Sick child in a rural hospital

Published on 23/06/2015 by admin

Filed under Emergency Medicine

Last modified 22/04/2025

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27.2 Sick child in a rural hospital

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.

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

Potential problems to the stabilisation the child

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).

What can be done to assist care in remote environments?