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Faculty Members - East Meets
West 2003:
Nicholas
Maurice
Anthony Costello
Margaret Mishra
Jo Cole
Barbara Wallace
Jeremy Osman
Richard Williams
Jacquie Smithson
Kate Guthrie
Neela Shabde
Subhash Daga
David Southall
Hrizantema Dobreva
Roderick MacFaul
Jane Cowan
Nick Hart
Jennifer Mabbot
Catherine Panter-Brick
Christina Clark
Sue Proctor
Ian Hurdley |
Deepak
Upadyau
Andrew Brown
Sanya Besarovic
Jenny Brown
Amelia Cumbi
Kavery Nambisan
Bob Taylor
Chris Hobbs
Remy Toko
Jackie Moores
Rajan Madhok
Lisa Smith
Jill Wood
Louise Giles
Gerry Purdy
Neel Kamal
Martin Schweiger
Bernie Dawson
Stephen Lindow
Jodie McVernon
Wali Wardak |
These videos are best viewed using
Microsoft
Windows Media Player version 9 or above.
Andrew Brown
Climbing Mountains; Rural Children and Young People’s Health and
Well-Being in England |
An overview of the health and well-being of children and
young people in rural England. The presentation will touch on the
information that is available showing the differences between rural and
urban children and young people; will look at context in which services
are being delivered and planned; and look at some of the issues that
children, young people and their families feel are particularly important.
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Jane Cowan
Consent in Children |
Children of all ages and in all countries have rights. As
health professionals, we need to be aware of these rights and how to
interpret the law appropriately wherever we work to ensure that we treat
children safely and in a legally robust manner.
Assumptions can occasionally be made about the extent of our
responsibilities for caring for children – without always giving adequate
consideration to the consent process.
Much has been written about consent to medical treatment including the
difficulties encountered when a patient is a minor. However – attention to
detail in the training of health professionals who are involved in the
care and management of children is sometimes (and in some areas, often)
sadly lacking.
In our experience at MPS – many junior doctors and other health
professionals have limited access to training on matters pertaining to
consent. This is not confined to the UK but in other areas of the world
where we have members.
Fortunately – in the majority of health care interactions, consent does
not create too many problems as a concept. However within any paediatric
unit in secondary care and in any primary care setting there will be
certain aspects of clinical practice when greater consideration should be
given to the legal framework surrounding consent.
The aims of the workshop are:
• to agree common practice
• build on the standards that exist
• discuss basic and relevant case law
• address some areas where more complex decisions on consent are
required
• consider case scenarios
• recognise training needs and responsibilities
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Amelia Cumbi
PHC – Oriented Health Cadres In Mozambique |
Since the late 1970s, the Mozambican health sector is
experimenting with professional cadres conceived to deliver basic
comprehensive services, mainly in rural areas. As a result, a variety of
professional figures have been created, from the front-line providers of
curative and preventive first-contact services, to district health care
managers, to basic-surgery practitioners. Job descriptions, training
methods and contents, deployment and utilisation have evolved over time,
in the constant pursuit of personnel appropriate to the changing demands
of the health services. To achieve that, their training has privileged
hands-on practice, problem-solving approaches, and prolonged rural
internships. During two decades, these cadres have been the backbone of
health care delivery in rural areas, spearheading the dramatic increase in
health service coverage that in the 1990s has taken place in those areas,
in this way greatly reducing their delay in relation to urban settings.
Despite the important role played by these health workers within the
health sector, the expansion of their ranks has met with growing
difficulties. The powerful medical and nursing lobbies have seen with
dissatisfaction the rising of an alternative variety of health workers,
while training venues have been occupied by other categories supported by
rich vertical programmes. The future of PHC – oriented health workers and
of comprehensive PHC itself is not granted in Mozambique, at a time when
the rising tide of AIDS loads the health sector with an additional heavy
burden.
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Subhash Daga
Management of Fever |
Prolonged fever is a common problem among
paediatric patients. Its management often relies on a host of
investigations. Blood counts, ESR, blood culture, urine examination, Widal
test, Mantoux test and chest x-ray are frequently ordered, necessitating
frequent hospital visits. This makes the management expensive as well. In
this communication, we share our experience of managing cases of prolonged
fever as per a pre-determined protocol based on minimum investigations and
at an affordable cost.
This study has been conducted at Cama and Albless Hospital, Mumbai.
Beneficiaries of the hospital services are almost exclusively from low
socio-economic group.This study has been conducted between June and
November 1999. During this period, 716 children were admitted to our
paediatric ward. Of these, 113 children above 2 months of age were
admitted with fever lasting 7 days or more and without cough, cold or
throat pain. They were the subjects of this study. The patients were
categorized as stable and sick. A stable child appeared normal except
during spike of fever. Sick child looked unwell, was eating less and
preferred to be in bed. Sick children were further categorized as those
suspected to have pneumonia or otherwise. Stable patients received co-trimoxazole
and chloroquine. Blood counts and urine examination were performed. If
intensity and/or frequency of fever spikes remained unchanged after 2-3
days of treatment, chloramphenicol and mefloquine were added. Sick
patients above 6 months of age received chloramphenicol and chloroquine.
