The United Nations adopted the eight Millenium
Development Goals (MDGs) in the year 2000 with the aim of global
development. MDG 4 specifically targets the reduction of childhood
mortality by two thirds by 2015. The Sustainable Development Goals
(SDGs) will replace the MDGs later in 2015; Goal 4 of the Draft SDGs is
to ensure healthy lives and promote the well being for all people of all
ages. The fact sheet by the World Health Organization (WHO) in 2013
reported 6.6 million deaths under 5 years of age globally. Most of these
deaths are from preventable causes, the leading ones being pneumonia,
prematurity, diarrhea, and malaria [1]. These statistics, unfortunately,
have not been showing much improvement, especially in low income,
developing countries. Primary prevention is certainly a strategy that
works but a large number of these patients require hospitalization.
An improvement in emergency hospital care
significantly reduces inpatient mortality rates. Clarke, et al.
[2] have demonstrated that an improvement in short term mortality can be
achieved by small changes including; a designated area for emergency
care, staff allocation to improve triage, the presence of simple medical
equipment such as pulse oximetry and thermometry, and training. WHO and
the United Nations Children’s Fund (UNICEF) have also incorporated a
strengthened emergency care in the concept of Integrated Management of
Childhood Illnesses [3]. However, Emergency medicine (EM) in India has
recently gained acceptance as a specialty. Currently there are 24
medical colleges that offer 48 MD seats in emergency medicine and are
recognized by the Government of India as per the Indian Medical Council
(IMC) Act. Additionally, there are 66 Diplomate of National Board (DNB)
seats of the National Board of Examination (NBE) in 20 accredited
hospitals for emergency medicine. The introduction of these programs has
created a momentum for development of academic standards, faculty
development, and accreditation standards for quality EM services in the
country. In contrast, pediatric emergency medicine (PEM) is still in its
infancy in India. This is not dissimilar to many countries that have an
unstructured approach to the evaluation of the ill and injured child.
Indeed, deficits in areas such as triaging, or managing disasters and
trauma along with prolonged waiting times in emergency departments (ED)
secondary to the lack of comprehensive emergency team services adversely
affect the outcomes of children requiring emergency management [4]. As
majority of the mortality occurs in the first 24-48 h of hospital
admission in the ED itself; it is imperative that efforts to strengthen
the pediatric emergency care infrastructure be pursued [5]. This white
paper aims to provide a status update on the the current state of PEM in
India and also suggests a model for establishing PEM largely based on
what is currently being practiced in the USA.
Pediatric Emergency Care: Indian Scenario
The pediatric ED in India is not an ED in the true
sense. An initial study from a leading pediatrics center in Northern
India showed that fever was the most common presenting complaint and
upper respiratory tract infection and acute gastroenteritis were the two
most common illnesses that required an ED evaluation [6]. Residents in
the pediatric ER screen all the patients and manage minor illnesses as
well; however, they are overburdened in a majority of instances. There
are substantial gaps in; (a) the prehospital arena including lack
of adequately trained ambulance personnel and appropriately equipped
ambulances, (b) inadequate in-hospital triage systems, (c)
lack of formal training in the evaluation and management of pediatric
trauma leading to a lack of skilled medical personnel including nursing
and other support services, and (d) availability of
evidence-based patient management protocols.
Prehospital Services in India
The medical system in India constitutes a multitude
of private and public sector organizations that are managed at different
levels; however, the coordination within the system is lacking. The
emergency transport system of patients is mostly by private vehicles
ranging from bullock carts to autorickshaws to cars and patients are
often transported by family members or relatives [7]. Roads are often
congested, which adds to the delay in accessing hospital services. Thus,
the basic tenets of managing the ABCs, i.e., airway, breathing,
and circulation of patients in an acute emergency is delayed. Verma,
et al. [8] reported an average delay of 168 min (~3 h) in
reaching the trauma facility. Most of these children were accompanied by
their fathers, or both the parents, and not by any trained prehospital
transport team. Few states at present have their centralized emergency
ambulance system, e.g. Delhi, the capital of India, has
Centralized Accident and Trauma Services (CATS) but the number of
ambulances are inadequate to meet the current demand and many of the
ambulances do not have the age-appropriate equipment. Furthermore,
prehospital services vary substantially among different states and do
not have a universal phone number. The basic principle of transport,
i.e., transport of the "right patient to the right hospital" is
often not followed and as a result, patients arrive at a place where
appropriate facilities are unavailable. This is especially true for
trauma victims, both adult and pediatric.
