R., Adina

Razzak, Junaid

Sajjad, Sheikh

English

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eCommons@AKUDepartment of Emergency Medicine Medical College, PakistanFebruary 2008The need for formal paediatric resuscitation trainingin Pakistan.Adina R.Aga Khan UniversitySheikh SajjadAga Khan UniversityJunaid RazzakAga Khan University, junaid.razzak@aku.eduFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_emerg_medPart of the Emergency Medicine Commons, and the Pediatrics CommonsRecommended CitationR., A., Sajjad, S., Razzak, J. (2008). The need for formal paediatric resuscitation training in Pakistan.. Journal of Pakistan MedicalAssociation, 58(2), 51-52.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_emerg_med/177More than 10 million children die each year beforetheir fifth birthday and almost all of these children are fromthe low income countries (LICs).1 In Pakistan alone morethan half a million children under five die every year.Multiple factors contribute to these alarming figuresincluding poverty, illiteracy, poorly integrated primary care,patchy emergency services and low quality of hospitalbased care.2,3 The focus of many of the current efforts is toimprove care at the primary/district level througheducational/training programmes and structural changes,such as Integrated Management of Childhood Illness(IMCI) introduced by WHO/UNICEF4 and EmergencyMaternal and Child Health Program (EMCH) of theAdvanced Life Support Group, UK, Child AdvocacyInternational, WHO and the Government of Pakistan.3While these programmes address important weaknesses inthe system, the hospital care, particularly the emergencycare of children in the hospital settings, remain neglected.  Astudy carried out in 7 developing countries, revealed aninadequate triage system, substandard, delayed andinappropriate assessment and treatment along withinsufficient monitoring.5 Another study in Malawi revealedinadequate triage resulting in avoidable deaths.6 Althoughwe have sparse data from Pakistan addressing these issues,it is safe to assume that situations are mirrored.The purpose of initial emergency medical care isstabilisation of patients with life or limb threatening injuryor illness.  Although there is no data directly linkingfavourable outcomes with good quality emergency care, theissue of quality of paediatric care in peripheral hospitals indeveloping countries has been raised by the PaediatricQuality Care Group.6 Nolan concluded that good qualityhospital care is crucial for reducing child mortality.5 It isexpected that improvements in triage, diagnosis andtreatment guidelines, appropriate monitoring and follow upmay reduce case fatality and iatrogenic complications, thusreducing the burden of disease in society.2In Pakistan, data regarding the epidemiology ofchildren attending emergency rooms requiring resuscitationis virtually non existent. However few studies reported fromPakistan do indicate the burden of seriously ill and injuredchildren. A study conducted at the Children's Hospital inIslamabad over three months admitted 192 children withserious injuries.7 Another study in Karachi observed that1320 injured children were transported over a three yearperiod to hospitals by the main provider of emergencymedical transport.8 Similarly a study from Lahore reported346 cases of acute poisoning out of 37000 paediatricemergency room attendances in a five year period.9 Thesefigures extrapolated to the Pakistani population of under 18s(73 Million) are phenomenal.1General acceptance is critical that paediatricresuscitation skills are essential for everyone involved inproviding paediatric care. Only then can paediatricresuscitation skills be incorporated into the graduate andpost graduate medical curricula. Currently worldwide, successful educationalstrategies used in teaching and learning paediatric lifesupport are in the form of short intensive courses over oneto three days e.g. Paediatric Advanced Life Support (PALS)provider courses, concentrating on cardiac emergencies andAdvanced Paediatric Life Support provider courses (APLS)taking a wider view and teaching cardiac as well as noncardiac paediatric emergencies. These were introduced toteach resuscitation in a structured, universally acceptedapproach..  APLS/PALS type courses may be introduced butthe content of such training should be relevant to our localneeds.  