September 2012, Volume 62, Issue 9

Editorial

Strengthening paediatric emergency medicine in Pakistan is our need to reach millennium development goal 4

Emad uddin Siddiqui  ( Department of Emergency Medicine, Aga Khan University Hospital, Karachi. Pakistan. )
Kiran Ejaz  ( Department of Emergency Medicine, Aga Khan University Hospital, Karachi. Pakistan. )

By year 2015 United Nation targets to achieve the Millennium Development Goal (MGD) 4, of reducing morbidity and mortality in children. Achievement of this goal especially in the low income countries (LIC) requires substantial strengthening of the health care system.1 Paediatric Emergency Medicine (PEM) needs growth in many aspects in our country. PEM in LIC such as Pakistan is at its weakest edge.2
In 1959, United Nation passed a declaration strengthening the fundamental needs and rights of children as a separate entity.3 The basis of this declaration was that, the children are different from adults in their anatomy and physiology, endocrine, psychological and behavioural variations. Their disease pattern, presentation and complications are all dissimilar from adults.4 Children at different ages have diversified symptoms of the same disease. Critically ill children have to wait in clinics and are admitted to general wards, which wastes precious golden hours of initial management.2 Consequences of these delays results in poor outcome. This often results in increased chronic illnesses, disability and mortality.
PEM physicians improve the quality care of ill or injured children in a timely fashion.5 If our physicians especially those dealing with children in acute distress are better trained to handle such problems, many morbidities can be prevented. PEM physician not only works within the premises of Emergency Department, but he acts as a counselor, advocator and social worker. Disease advocating, managing and dealing the critical Paediatric disease/injuries remains the greatest challenges of future in the ultimate care of children even in the developed countries.6
There are numerous training programmes for acute care management of adult patients i.e. Basic Life Support, Advance Cardiac Life Support, Advance Trauma Life Support, Emergency Surgical Skills (Emergency Maternal and Child Health), Fundamentals of Critical care and Essential Burn Care and are designed for the early detection and immediate emergency and critical care management for adults. In most emergency rooms of Pakistan, experienced physicians in acute care management of adult patients are also managing Paediatric patients without formal training or experience in PEM. Due to wide variation of uncontrolled emergent Paediatric situations specialized programmes have been implemented and formulated for more concise, acute and accurate assessment and management. They are exclusively different from those practices in controlled settings of general Paediatric ward based on the précise guidelines of Paediatric Advance Life Support, Advance Paediatric Life Support and Advance Trauma Life Support.7
Thirty percent of all emergency department visits comprise of Paediatric patients.8 To date we have been managing this academic and administrative problem without any specific PEM training available in Pakistan. Condition of PEM is far behind a satisfactory benchmark in majority of our hospitals. These problems can partially be explained by massive lack of resources for health care in LIC.9 There are undersupplied laboratories and support services, hospital management, and equipment supplies.10 This further makes management of poor and vulnerable Paediatric patients even more difficult.
Our need is to develop the infrastructure and build human resources and skills at a national level. This can be accomplished through a structured and aspiring PEM residency/fellow training programme. Paediatric trauma care, Paediatric formulary, pain management, toxicology and ambulatory services further build the decipline.4 Policy makers of LIC have unfortunately been unable to recognize the importance of PEM as a highly impactful stake holder to achieve the MDG4. Formulated and focused core curriculum, training programmes and workshops along with private and public sector collaboration is indeed essential to achieve our goals efficiently. It is time for PEM to step out of its embryonic and evolving phase to a recognized, matured and established specialty.

References

1. Millennium Development Goals: progress towards the health-related Millennium Development Goals Fact sheet N°290: World Health Organization; May 2011. (Online) (Cited 2011 June 28). Available from URL: http://www.who.int/mediacentre/factsheets/fs290/en/.
2. Baker T. Paediatric emergency and critical care in low-income countries. Paediatr Anaesth 2009; 19: 23-7.
3. Feigelman S, Marcel V A. Growth, Development and Behavior. Kliegman Nelson Text Book of Paediatric. Philadelphia Saunders/Elsevier publication, 2007. Vol. 1 Part 1- XVI, 18th edi. Chapter 1, Page 1-12.
4. Siddiqui EU, Razzak JA. Paediatric emergency medicine--an evolving sub-speciality in Pakistan. J Coll Physicians Surg Pak 2008; 18: 135-6.
5. Walker MD, Tolentino RV, Teach JS. Trends and challenges in international Paediatric emergency medicine. Curr Opin Pediatr 2007; 19: 247-52.
6. Rivara FP, Grossman DC. Prevention of traumatic deaths to children in the United States: How far have we come and where do we need to go? Paediatrics 1996; 97: 791-7.
7. Ralston M, Hanzinski M F, Zaritsky A L, Schexanyder S M, Kleinmman M E. Paediatric Advance Life Support Manual. American Heart Association Dallas. Provider Manual 2006; Chapter 1, page 1-32.
8. Sinclair D, Sub specialization in emergency medicine. Where do we go from here? Can Emerg Med 2005; 7: 344-6.
9. Kobusingye OC, Hyder AA, Bishai D, Hicks ER, Mock C & Joshipura M. Emergency medical systems in low- and middle-income countries, recommendations for action. Bull World Health Organ 2005; 83: 626-63.
10. Jochberger S, Ismailova F, Lederer W, Mayr V D, Luckner G, Wenzel V, et al. Anesthesia and its allied disciplines in the developing world: a nationwide survey of the Republic of Zambia. Anesth Analg 2008; 106: 942-8.

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