Sick child in a rural hospital

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27.2 Sick child in a rural hospital

Murali Narayanan, Robert Henning

Essentials

1 There are significant challenges in translating experience from the urban to rural healthcare settings including differences in the patients, illnesses and health services available.
2 The ‘scoop and run’ model of pre-hospital care is not appropriate in rural/remote medicine – patients must be ‘packaged’ as much as possible before transport.
3 Coordination between rural, central and retrieval services must be optimal.
4 Rural services should be supported through targeted training of personnel tailored to the needs of rural clinicians, easily accessible guidelines, accessible consultation services, rural clinical facilities with necessary resources and a supportive relationship with a major urban centre.

Introduction

Most emergency physicians are trained in urban centres. Their skills and knowledge are most readily applied when trained staff, equipment and hospital facilities are immediately available, and when there is ready access to specialists. This becomes an issue when the sick child presents to the emergency department in a rural hospital. Protocols and treatment plans that are appropriate to urban hospitals may be difficult to apply directly.

Challenges in the rural setting

One-third of Australians live in areas defined as rural or remote (areas outside major cities). While Aboriginal and Torres Strait Islanders (ATSI) constitute 2.5% of the total Australian population, they make up 24% of the population in remote areas and 45% of the population in very remote areas. Chronic or recurrent infection, malnutrition, lack of transport, lack of access to health care and educational deficits are all factors which contribute to poorer health status of the people living in these areas.

Income

Although the overall income differences between rich and poor may be smaller, the median household income in rural Australia is 25% lower than that in major cities, and rural families are 50% more likely to be dependent on government pensions and allowances than urban families.

Low income can lead to reluctance to consult a doctor and to reluctance of the doctor to prescribe expensive though appropriate treatments or to commit the family to expensive travel to consult specialists in urban hospitals.

Housing

The quality of housing and of home maintenance is lower in rural areas: maintenance costs are higher, and dwellings deteriorate faster in harsh environments and scarce accommodation leads to overcrowding.

Education

Lower rates of secondary school completion in rural areas than in the city affect both the child and her parents. Infant mortality is closely related to the level of education completed by the mother.

These issues apply also to children in isolated indigenous communities, where the additional problems of distance, access to health care and a relative scarcity of indigenous health workers lead to relatively late hospital presentation of severe illness.

Culture

A tradition of self-reliance and stoicism, combined with suspicion of medical services or of European society in general and varying issues with language difficulties may lead to reluctance to report illness and to delay presentation to seek medical attention. Certain cultural issues, for example not speaking the name of a deceased Aboriginal person, or the tendency of Aboriginal women to avoid eye contact with a strange man, become important considerations in the setting of paediatric emergency medicine.

The illnesses

Birth history

Low birth weight and difficult access to antenatal care in rural areas (especially in indigenous communities) can lead to severe illness in the newborn period, with consequent disability and need for hospital care.

Trauma

Age-standardised rates of serious injury in children from road trauma, interpersonal violence and self-harm increase with distance from major cities in Australia: from 50% greater in inner regional areas to 100% greater in very remote areas. Farm accidents occur frequently: 2/3 of accidental child deaths on farms occur in boys.

Farm vehicles, and especially all-terrain vehicles and four-wheel motor bikes, account for many deaths and injuries, especially to farm visitors. 35–40% of child deaths on farms are due to drowning in dams or drains, especially in children aged less than 5 years.

Infection and diet

Infective conditions, especially of the skin, respiratory and gastrointestinal systems, occur commonly in children from remote communities, where rheumatic heart disease and post-streptococcal glomerulonephritis may result.

There is lack of easy access to fresh food, fruits and vegetables in remote areas. Dietary deficiencies and substance abuse may also contribute to patterns of illness different from those found in children who present to urban hospitals.

The health services

These include community clinics staffed by nurses and/or general medical practitioners (GPs); local hospitals (staffed by nurses, remote emergency physicians and GPs) and ambulance services; regional (base) hospitals which often have paediatricians, emergency physicians, surgeons, anaesthetists and advanced radiology and pathology facilities. Finally, there are city-based patient retrieval services and tertiary hospitals with access to paediatric and neonatal intensive care facilities.

Although inner and outer regional and remote/very remote areas in Australia all have more primary care medical practitioners per 100 000 population than urban areas, this is far outweighed by the ready access of city dwellers to urban hospitals and to specialist care.

Rural general medical practitioners deal with a wide range of illness in a wide range of patients. The nature of general practice means that any single practitioner may rarely (or never) encounter any one of the critical life-threatening illnesses of childhood. This can potentially contribute to a delayed diagnosis and may lead to dilemmas in management. In many rural and remote areas, GPs may be in solo practice, so that consultation with a colleague is difficult, and many regions lack a regional paediatrician to provide timely consultation.

Regional hospitals frequently offer subspecialty clinics staffed by visiting specialists (e.g. paediatric surgery or paediatric cardiology) but these are relatively infrequent and may not coincide with the child’s severe illness. The burden of diagnosis and treatment then falls on the clinician on the spot.

