Sick child in a rural hospital

27.2 Sick child in a rural hospital



Murali Narayanan, Robert Henning




Essentials



1 There are significant challenges in translating experience from the urban to rural healthcare settings including differences in the patients, illnesses and health services available.

2 The ‘scoop and run’ model of pre-hospital care is not appropriate in rural/remote medicine – patients must be ‘packaged’ as much as possible before transport.

3 Coordination between rural, central and retrieval services must be optimal.

4 Rural services should be supported through targeted training of personnel tailored to the needs of rural clinicians, easily accessible guidelines, accessible consultation services, rural clinical facilities with necessary resources and a supportive relationship with a major urban centre.


Introduction


Most emergency physicians are trained in urban centres. Their skills and knowledge are most readily applied when trained staff, equipment and hospital facilities are immediately available, and when there is ready access to specialists. This becomes an issue when the sick child presents to the emergency department in a rural hospital. Protocols and treatment plans that are appropriate to urban hospitals may be difficult to apply directly.



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.



Income


Although the overall income differences between rich and poor may be smaller, the median household income in rural Australia is 25% lower than that in major cities, and rural families are 50% more likely to be dependent on government pensions and allowances than urban families.


Low income can lead to reluctance to consult a doctor and to reluctance of the doctor to prescribe expensive though appropriate treatments or to commit the family to expensive travel to consult specialists in urban hospitals.



Housing


The quality of housing and of home maintenance is lower in rural areas: maintenance costs are higher, and dwellings deteriorate faster in harsh environments and scarce accommodation leads to overcrowding.



Education


Lower rates of secondary school completion in rural areas than in the city affect both the child and her parents. Infant mortality is closely related to the level of education completed by the mother.


These issues apply also to children in isolated indigenous communities, where the additional problems of distance, access to health care and a relative scarcity of indigenous health workers lead to relatively late hospital presentation of severe illness.



Culture


A tradition of self-reliance and stoicism, combined with suspicion of medical services or of European society in general and varying issues with language difficulties may lead to reluctance to report illness and to delay presentation to seek medical attention. Certain cultural issues, for example not speaking the name of a deceased Aboriginal person, or the tendency of Aboriginal women to avoid eye contact with a strange man, become important considerations in the setting of paediatric emergency medicine.



The illnesses



Birth history


Low birth weight and difficult access to antenatal care in rural areas (especially in indigenous communities) can lead to severe illness in the newborn period, with consequent disability and need for hospital care.



Trauma


Age-standardised rates of serious injury in children from road trauma, interpersonal violence and self-harm increase with distance from major cities in Australia: from 50% greater in inner regional areas to 100% greater in very remote areas. Farm accidents occur frequently: 2/3 of accidental child deaths on farms occur in boys.


Farm vehicles, and especially all-terrain vehicles and four-wheel motor bikes, account for many deaths and injuries, especially to farm visitors. 35–40% of child deaths on farms are due to drowning in dams or drains, especially in children aged less than 5 years.



Infection and diet


Infective conditions, especially of the skin, respiratory and gastrointestinal systems, occur commonly in children from remote communities, where rheumatic heart disease and post-streptococcal glomerulonephritis may result.


There is lack of easy access to fresh food, fruits and vegetables in remote areas. Dietary deficiencies and substance abuse may also contribute to patterns of illness different from those found in children who present to urban hospitals.



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.

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Sep 7, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Sick child in a rural hospital

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