Ramanujam, et al. [9] reported that half of
the trauma victims reporting to the ED actually received no prehospital
care. Pallavisarjii, et al. [10] in their study from Southern
India documented the lack of adequate skills among laypersons, including
police, taxi drivers, and primary and middle school teachers, to handle
an emergency although most of them revealed a willingness to learn these
skills. Roy, et al. [7] suggested training informal service
providers who exist such as traffic police and taxi drivers in
prehospital emergency medical service (EMS). Joshi, et al. [11]
emphasized the need of Integrated Emergency Communication Response
Service in India and proposed a model for development in the country.
Hospital Emergency Care System
Most of the pediatric emergencies, including
tertiary-care teaching hospitals, are managed by pediatric residents who
are trained in pediatric medical care that often excludes trauma
training. Many of these pediatric providers are overburdened and
simultaneously manage non-emergent conditions such as upper respiratory
infections and acute gastroenteritis without dehydration [6]. Dedicated
triage teams are unavailable in pediatric ED. As a result, the
management of sick patients is delayed, thus adversely affecting the
outcome. According to a systematic review by Rowe, et al. [12],
Triage Nurse Ordering was an effective intervention in mitigating
overcrowding in ED and it reduced the length of stay in the ED
substantially [12]. Triaging is especially important in the context of
mass casualties and disasters. Quick survey using Pediatric Assessment
Triangle (PAT) from Pediatric Advanced Life Support guidelines can be
used to identify life-threatening illnesses. Combination of certain
simple clinical signs can identify hypoxemia in an emergency and help in
prioritizing patients [13]. The availability of simple bedside tests
such as pulse oxymetry can be a useful and cost-effective adjunct to
improve emergency care [14]. Certain clinical scores such as "signs of
inflammation in children that kill (SICK)," and "temperature, oxygen
saturation, pulse rate, respiratory rate, saturation and seizures
(TOPRS)" have been validated in Indian children and used for the purpose
of triaging [15,16].
Pediatric Disaster Management
Large volumes of incoming patients involved in
natural disasters such as earthquakes and tsunamis or unnatural
disasters such as terrorist attacks can immediately overwhelm even the
most advanced and resourced setting. Children are likely to suffer even
more for multiple reasons: Children may arrive unaccompanied,
inexperience of the staff in the pediatric emergency setting, inadequate
infrastructure including equipment, the need for subspecialists such as
dedicated trauma surgeons, orthopedicians, burn specialists, and
pediatric residents who are the first line providers and who often have
no experience in these specialties and hence, no exposure to handle
these situations. The International Pediatric Association (IPA) started
"training of trainers" on a worldwide level with the aim to manage
children during disasters. The Indian Academy of Pediatrics formed a
National Task Force on "Child at Risk" and the first report by the
"Disaster Management Committee" was published in the year 2005. It
emphasized the coordinated efforts of the government, along with
nongovernment agencies (NGOs), the Red Cross, armed forces,
international agencies, UNICEF, etc [17,18]. This was the first
ever effort from India in the field of disaster management; however,
further efforts in this direction are urgently needed.
