Child Death in a Resource-Limited Setting: A Simulation Case for Pediatric Residents to Prepare for Global Health Electives.

Introduction: Pediatric residents are increasingly pursuing global health electives. Differences in cultural norms and management around pediatric deaths in resource-limited settings can be emotionally overwhelming for residents. Educational resources are needed to better equip them for handling these stressful situations. We developed a predeparture simulation child death case to prepare pediatric residents for their global health elective. Methods: The simulation module included a clinical case followed by a multidisciplinary structured debriefing. The case featured a 5-year-old, malnourished child in hypovolemic shock who clinically deteriorates and dies. After obtaining a history and performing a physical examination, residents were expected to diagnose severe malnutrition, treat hypovolemic shock, and decide how far to extend resuscitation with the limited resources. Upon returning from abroad, residents were invited to complete a survey on the utility of the simulation case module in preparing for their elective. Results: Twenty-nine residents participated in the simulation case module, and 18 completed the survey. Seventeen agreed or strongly agreed that the simulation module was a useful tool for preparation (Mdn = 4.5 on a 5-point Likert scale). Residents reflected that the simulation module helped manage expectations and provided them with an understanding of the cross-cultural differences in managing pediatric deaths in a resource-limited setting. Discussion: Pediatric residents trained in resource-rich countries do not encounter death often. Postgraduate training programs could consider simulations like this one to prepare such residents for cross-cultural differences in managing pediatric deaths and build resiliency to operate in resource-limited settings.

Recognition and Management of Pediatric Sepsis in a Resource-Limited Emergency Department in Mwanza, Tanzania: A Qualitative Study.

OBJECTIVE: The World Health Organization aims to reduce worldwide under-five mortality rates (U5MR), with a focus on resource-limited settings (RLS). Tanzania reports a mean U5MR of 54 per 1000 live births, largely due to treatable infectious diseases that may lead to sepsis, accounting for 40% of the under-five deaths. Bugando Medical Centre in Mwanza, Tanzania represents a resource-limited setting in Sub-Saharan Africa and estimates a 14% pediatric mortality rate. We sought to better understand provider experience in recognizing and managing pediatric sepsis in the emergency department (ED) at Bugando Medical Centre in Mwanza, Tanzania. METHODS: We conducted a qualitative study with a purposive sampling of 14 Bugando Medical Centre ED providers from January to February 2019, via minimally structured interviews, to identify factors influencing the recognition and management of children presenting to the ED with concern for sepsis. Interviews were conducted in English, audio recorded, and transcribed. Data saturation determined the sample size. Three primary coders independently coded all transcripts and developed an initial coding list. Consensus among all authors generated a final coding scheme. A grounded theory approach guided data analysis. RESULTS: We achieved thematic saturation after 13 interviews. Responses identified patient-, provider-, and health care system-related factors influencing sepsis recognition and management in children presenting to the ED. Patient-related factors include the use of traditional healers, limited parent health literacy, and geographic factors impacting access to medical care. Provider-related factors include limited knowledge of pediatric sepsis, lack of a standard communication process among providers, and insufficient experience with procedural skills on children. Health care system-related factors include limited personnel and resources, delayed transfers from referral hospitals, and lack of standard antibiotic-use guidelines. CONCLUSIONS: This qualitative study identified patient, provider, and health care system-related factors that influence the emergency care of children with suspected sepsis in a quaternary hospital in Mwanza, Tanzania. These factors may serve as a framework for educational opportunities to improve the early recognition and management of pediatric sepsis in a resource-limited setting.

An International Virtual Classroom: The Emergency Department Experience at Weill Cornell Medicine and Weill Bugando Medical Center in Tanzania.