IMCI has developed a guide with regard to the mostcommon presenting childhood illnesses in the developingworld.4 A study from Chandigarh, India, analysed 43800paediatric emergency room visits over six years, andhighlighted the variable epidemiology of childhoodemergencies.10 Comparison of such data reveals the coursecontent of the APLS to be valid in its entirety but certainalterations are required to be completely relevant to ourpopulation.The question remains as to how and who willimplement this.  There are two major considerations. Firstlyis the establishment of a central body, such as aResuscitation Council, to set standards and co-ordinate theprocesses.  Secondly, training needs to be made a statutoryrequirement for it to be taken seriously.  Establishing a resuscitation council is a Herculeantask. Such a council would not only oversee paediatricEditorialThe Need for Formal Paediatric Resuscitation Training in PakistanAdina R. Sheikh-Sajjad, Junaid A. RazzakDepartment of Paediatrics, Aga Khan University Hospital, Karachi.Vol. 58, No. 2, February 2008 51resuscitation training but also adult resuscitation. It wouldcomprehensively look over all the healthcare institutes withregards to providing an effective resuscitation service,ensure adequate training of the staff, and ensure appropriateequipment availability, financial planning, and continuedreappraisal of standards and protocols.Who would constitute this council? Representativesfrom the Ministry of Health, members dealing withemergencies from all major health care institutes (privateand public sector as well as the military establishments),representatives from  Pakistan Medical and Dental Counciland CPSP Pakistan.How would the council target the requiredpopulation? The established institute CPSP can enforce thislegislation to its postgraduates. For the remaining medicalpractioners, keeping in mind the limitations of medicalgraduates obtaining PMDC certification on the day ofgraduation and not all graduates receiving post graduationtraining, the task becomes complicated. The PMDC isslowly moving towards the introduction of ContinuousMedical Education (CMEs) for its registrants. Resuscitationtraining can become a part of this. Additionally, the PMDCwould have to intervene at the undergraduate level andestablish relevant resuscitation training as a part of themedical curriculum.The major question is the availability of funds. Costswill be incurred at every step from the establishment of thecouncil to the training and beyond. Governmental as well asexternal agencies will have to play a role.These efforts will be sustained by dedicatedclinicians and governmental and external agencies.However the common denominator is valuing itsimportance.   Critically ill and injured children are dying becausea substantial number of staff treating them have received noformal training in resuscitation.  These lives may be savedby our collective efforts.  The changes required needacceptance by all stakeholders including the government,governing and certifying bodies, health care institutionsboth private and public and most of all the doctors handlingthese very fragile lives.References:1. UNICEF- the State of the World's Children 2005,www.unicef.org/swoc05/english accessed May 2006.2. Razzak JA, Kellermann AL. Emergency medical care in developing countries:Is it worthwhile? Bull World Health Organ 2002; 80: 900-5.3. Hafeez A, Riaz R, Shah SU, Pervaiz J, Southall D. Integrating health care formothers and children in refugee camps and at district level. BMJ2004;328:834-6.4. Gove S. Integrated management of childhood illness by outpatient healthworkers: technical basis and overview. Bull World Health Organ 1997; 75: S7-24.5. Nolan T, Angos P, Cunha A, Muhe L, Qazi S,    Simoes EA, et al. Quality ofhospital care for seriously ill children in less developed countries. Lancet2001; 357:106-10.6. Duke T, Tamburlini G, Silimperi D. The paediatric Quality Care Group,Improving the quality of paediatric care in peripheral hospitals in developingcountries.  Arch Dis Child , 2003; 88: 563-5.7. Singer MS, Ghaffar A. Risk factors for road traffic injury in Pakistanichildren. J Coll Physicians Surg Pak 2004,14: 709-12.8. Razzak JA, Luby SP, Laflamme L, Chotani H. Injuries among children inKarachi, Pakistan--what, where and how. Public Health 2004;118:114-20.9. Hameed MH, Butt T Baloch GR, Maqbool S. Acute poisoning in children. JColl Physicians Surg Pak 2005, 15: 805-8.10. Singhi S, Jain V, Gupta G. Paediatric emergencies at a tertiary care hospital inIndia. J Tropi Pediatr 2003; 49:207-11.52 J Pak Med Assoc

The need for formal paediatric resuscitation training in Pakistan.

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The need for formal paediatric resuscitation training in Pakistan.

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