USA Model of PEM Training Program
Since the recognition of PEM as a separate field in
pediatrics and EM in the 1980s, fellowship programs have evolved and
continue to evolve both in terms of the structure and quality in which
PEM training is conducted. Many EM programs were established prior to
that decade yet none devoted more than 8 weeks of training for pediatric
surgical and medical emergencies, which was considered as the weakest
link [19]. As the programs were gradually established, core competencies
evolved within a decade to address the needed skills to complete the
requirements for this nascent specialty [20-22]. Residency graduates
from pediatrics or EM training programs in the USA are eligible to apply
for PEM fellowship, with clearly defined difference in duration of
training and requirements for scholarly activities to successfully
achieve fellowship completion. In 1990, the American Board of Emergency
Medicine (ABEM) and the American Board of Pediatrics (ABP) sought the
approval of the American Board of Medical Specialties (ABMS) to
recognize PEM as a subspecialty requiring independent certification. The
request was granted in 1991 and the first exam was conducted in 1992
[23,24]. In 1998, PEM became a fully accredited training course by the
Accreditation Council of Graduate Medical Education (ACGME) that shaped
the final outlook of a three year training program that included a
mandatory 1-year research component for pediatricians. However,
applicants from EM residency programs have a 2-year training program
compared to the 3 years for pediatric residency-trained applicants.
Fellowship programs (if accepting fellows from both boards) are required
to establish two separate formal curricula to address the differences in
training experience [25]. ACGME also defined the program role, faculty
responsibility, and facility requirements in creating an environment
that would help the trainees to achieve their educational goal. These
steps helped to develop the scope of training and create its goals and
objectives that are being implemented in many training programs in the
USA at present.
Rotations
Clinical rotations have gone through many iterations
and multiple revisions to help create the ideal experience for trainees
to acquire the needed knowledge, experience, and ability to manage
children in acute care settings [22]. The clinical experience includes
four main domains (teaching, consulting, administrative, and research
training) that fellows in PEM are exposed to, through the three years of
training. Research training and clinical pediatric ED are in the form of
12 one-month blocks spread throughout training to meet the required
educational experience.
Other rotations are scheduled and planned to address
the much-needed exposure (when available) to medical and surgical
subspecialties (anesthesia, adult emergencies, orthopedic surgery,
pediatric intensive care, EMS, pediatric radiology, toxicology, trauma,
ultrasound, administration and risk management). Although different
programs vary in their structure and design they all share a common core
of essential rotations in trauma, orthopedic surgery, pediatric ED,
anesthesia, intensive care, EMS, and adult emergencies. Furthermore,
programs require fellows to be certified in Advanced Trauma Life Support
(ATLS), Neonatal Advanced Life Support (NALS), Pediatric Basic (PBLS),
and Advanced Life Support (PALS).
Pediatric Emergency Services in the USA
The need for prehospital care was first recognized
with a joint landmark report in 1966 when the National Academy of
Science (NAS) and the National Research Council (NRC) highlighted trauma
as the leading cause for disability and death for persons 1-37 years of
age in the USA [26]. Prior to that report, ambulance services were
inconsistent, privately-owned, and lacked appropriate equipment and
training specifically designed to meet pediatric demands. During the
1970s, the EMS system grew to its general form with increasing national
awareness of the benefits of reducing morbidity and mortality of the
adult population. The Emergency Medical Service Systems Act of 1973
changed the shape of medical practice by recognizing this need for
developing comprehensive, area-wide emergency medical systems that are
well-funded and well-connected [27]. This law also mandated the
development of local plans and provided funding for the initial
establishment of operational systems, the conduct of research in
emergency medical techniques and devices, expansion of acceptable
existing systems, creation of adequate communications systems, and the
providing of appropriate education for emergency medical personnel. By
the 1980s, the system realized the gap of care for children when Seidel,
et al. [28] published that needs of children in prehospital
settings were not met that potentially contributed to higher mortality
rates when compared to adults. Within the same period, curricula were
established to train EMS personnel in pediatric care and pediatric
surgeons took the lead in establishing specialized prehospital trauma
care for children. These steps have helped shape the initial steps in
creating regional EMS systems for the decades that followed and the
Institute of Medicine (IOM) published its report on prehospital and
hospital care for children that provided some insight of the current
shortfalls in the system [24]. Finally, the current system recognizes a
multilevel of care tailored to the individual needs of the children
transported (first responders, emergency medical technician (EMT)–basic,
EMT–intermediate, EMT–paramedic). Each of these levels exercise
different abilities and equipments that are essential to manage the
target population referred by the central command of the regional EMS
system. Despite all these steps, the current system still needs
improvement of coordination between hospitals and prehospital care,
improvement of disaster preparedness, and the establishment of an
evidence-base for assessing as to how the specialty is evolving to meet
the current needs.