Emergency medicine (EM) is rapidly being recognized as a specialty around the globe. This has particular promise for low- and middle-income countries (LMICs) that experience the largest burden of disease for emergency conditions. Specialty education and training in EM remain essentially an apprenticeship model. Finding the required expertise to educate graduate learners can be challenging in regions where there are low densities of specialty providers.We describe an initiative to implement a sustainable, bidirectional partnership between the Emergency Medicine Departments of Weill Cornell Medicine (WCM) in New York, NY, USA, and Bugando Medical Center (BMC) in Mwanza, Tanzania. We used synchronous and asynchronous telecommunication technology to enhance an ongoing emergency medicine education collaboration.The Internet infrastructure for this collaboration was created by bolstering 4G services available in Mwanza, Tanzania. By maximizing the 4G signal, sufficient bandwidth could be created to allow for live 2-way audio/video communication. Using synchronous and asynchronous applications such as Zoom and WhatsApp, providers at WCM and BMC can attend real-time didactic lectures, participate in discussion forums on clinical topics, and collaborate on the development of clinical protocols. Proof of concept exercises demonstrated that this system can be used for real-time mentoring in EKG interpretation and ultrasound technique, for example. This system was also used to share information and develop operations flows during the COVID-19 pandemic. The use of telecommunication technology and e-learning in a format that promotes long-term, sustainable interaction is practical and innovative, provides benefit to all partners, and should be considered as a mechanism by which global partnerships can assist with training in emergency medicine in LMICs.

Impact of Enteroviral Polymerase Chain Reaction Testing on Length of Stay for Infants 60 Days Old or Younger.

OBJECTIVE: To determine the impact of a cerebrospinal fluid enterovirus polymerase chain reaction (PCR) test performance on hospital length of stay (LOS) in a large multicenter cohort of infants undergoing evaluation for central nervous system infection. STUDY DESIGN: We performed a planned secondary analysis of a retrospective cohort of hospitalized infants ≤60 days of age who had a cerebrospinal fluid culture obtained at 1 of 18 participating centers (2005-2013). After adjustment for patient age and study year as well as clustering by hospital center, we compared LOS for infants who had an enterovirus PCR test performed vs not performed and among those tested, for infants with a positive vs negative test result. RESULTS: Of 19 953 hospitalized infants, 4444 (22.3%) had an enterovirus PCR test performed and 945 (21.3% of tested infants) had positive test results. Hospital LOS was similar for infants who had an enterovirus PCR test performed compared with infants who did not (incident rate ratio 0.98 hours; 95% CI 0.89-1.06). However, infants PCR positive for enterovirus had a 38% shorter LOS than infants PCR negative for enterovirus (incident rate ratio 0.62 hours; 95% CI 0.57-0.68). No infant with a positive enterovirus PCR test had bacterial meningitis (0%; 95% CI 0-0.4). CONCLUSIONS: Although enterovirus PCR testing was not associated with a reduction in LOS, infants with a positive enterovirus PCR test had a one-third shorter LOS compared with infants with a negative enterovirus PCR test. Focused enterovirus PCR test use could increase the impact on LOS for infants undergoing cerebrospinal fluid evaluation.

Magnetic Foreign Body Ingestions.

Magnets are inherently attractive to young children, but present a risk when ingested. If consumed alone, small, smooth magnetic foreign bodies are likely to pass without significant event; however, ingestion of multiple magnets may have catastrophic consequences, including bowel perforation, obstruction, peritonitis, and death. Increasing reports of morbidity and mortality in recent years from the US National Electronic Injury Surveillance System has led to numerous safety statements from the American Academy of Pediatrics and the Centers for Disease Control and Prevention, as well as several product recalls from the Consumer Product Safety Commission. This article presents the background and mechanism of injury of magnet ingestion, as well as recommended management and potential complications. We also review current legislation and opportunities for further patient advocacy regarding this polarizing problem.

Management Of Headache In The Pediatric Emergency Department.

Headaches are a common complaint among children, with increasing frequency in adolescence. According to the Agency for Healthcare Research and Quality, more than 3 million Americans seek emergency care every year due to headaches, and one-third of them are attributable to migraines. Headaches have a significant impact on the lives of children and adolescents, resulting in school absence, decreased extracurricular activities, and poor academic achievement. Among patients, the spectrum of pathology varies widely, continually challenging healthcare providers to recognize serious, life-threatening conditions, while judiciously evaluating and treating all patients. This issue reviews the broad differential of primary and secondary headaches in the pediatric emergency department, summarizes effective strategies for diagnosis, and evaluates the current evidence supporting safe, appropriate treatment. As emergency clinicians treat increasingly more medically complex patients, they should be aware of the best current practices to evaluate and treat headaches in the pediatric population.