The resources available in rural hospitals vary: for example, pathology and radiology staff may be on-call rather than in-house after hours, and the selection of tests, scans and other investigations that are available may be limited.

Distance and difficulty of access to some rural hospitals means that the delay before arrival of a city-based retrieval team can be protracted, sometimes many hours. During this time, the rural clinician often has to manage a very ill and unstable child within the resources of the local hospital.

Caring for the critically ill child

Decisions to consider when child presents with an emergency

The ‘scoop and run’ model which may be appropriate in some metropolitan environments is not applicable in the remote setting. In fact, the vast distances over which these patients may need to be transported (usually by the RFDS or other state-based retrieval service) mandates that they need to be very well stabilised prior to transfer. It needs to be appreciated that the time taken to adequately prepare a patient for transfer from a remote setting is far in excess of the time taken for the same patient in an urban setting. Effective and ongoing communication between the treating doctor, their specialist colleagues in the tertiary emergency department or paediatric intensive care unit, and the RFDS/Retrieval Service is critical to the child’s management.

Coordination of a resuscitation team prior to the child’s arrival

If the staff in a remote location have prior warning of the arrival of a sick or injured child, they have the opportunity to mobilise any local resources available to them, and also to liaise with tertiary specialist colleagues and ensure that lines of communication are open for when more clinical information is available.

Potential problems to the stabilisation the child

• The reality is that should something go wrong during an air transport, it usually goes badly wrong, and is difficult to fix whilst in the air. Preparation and anticipation of the potential problems in individual cases is thus critical to minimise avoidable pitfalls, prior to patient transfer.
• Vascular access needs to be ‘bullet proof’ (i.e. more than one intravenous cannula, well secured, and kept patent), endotracheal tubes must be very well secured, and painful unstable injuries appropriately immobilised and pain relieved.
• Preparation of equipment, drugs: ensure there are adequate lines for potentially required infusions inserted and well secured. Plan for adequate stocks of medications, compatible fluids and disposables.
• Local temperature issues: for an airplane transport on a 45°C day, the temperature on the tarmac is easily 55–60°C. This may have critical implications for a neonate in a Perspex transport cot which is directly exposed to the sunlight, especially if there is a delay in boarding the craft. Equally, cold, wet and windy conditions may dramatically impact on the stability of a critically ill child.
• Flight weather problems: a common problem during summer in Northern Australia, air turbulence, severe electrical storms and even cyclones can have major logistical implications for the transfer of the patient. Flight plans may need to be changed, sometimes once the patient is already en route, and back-up plans need to be in place. Liaising with the highly experienced doctors and operational staff of the RFDS/ Retrieval Service is critical in such a situation.
• Aeromedical problems: consideration needs to be given to changes in cabin pressure, oxygenation and temperature which may affect the patient (e.g. child with a pneumothorax). The highly experienced doctors of the RFDS are an invaluable resource in this regard.

It is important to utilise the expertise of GPs and nurse practitioners, clerical staff, orderlies, RFDS staff and rural medical personnel to share the load when dealing with the multitasking required in the management of the critically ill child. Midwives are very able in caring for sick neonates. One should be mindful of the fact that it is very stressful for the healthcare practitioner dealing with a paediatric emergency in the isolated remote setting. From their perspective they should utilise all available resources to help share the load. Do not underestimate the value of the telephone as an important ‘piece of resuscitation equipment’ to avail resources in times of need.

Conversely, from the perspective of the receiving tertiary unit, it is important to offer ongoing advice and support, and to help plan and facilitate the transfer by liaising supportively with the transferring team (Fig. 27.2.1).

image

Fig. 27.2.1 The ‘Communication Loop’ – don’t stop communicating!

What can be done to assist care in remote environments?

Personnel

The numbers of medical and nursing practitioners available in rural communities may be increased by financial and educational incentives and by imposing conditions on professional registration that require a period of rural service. These may be backed up by enhanced arrangements for in-service education, and facilitation of career paths. If these arrangements are to succeed, serious consideration must be given to spouse employment, education of children and provision of incentives such as a house and car.

Education

Regular education sessions to remote environments can be arranged through urban tertiary paediatric hospitals. These should be on-line when possible, with self-testing. They should be relevant to the needs of the local practitioner and should be followed up by face-to-face teaching sessions which are primarily hands-on, using the information given in the on-line tutorials. The hands-on teaching may consist of procedural sessions, as well as paediatric mock scenario teaching and group discussions of clinical issues which have arisen within the hospital.

This form of regular in-service teaching should be centrally coordinated, with input from the local practitioners’ organisation. It must be centrally funded, with adequate time allocation in the local practitioners’ calendar.

As tertiary paediatric hospitals have responsibility for medical care of children in their region, they may organise hands-on training programs (e.g. APLS courses), relevant to rural practice and located in the paediatric hospital, in which rural doctors are invited to participate.

Content of training

Illness recognition and resuscitation courses such as APLS, PALS, ATLS/EMST should be very freely available and the fees government-subsidised for nurses and doctors in rural hospitals. Follow-up training in these areas and on-line plus face-to-face courses on topics relevant to severe childhood illness should also be provided by the staff of the regional tertiary hospital.