Pediatric Emergency Training Program in India
Current lacunae in pediatric emergency care
underscore the need for incorporation of PEM training program in our
medical education and training system. The Medical Council of India
(MCI) has already recognized a 3-year MD course in EM in 24 medical
colleges across the country. Children are physiologically,
developmentally and emotionally, substantially different from adults and
it is increasingly being recognized that providers need to be trained to
meet those special needs. We are about to have MCI-recognized
postgraduate degree and diploma courses in pediatric emergency medicine.
It is imperative that a well structured postdoctoral superspecialty
training program in pediatric EM is developed to enhance the emergency
care for India’s children.
Current Training in India
Comprehensive management of the patient and taking
care of surgical, orthopedic, ophthalmologic, otolaryngologic,
dermatologic, and gynecological emergencies in pediatric ED are lacking.
No consideration is given to the child’s psychiatric and psychological
needs in the ED. Specialists are usually on call and attend pediatric
patients only when called – this adversely impacts care due to lack of
access to adequately-trained subspecialists. Expertise and skills
related to basic life- and limb-saving procedures such as the use of and
access to alternate emergency airways, foreign body removal,
thoracostomy, suturing, and splinting, to name a few, are not being
taught. Defined protocols for standardized evidence-based evaluation,
management, and disposition of children treated in EDs are lacking.
Preparedness for multiple casualties and disasters is another domain
that is under-emphasized and hence, under-resourced with many
institutions being under-prepared.
Academic Model for Pediatric Emergency Training in
India
After the initiation of MCI recognized residency
programs in the discipline of EM (MD in EM), it is essential for the MCI
to recognize the need for a superspecialty in PEM. Rising patient volume
in pediatric emergency centers across the country re-emphasizes the
importance of starting DM and DNB programs (3 years, including
examination) in PEM in recognized medical colleges and hospitals. Such
institutions with diverse and high-volume patient population are the
ideal sites in India for initiating DM programs in PEM.
The Academic College of Emergency Experts in India
(ACEE INDIA) is an INDO-US Emergency and Trauma Collaborative initiative
that has started a 1-year capacity-building training program in PEM,
with the objective of introducing the concepts of PEM for those
providers who may be interested in pursuing PEM as a career. The
essential qualification for this program is MD/DNB in Pediatrics, MD/DNB
in EM or a Fellow of ACEE INDIA. The College is actively working toward
its vision of starting DM and DNB in PEM. The Joint Working Group of
ACEE INDIA proposes the guidelines for development of such a program. A
MD/DNB program in PEM should have the following components:
• Knowledge – Imparted though departmental
teaching activities such as seminars, lectures, journal clubs, and
self directed learning
• Clinical skills – Imparted through the
apprentice model and rotational postings in different disciplines
• Communication skills – Imparted though formal
trainings and rotational postings in day-to-day practice
• Undertaking research by undertaking thesis –
Protocol writing in the first year, research and thesis completion
in the second year
• Encouraging publication of research work
• Scholarship and excellence in professional
work.
Eligibility Criteria
It has been proposed that a medical graduate who has
completed a 3-year course of MD/DNB in Pediatrics or MD/DNB in EM shall
be eligible for DM or DNB course in PEM [29].
Core Curriculum and Rotations
The accredited programs should develop specific
residency rotations and predefined aims and learning objectives.
