DIE KINDER

“There can be no keener revelation of a society’s soul than the way in which it treats its children.” Nelson Mandela, Former President of South Africa

A few years ago while working in the outpatient department I attended to a four-year-old who had presented for a surgical review. He had been discharged about a week prior to having undergone surgery to create a temporary colostomy stoma. This was after presenting with sepsis secondary to a ruptured appendix. Further discussions with his surgeon revealed that the child had been presenting to different ERs with severe abdominal pain and would always be discharged with analgesics and at times even dewormers. It had been unclear in all those visits that he maybe suffering from an acute abdomen and by the time it was being identified his abdomen was taut, very tender and he was in septic shock. Maybe it is just me but in my years of practice am coming to appreciate how challenging it can be to handle this special population. This has further been reinforced with the children being at home in this pandemic season.  In the past several months, we are witnessing an influx of children presenting to the ER or outpatient with one form of emergency or another. Depending on the gravity of the situation some actually then end up in the pediatric wards, HDUs, ICU and the most fortunate are just sent back home for observation.

At this point then I pose the question. As a health professional or as a working parent in any career. Do you have children? Are you the primary caretaker/guardian of this special group? Are you content with the fact that if anything was to happen to them they would receive the most appropriate care in any health facility they are attended at? That includes where you currently practice. Well, the World Health Organization creates a dim outlook in its updated 2016 guidelines. They begin by stating that most pediatric deaths occur within the first 24 hours of admission. They majorly attribute this to;

•  Ineffective triage processes.
•  Delay in presenting the sick child to the hospital.
• Inadequate resources at the health facilities.
• Lack of basic skills and knowledge among the health workers in initiating appropriate treatment.

To explore this further read the following pdf document Updated guideline: pediatric emergency triage, assessment, and treatment: care of critically-ill children. Johanson et al; stated that in low-income countries, emergency care is among the weakest parts of its health systems. This is despite these systems experiencing higher patient loads and mortality than other regions, particularly for pediatric emergency patients. To view, this journal article click here Accessibility of basic pediatric emergency care in Malawi.

According to etat guidelines, pediatric emergencies are commonly categorized as trauma, seizures, respiratory distress, and toxicologic emergencies. A lot of emphasis is currently being placed in medical emergencies and it is wonderful that we are now observing a gradual improvement in practice. This has been facilitated further by the provision of periodically updated  MOH guidelines for instance  Basic pediatric protocols for ages up to 5 years. However, what strides have we made in handling pediatric surgical emergencies? How many specialists are available? Is it easy to even access those who are currently present?

Did you know that Africa is considered the most dangerous continent to live in? Naidoo and Murckart deduced so from the extensive studies they reviewed while conducting their own research. In their study, they identified that among the 181 children admitted with trauma injuries in their  Trauma Intensive Care Unit(TICU) 26 of them died. Among those who died, 88.4% of them had head injuries, 46.2% had injuries to their extremities, 38.5% had external injuries, 34.6% had abdominal or chest injuries, 19.2% neck injury and 11.5% had facial injuries. For a more in-depth analysis view it here  Paediatric polytrauma admitted to a level 1 trauma intensive care unit over a 5-year period. A study done at a tertiary teaching hospital in Kenya found that of all the pediatric trauma cases admitted in the facility most injuries were amongst boys (65.3%) and the very young had a mean age 6,  42.4% of the injuries occurred at home while 25.7% at residential institutions. The injuries were typically caused by falls (56.3%) or penetrating trauma (13.2%) and that they mostly resulted in extremity fractures (45.8% closed, 4.9% open)other types of injuries were burn or head injuries (in infants and small children). This study further revealed that their patients either received very little or no pre-hospital care (51.4% no care). Additionally, children with burns, brain injuries, or poly-trauma had the longest hospital stays and the highest rates of mortality. Such figures should prompt us to do better. What role have you played to make the needed improvements? To view the above article click here Patterns and outcomes of pediatric trauma at a tertiary teaching hospital in Kenya.

Simple ways we can improve outcomes is such cases can be broadly categorized as;

1. Human factors

1. Effective documentation to capture details on conditions and contributing factors present in the environment.Retrospect analysis of such data aid in the establishment of the root cause. eg Intentional trauma versus accidental trauma, good documentation makes it easier for researchers aiming to conduct chat reviews for further studies in this field, effective documentation provides a great opportunity for the collection of full information needed to conduct case presentations, etc. 
2. Effective communication - Asking the right questions the right way helps obtain information that may aid in treatment and identifying the mechanism of the injury which facilitates the early introduction of appropriate care.
3. Building a culture of learning- By enhancing our skills and knowledge on special groups it will help avoid the confusion and human errors generated by the use of the inappropriate intervention.

2. Organizational factors

1. Provision of needed equipment- Availability of basic emergency apparatus such as different branula bores, intravenous fluids, bag valve masks, oxygen therapy, splints, etc go a long way in stabilizing most trauma cases as a further plan of action is being created.
2. Creation of policies and guidelines that encourage adoption of appropriate care.- Policies by themselves create little to no change but the emphasis in their adoption does.
3. Put under consideration the development of health workers' exchange programs- Exchange programs aid in exposure to different setups hence one is more likely to learn while maintaining cost efficiency. This is so true when one gets the opportunities to train in resource-rich centers and transfer the new knowledge and skills to the resource-limited environment.

Other useful resources

• Identifying areas for improvement in pediatric trauma care in NSW Australia using a clinical, system, and human factors peer-review tool
• Kenya pediatric association
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In conclusion, as we seek to improve our health delivery services let us build a culture of thinking while doing and in this way, we shall be able to generate creative ways in improving the services we deliver. Remember this; “All children are born to grow, to develop, to live, to love, and to articulate their needs and feelings for their self-protection.”Alice Miller