Consultation support

A centrally organised and funded framework for provision of 24-hour, 7-day advice on all medical sub-specialties (including paediatric subspecialties) would relieve much of the uncertainty of remote rural practice and would remove many of the delays currently seen in diagnosis and management of relatively uncommon conditions.

The use of telemedicine, including teleradiology, as well as the widespread availability of point-of-care biochemical testing can narrow the uncertainty in diagnosis and allow more accurate assessment and monitoring of the response to treatment in the remote setting.

A centrally coordinated telemedicine network requires a terminal at each point of care (rural medical centre or rural hospital emergency department or paediatric ward), capable of high resolution video transmission and reception, and one or more corresponding terminals within the city paediatric hospital (and general teaching hospitals for other medical specialties). Facilities for on-line transmission of medical imaging to a centrally located radiologist are also needed.

A roster of designated subspecialty consultants with access to telemedicine facilities 24 hours per day would complete the consultation support network.

Transport

In some cases, even the above consultation system will not enable the child to be managed at the rural hospital, and specialist care at a paediatric hospital will be needed. A centrally located paediatric triage and retrieval service, staffed by nurses and doctors with training and experience in triage and paediatric retrieval (see Chapter 27.1) can transfer severely ill and unstable patients to an urban tertiary hospital.

When distances to a large city are very great, it may be more appropriate to transfer the child to a smaller base hospital closer to the child’s home, if the severity of the child’s illness permits.

Management protocols

These should be available for a range of severe childhood illnesses and be immediately available (e.g. on-line) in the emergency department of rural hospitals. These protocols should be up-dated regularly to keep abreast of current therapies. They should be modified to be clearly appropriate to rural hospital circumstances, although they may be adapted from those in use in the regional tertiary hospital.

These protocols should be jointly produced by tertiary hospital staff, regional paediatricians and community general practitioners, to ensure suitability for the conditions which prevail in a rural hospital. They should contain advice on when to consult, whom to consult, and how to arrange transfer to a paediatric hospital or to the paediatric ward of a regional base hospital.

Hospital facilities

Apart from telemedicine, teleradiology and point-of-care biochemistry facilities, mentioned above, the emergency department of a country hospital which only occasionally treats severely ill children needs to be equipped adequately and appropriately to deal with the child on those infrequent occasions.

A collection of appropriate resuscitation and paediatric care equipment, common to all rural hospitals, maintained by the central health authority of the state or country, devised and updated by people who are using such equipment frequently, should be supplied to each hospital. This equipment should be kept in the emergency department of the rural hospital and checked daily. When an item is used or out of date, it should be replaced promptly from the regional urban store. Such items include a paediatric range of cervical collars; arm splints; intravenous cannulae; laryngoscope blades; endotracheal tubes; oropharyngeal airways and laryngeal mask airways (LMAs).

Relations between rural and urban hospitals

In the interests of better coordination and of uniformly good service provision to children in rural areas, the mechanism by which facilities are extended to rural hospitals and their staff should be administered at the regional paediatric hospital. This mechanism should be sensitive to the needs of staff of rural hospitals, and responsive to their suggestions about changes.

Clearly, it is very important that tertiary hospital staff work co-operatively with practitioners in rural areas, and that members of this team are aware of each other’s needs. This culture of co-operation, support and mutual respect should be part of the way in which the tertiary hospital sees its role in the health system.

Regular communication between urban and rural practitioners, aided by teaching exchanges, training visits and telemedicine consultations, can promote awareness by each party of the concerns and ideas of the other.

Further reading

Australian Institute of Health and Welfare. Australia’s health 2008. Canberra: AIHW; 2008. Cat. no. AUS 99

Australian Institute of Health and Welfare. A picture of Australia’s children 2009. Canberra: AIHW; 2009. Cat. no. PHE 112

Australian Institute of Health and Welfare. Medical Labour Force 2007. In National Health Labour Force Series no. 44. Canberra: AIHW; 2009.

. Emergency Medicine in Rural Australia. Submission to DoHA by the Rural Doctors Association of Australia. 2007. Available from: http://www.rdaa.com.au/Uploads/Documents/Emergency%20Medicine%20in%20Rural%20Australia_20101012041618.pdf [accessed 29.10.2010]

Fragar L.J., Stiller L., Thomas P. Child injury on Australian farms. Canberra: RIRDC; 2005. Rural Industries Research and Development Corporation, and Australian Centre for Agricultural Health and Safety

Goh A. Y-T., Abdel-Latif M. El-A., Lum L.C-S., Abu-Bakar M.N. Outcome of children with different accessibility to tertiary pediatric intensive care in a developing country – a prospective cohort study. Intens Care Med. 2003;29:97-102.

Marcin J.P., Nesbitt T.S., Kallas H.J., et al. Use of telemedicine to provide pediatric critical care inpatient consultations to underserved rural Northern California. J Pediatr. 2004;144:375-380.

Peake S.L., Judd N. Supporting rural community-based critical care. Curr Opin Crit Care. 2007;13:720-724.

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