Suggested core content for the residency program has been given in
Table I. The curriculum should be directly influenced by the
epidemiology of pediatric emergencies in India. For instance, the
toxicology curriculum will need to focus on locally prevalent ingestions
such as organophosphates and hydrocarbons (kerosene) rather than
tricyclic antidepressants, which are more common in the USA. Infectious
diseases, which constitute a large and diverse volume in children should
have a tropical perspective. Pediatric trauma and unintentional
injuries, largely a neglected domain, constitute a huge burden of
morbidity and mortality [30]. The rotations should include residency
training in trauma and pediatric surgery wards and the gaining of
expertise in managing various trauma mechanisms such as motor vehicle
crashes, falls, and blunt and orthopedic injuries. Burns and
electrocution injuries are also common in both urban and rural settings;
hence, rotations should include burns and plastic surgery wards too
[31,32]. Adolescents are a specialized group of the population who have
different needs altogether. Gynecological problems in females as well as
sexually transmitted diseases and psychiatric and psychological problems
need to be recognized; hence, a rotation in the departments of
Obstetrics and gynecology and Psychiatry becomes mandatory. Child
maltreatment and sexual abuse are prevalent in society and often go
unrecognized in pediatric emergencies [33]. Sensitization of pediatric
emergency residents to these conditions and rotation in psychiatry
medicine also need to be incorporated in the curriculum.
TABLE I Suggested Disciplines in Pediatric Emergency Curriculum
Adolescent OPDs* and wards |
Orthopedics |
(or medicine OPDs and wards) |
Otorhinolaryngology |
Anesthesia |
Pain clinic |
Burns |
Pediatric Cardiology |
Dermatology and Venereology |
Pediatric Emergency |
Disaster wards (if available) |
Department |
Forensic Medicine |
Pediatric Intensive Care |
Infectious Diseases |
Pediatric Nephrology |
Gastroenterology |
Pediatric Surgery |
Neurosurgery |
Psychiatry |
Obstetrics and Gynecology |
Radiology |
Ophthalmology |
Trauma |
|
Toxicology |
*OPDs: Outpatient departments |
TABLE II Suggested Rotations for a 3-Year Residency Program
First year |
Second year |
Third year |
Pediatric ED* (3 mo) |
PICU** (2 mo) |
Obstetrics and gynecology (1 mo) |
Labor room (1 mo) |
Orthopedic trauma (2 mo) |
Neonatology (1 mo) |
Anesthesia (2 mo) |
Pediatric surgery (2 mo) |
Pediatric ED (5 mo) |
Neonatology (2 mo) |
Ophthalomology (1 mo) |
Elective posting (2 mo) |
PICU (2 mo) |
Otolaryngorhinology (1 mo) |
Psychiatry (1 mo) |
Forensic (1 mo) |
Burns (1 mo) |
Radiology (1 mo) |
Dermatology and VD*** (1 mo) |
Adult casualty (1 mo) |
Disaster wards (1 mo) |
|
Pediatric ED (2 mo) |
|
*ED: Emergency Department; **PICU: Pediatric intensive care
unit; ***VD: Venereal Diseases. |
The 3-year curriculum in PEM should include rotations
in various departments as shown in Table II. Specific
objectives need to be developed and validated for each rotation. A few
examples of these objectives are depicted in Table III. An
objective evaluation of skills should be required in the form of
maintainence of a procedure "logbook" for all trainees. Along with a
record of participation in the teaching activities in the department,
presentations made, case-record mainte-nance, procedures learnt and
performed, counseling skills and the right attitude toward patients and
relatives should be kept. Table IV gives the description
of the topics that need to be incorporated in PEM DM curriculum. The
core text book for PEM should be Fleisher and Ludwig’s Textbook of
Pediatric Emergency Medicine. Apart from this, Tintinalli’s
Textbook of Emergency Medicine, and Goldfrank’s Toxicologic
Emergencies should be used as reference books. However, these will
need to be supplemented with other pertinent texts, especially those
written for Indian conditions.
