on occurrence, referral, and transportation to a specialised centre when required, follow-up in the hospital, rehabilitation on discharge from the hospital, and further follow-up. It is a continuum of care requiring proper training of healthcare providers, provisioning of emergency equipment and medications, protocols on management of critical cases in office, and regular mock drills. Also, education of parents is also an essential component of EMS in children to prevent and treat an emergency and to decrease the risk of an unfavourable outcome.2,9,10

For instituting proper emergency treatment appropriate equipment is required. Every office of a physician should be equipped with emergency equipment and drugs, which can be used in children of various age groups. The equipment should be regularly checked for its functionality and kept in working condition in an easily accessible place. Basic equipment to tackle paediatric emergencies in office practice includes oxygen cylinder/ concentrator, masks of various sizes, ambu bag, suction apparatus, airways of different sizes, catheters, feeding tubes, intubation equipment, intravenous fluids, and emergency drugs.1 It is also very important to have treatment protocols prepared for different emergencies with prominently displayed dosages. Dose of drugs administered in children is dependent on weight/surface area. At times it may not be possible to determine the child’s weight during emergency and while being resuscitated. Bavdekar et al compared the dosages of drugs based on weight given in standard textbooks with dosages calculated by foot-length measurement.4 This study has shown that foot-length correlates with anthropometric parameters such as weight, total length, and body surface area. The authors have postulated that doses calculated on the basis of this predicted weight exceeds standard dose by only 2.35–2.4%. This may be a handy tool during management of a child in a critical condition. There are other emergencies besides what have been mentioned earlier which a family physician or a general practitioner may encounter in their office practice. Kumar et al5 conducted a retrospective analysis of otolaryngology or ENT (ear, nose, and throat) paediatric emergency cases seen in Lok Nayak Hospital in Delhi. These cases were referred to the hospital from paediatric emergency services. One third of all ENT cases were children, majority in the 3–4 year age group. Foreign body nose, ear, and aero-digestive tract comprised the maximum number of cases along with infection/pain in the ear, though only 19% of cases required admission to the hospital. Many of the cases did not warrant emergency management but were brought to the Emergency Department because of parental anxiety. Emergency medical services in our country are woefully inadequate even in Metros. A study conducted by Ramanujam et al in Chennai found that EMS in that city was almost nonexistent and comprised mainly of ill-equipped ambulances.6 They have proposed the revamping of EMS in our country and recognition of EMS as a separate specialty. India having a population of more than a billion with the increasing number of cardiovascular and other diseases, and increase in road traffic accidents and trauma cases, Praveen Kumar et al have also emphasised on establishment of EMS in various cities in our country and Emergency Departments in medical colleges in India.7 Recently, the Ministry of Health and Family Welfare has come out with a paper titled ‘EMS in India: a concept’.8 The paper has stated that various studies including a review of Emergency Management and Research Institute (EMRI) found many gaps in the existing EMS in India. The study has suggested that in revamping of the EMS, the focus should be on MJAFI Vol 68 No 1

REFERENCES 1.

Dowd MD, Rivara FP. Emergency medical services for children. In: Nelson Textbook of Pediatrics 18th ed. Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Philadelphia: Saunders 2007:375–380. 2. Wheeler DS, Kiefer ML, Poss WB. Pediatric emergency preparedness in the office. Am Fam Physician 2000;61:3333–3342. 3. Klig JE, O’Malley PJ. Pediatric office emergencies. Curr Opin Pediatr 2007;19:591–596. 4. Bavdekar BS, Sathe S, Jani P. Prediction of weight of Indian children aged upto two years based on foot-length: implications for emergency areas. Indian Pediatr 2006;43:125–130. 5. Kumar S, Gulati A. Pediatric emergencies in otolaryngology in a metropolitan city. Indian Pediatr 1999;36:1256–1258. 6. Ramanujam P, Aschkenasy M. Identifying the need for pre-hospital and emergency care in the developing world: a case study in Chennai, India. J Assoc Physicians India 2007;55:491–495. 7. Aggarwal P, Banga A, Kurukumbi M, Gupta M. Emergency physicians and emergency medicine: an imminent need in India. Natl Med J India 2001;14:257–259. 8. Emergency Medical Service (EMS) in India: A Concept Paper. National Health Systems Resource Centre (NHSRC), Technical Support Institution with National Rural Health Mission (NRHM), Ministry of Health & Family Welfare, Government of India, New Delhi. 9. Toback SL. Medical emergency preparedness in office practice. Am Fam Physician 2007;75:1679–1684. 10. Frush K. Preparation of emergencies in the offices of pediatricians and pediatric primary care providers. Pediatrics 2007;120:200–212. 5

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Paediatric emergencies in office practice-an overview.

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