TABLE III Objectives in Various Rotations
Anesthesia |
Orthopedics |
Learn airway management; Drugs during various procedures |
Learn splinting and immobilization, Suspect and manage
|
and intubation; Pain management |
common pediatric fractures |
PICU |
Surgery |
Develop expertise in putting various lines; Learn initiation of
ventilation; Management of electrolyte emergencies |
Learn suturing; Identify common surgical emergencies such as
intussusceptions, peritonitis, and perforation |
Forensic |
Obstetrics and Gynecology |
Common poisonings, bites, and stings prevalent in that area |
Management of teenage pregnancy, ectopic pregnancy, and sexually
transmitted diseases |
Radiology |
Neurosurgery and Neurotrauma |
Ultrasound (add-on training in emergency and ICU*) |
Management of head trauma, raised intracranial tension, and
shunt complications |
*ICU: Intensive care unit. |
TABLE IV The 3-Year Curriculum for PEM DM Training Program
Neonatal Advanced Life Support Guidelines |
Anaesthesia, analgesia, and sedation |
Pediatric Advanced Life Support Guidelines |
Mechanical ventilation in ED |
Advanced Trauma Life Support Guidelines |
Transport of sick patient |
|
Biological and chemical warfare and terrorism |
Symptom-based approach |
General |
Nervous system |
Pallor |
Seizures |
Cyanosis |
Syncope |
Lymphadenopathy |
Coma |
Jaundice |
Weakness |
Petechiae |
Ataxia |
Rashes |
Headache |
Edema |
Renal |
Fever |
Oligura |
Gastrointestinal |
Dysuria |
Abdominal pain |
Hematuria |
Abdominal distension |
Endocrine |
Diarrhea |
Polyuria |
Dehydration |
Polydyspsia |
GI bleed |
Orthopedic |
Respiratory |
Trauma |
Sore throat Cough |
Joint swelling |
Wheezy child |
Joint pain |
Respiratory distress |
Ophthalmic |
Apnea |
Red eye |
Cyanosis |
Eye discharge |
Chest pain |
Eye pain |
Cardiovascular |
Squint |
Palpitatiopns |
ENT* |
Murmers |
Hearing loss |
Hypertension |
Ear pain |
Gynecologic |
Miscellaneous |
Vaginal bleeding |
Foreign body |
Vaginal discharge |
Shock |
Oligomenorrhea and polymenorrhea |
|
System-wise emergencies |
Abdominal emergencies |
Neurologic emergencies |
Adolescent and gynecologic emergencies |
Neurosurgical emergencies |
Bites and toxins |
Orthopediac emergencies–– |
Burns |
Nontraumatic |
Cardiac emergencies |
Orthopedic emergencies–– |
Child abuse |
Traumatic |
Dermatologic emergencies |
Oncologic emergencies |
Dental emergencies |
Ophthalmologic emergencies |
Electrolyte abnormalities |
Otolaryngologic emergencies |
Environmental emergencies |
Psychiatric emergencies |
Hematology emergencies |
Psychologic emergencies |
Infectious diseases |
Respiratory emergencies |
Metabolic emergencies |
Renal emergencies |
Minor injuries |
Surgical emergencies |
Musculoskeletal trauma |
Transplant emergencies |
Neonatal emergencies |
Thoracic emergencies |
|
Urologic emergencies |
*ENT: Ear, nose, and throat |
Research
Research in the form of thesis should be a mandatory
requirement for partial fulfillment of the DM course. Apart from that,
acceptance or publication of at least one paper in journals and one
presentation in conference should be part of the eligibility criteria
for appearing in the examination. This is being done for MD courses too.
Setting of such high academically-oriented standards will help future
emergency pediatricians to have the aptitude of research [34,35].
Faculty/Staff
A minimum of three faculty members, namely, a
professor, an associate professor, and an assistant professor would be
required for starting the DM program. A similar staff and academic
criteria need to be evolved for DNB program. Since the specialty is
still in the evolving stage, special consideration may be given with
regard to the qualification for the faculty posts, e.g., for the
post of Assistant Professor, 3 years of post-PG experience out of which
2 years in managing pediatric emergencies from a recognized medical
college should suffice. Detailed guidelines for each post need to be
adopted keeping in view the roadmap for program development.
Faculty development should include exchange programs
with established centers in the developed world and distance learning by
telemedicine and teleconferencing. INDO-US Emergency and Trauma
Collaborative provides an excellent opportunity for pediatricians who
wish to establish and pursue PEM in the public and private sectors as
exchange programs.
Infrastructure
Bed strength
As per the existing norms of recognition to start a
DM program, a pediatric emergency unit with a minimum of 20 beds should
be available for PEM.
Equipment
Table V gives a comprehensive list of
the equipments needed in a setup providing DM course in PEM for the
purpose of patient care, training, and research.
TABLE V List Of Equipments in Pediatric Emergency Medicine
Total beds 20, including 6 ICU* beds |
Drug crash carts 4 |
Central oxygen and suction 20 |
Syringe pumps 20 |
Vital sign monitors 7 |
Phototherapy machine 1 |
Central monitor connected to 6 beds |
Open care resuscitation trolley 1 |
Defibrillator 1 |
Endotracheal tubes of all sizes |
Ventilators 6 (2 neonatal and 4 pediatric) |
Ambubags 10 |
Bubble CPAP** 2 |
Laryngoscopes with pediatric and neonatal blades 10 |
Transport ventilator 1 |
Broselow pediatric emergency tape 10 |
Portable pulse oxymeters 3 |
Chest tubes of all sizes |
Portable x-ray machine 1 |
Central lines of all sizes |
Portable ultrasound machine with pediatric ECHO*** probe 1 |
Cervical collars |
Point of care arterial blood gas and electrolytes machine
1 |
Spine boards |
Ultrasonic nebulizers 4 |
Splints |
Portable suction machine 2 |
Glucometers with compatible glucosticks |
Resuscitation trolley 2 |
Essential drugs |
|
Infant warmers 3 |
*ICU: Intensive care unit; **CPAP: Continuous positive
airway pressure; ***ECHO: Echocardiogram. |
Mandatory Courses and Skills
As ED is constantly dealing with sick patients, the
development of resuscitative skills becomes important. Certification in
Neonatal Advanced Life Support (NALS), Pediatric Advanced Life Support
(PALS), Advanced Trauma Life Support (ATLS), and Advanced Cardiac Life
Support (ACLS) should be a mandatory part of the training program.
Equivalent courses from India Neonatal Resuscitation Program by the
National Neonatology Forum of India, Indian Academy of Pediatrics –
Advanced Life Support should be recognized for the residency program.
During their rotations in the concerned specialties, PEM residents
should receive training in skills such as airway management, vascular
access, wound management, incision and drainage, foreign body removal,
and suturing and splinting. Table VI enlists the
competencies that a DM candidate pursuing the training should acquire
during his or her 3-year training program. Ultrasound in emergency, a
noninvasive bedside test, is a useful adjunct for airway management,
central line placement, identification of fluid and air in various
cavities requiring emergency management such as the pneumothorax,
pericardial tamponade, and hemoperitoneum [36-38]. A few standardized
courses are available in India, and collaboration with such skill
schools is needed to provide training in ED ultrasound for establishing
the diagnosis and performing therapeutic procedures.
TABLE VI Procedural Skills In Pediatric Emeregency Medicine
Neonatal resuscitation |
Pleural tap and chest tube insertion |
Pediatric resuscitation |
Pericardiocentesis |
Resuscitation in trauma victim |
Lumbar puncture |
Management of basic and advanced airway |
Focus abdominal sonography for trauma |
Central venous line insertion |
Topical anasthesia and direct wound Infitration |
Arterial line insertion |
Suturing |
Peripherally inserted central line |
Splinting of musculoskeletal Injuries |
Umbilical venous catheterization |
Close reduction of dislocations |
Intraosseous line |
Zipper injury management |
Defibrillation/cardioversion |
Reduction of torted testes |
Foreign body removal (ear, nose) |
Reduction of nursemaid elbow |
Hair tourniquet removal |
Incision and drainage (abscess, paronychia, and felon)
|
Removal of rings |
Drainage of subungual hematoma |
Nasogastric tube placement |
Drainage of septal hematoma, nasal packing |
Gastric lavage |
Fundus examination |
Bladder catheterization suprapubic bladder Aspiration
|
Interpretation of x-rays, ECG*, CT** scan, |
Reduction of incracerated inguinal hernia |
and MRI*** |
Rectal prolapse |
Transportation of sick patients |
Evaluation of VP**** shunt |
|
*ECG: Electrocardiogram; **CT: Computed tomography; ***MRI:
Magnetic resonance imaging; ****VP: Ventriculoperitoneal. |
Assessment
Formative assessment should be carried out during the
three years of training program, which should be made a part of internal
assessment. Summative assessment of both theory and clinical practice
should be done at the end of 3 years. The grading or marking system may
be used for successful completion of the course.
Theory examination should consist of three question
papers. These should be:
• Paper I: Basic Sciences as applied to
PEM
• Paper II: Systemic PEM (abdominal,
gastrointestinal, respiratory, cardiac, renal, and endocrinologic
emergencies)
• Paper III: Systemic PEM (orthopedic,
ophthalmic, ear, nose, and throat (ENT), surgical, hematologic,
oncologic, phychiatric, and behavioral emergencies).
The distribution of these three papers may be made on
organ systems and procedures/highly focused areas only. In each paper,
10% weightage may be given to recent advances.
The practical examination should have:
• Objective structured clinical examination
(OSCE)
• Cases (four).
Cases should focus on communication, management, and
demonstartion of clinical skills so as to examine all the four domains
of education.
The practical examination should incorporate
assessment tools that offer high reliability and validity.
• Tables with viva voce on procedures,
instruments, x rays, electrocardiogram (ECG), arterial blood gases,
and clinical photographs
• Procedures on simulators.
Assessors
A minimum of four examiners with experience of
imparting teaching, training, and assessment of postgraduates in EM and
pediatric emergencies from MCI/NBE recognized colleges should be
assessing the candidate. Ideally, all examiners should have prior
exposure and formal training in the assessment tools. As it is a new
specialty, qualified faculty might not be available in the initial
years; efforts be made to create a pool of examiners/assessors with 8
years of post-PG standing in teaching and training and in imparting
formal training in assessment.
Key Recommendations
The Joint Working Group of the Academic College of
Emergency Experts in India (JWG ACEE INDIA) proposes the following
recommendations to start MCI recognized DM/DNB course in PEM in India.
The aim is to produce trained and skilled pediatric emergency physicians
to provide the standard of care that is at par with the Western world
and to improve overall childhood mortality and morbidity.
• PEM should be recognized as a superspecialty as
per provisions of the Indian Medical Council Act and a 3 year MD/DNB
program in PEM should be started in recognized medical colleges and
institutes
• MD/DNB pediatrics or MD/DNB in EM should be
considered as an essential qualification to be eligible for this
course
• A 20-bedded pediatric emergency unit should be
earmarked where resuscitation and treatment of sick patients may be
carried out
• Faculty requirement should be a minimum of
three faculty members, namely, a professor, an associate professor,
and an assistant professor for starting a PEM MD/DNB program
• Since the faculty fulfilling the mandatory
teaching requirement may not be available in the initial stages,
relaxation may be given to begin with. For example, 3 years of
post-PG experience out of which 2 years in managing pediatric
emergencies from a recognized medical college should suffice for the
post of Assistant Professor
• Faculty should be a fulltime faculty dedicated
to pediatric ED
• Adequate infrastructure and equipment as
enlisted should be available for starting the course
• Residents pursuing DM course in PEM should have
a defined rotational plan to have an exposure to all the related
specialties
• Residents should acquire the mandatory
procedural skills and a logbook should be maintained by the
department for the same
• To promote research among residents, thesis
should be a mandatory requirement toward fulfilling the DM/DNB
course
• Assessment of theoretical as well as clinical
skills should be done by at least three formative assessments during
the residency training and a final summative assessment at the end
of three years by a panel of assessors.
Conclusion
The Academic College of Emergency Experts in India
(ACEE-INDIA) is working incessantly to strengthen EM training in India.
The MCI has recognized MD in EM as a specialty and now, it is time to
move a step ahead. The Joint Working Group of ACEE INDIA proposes to
start DM/DNB course in PEM as superspecialty in MCI-recognized medical
colleges. Through this paper, a structured curriculum has been provided
to start such a course so that well-trained, competent, and skilled
pediatric emergency physicians are produced who can manage all the types
of pediatric emergencies.