Blood counts and urine examination were performed. . If there was no
response in 2-3 days, mefloquine was added. Chest x-ray was taken if
pneumonia or tuberculosis were suspected. Whenever clinical and/or
radiological suspicion of tuberculosis was strong, anti-tubercular
treatment was started pending confirmation or otherwise of the disease. A
sick baby below 6 months received cefatoxime and chloroquine and
gentamicin was kept as an option in case of non-response. Urine
examination was not performed in children below 6 months.Urinary tract
infection was diagnosed by presence of pyuria or detection of bacteria on
Gram stain of urine. Bacteremia was diagnosed when blood counts were
abnormal. Malaria was diagnosed in presence of parasitemia or anemia and
splenomegaly .
Response to first line of treatment was noted in 81.4% cases and 79.5%
patients were afebrile by 48 hours (Fig no.1). Average expenditure on
drugs was US$ 0.2 and 0.5 on stable and sick children respectively.Causes
of fever included malaria (31.8%), bacteremia (25.7%), UTI(15.%),
pneumonia(7.5%) and tuberculosis (2.7%). Cause of fever could be
established in 20.3% cases. Based on this study and subsequent experience,
the protocol presently practiced is shown in figure 2.A comparison of pre
and post protocol period is discussed so also distribution of sepsis
syndrome and septic shock among critically sick children with fever.
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Hrizantema Dobreva
Paediatric oncology in the developing world |
Combating nutritional deficiency and infectious disease is
an accepted priority in the developing world, however as health care is
seen to respond to these urgent needs, other underlying problems such as
childhood malignancies come to light.
The challenge of paediatric oncology in resource-poor parts of the world
is additionally heightened by the inevitable ethical tension associated
with the high cost of cancer detection and treatment for every individual
patient.
This presentation shares information about personal experience in the
management of Burkitt’s Lymphoma with a low cost treatment protocol and
recognition of other unusually presented malignant diseases.
The need for the development of comprehensive and holistic strategies for
management of the paediatric malignant conditions in the developing world
will be discussed.
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Louise Giles
Tele-lunch in Winnipeg Canada: MbTeleHealth & Linking Physicians to
Patients |
Departments of Pediatrics and Child Health & Physiology,
University of Manitoba, Winnipeg, Manitoba, Canada
Winnipeg Manitoba is located at the epicentre of the North American
Continent. Winnipeg, a Cree word meaning muddy waters, served as a meeting
place for ancient and more recent peoples. Climate has a significant
impact on the city and area, having one of the widest ranges of
temperatures in the world (summer 35C to -40C in the winter). Health care
in Canada is a public system: basic health care needs of all Canadians are
covered by various levels of Government. The delivery of health care in
Manitoba is challenged by numerous factors: geography, remoteness of many
people, one tertiary level center, and providing medical coverage for the
far north. Manitoba, land area of 649,950 sq km, has 1.1 million people
contrasting with the UK whose 59.8 million peoples live in 244,840 sq km
of land. One innovative way to provide specialist medical care to our vast
and remote population has been via Manitoba Tele Health (MbTeleHealth),
where physicians conduct clinics via established telephone or internet
lines, or satellite links. Digital equipment has been developed with
significant positive impacts on the clinical visit. One may examine the
ears or throat, listen to heart and lung sounds, examine a wound,
interpret x-rays and CT scans and provide sound medical advice across the
miles. Future innovations for MbTeleHealth include bringing physicians and
patients together from around this global village to promote health in all
people.
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Nicholas Hart (After Dinner Speaker)
Cleft Lip and Palate Surgery in Pakistan |
Over the last four years a cleft team called HEROPSA (Hull
& East Riding Overseas Plastic Surgery Appeal) comprising, Mr Hart, Dr
Purdy, Consultant Anaesthetist and number of nurses and ODP’s have been
visiting Pakistan and more recently India to operate on cleft lip and
palate patients. Mr Hart will give an account of these visits and the
results achieved.
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Ian Hurdley
They Shoot Children, Don’t They? |
The literature distributed with the delegate pack gives a
comprehensive outline of the work we do to enable street children to leave
the street and (hopefully) reintegrate with their extended family.
Today I want to deal with another extremely important role which has been
thrust upon us by the inaction and lack of concern shown by governments in
two Central American countries to the physical and sexual abuse of
children. I will refer to the high murder rates in Honduras and Guatemala,
and to the traffic in Guatemalan babies for adoption. I will also draw
attention to the problem of sex tourism into Costa Rica.
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Neel Kamal |
Understanding Child Health – A Panorama
The presentation covers a wide range of issues and topics of relevance to
Child Health across the World. Largely based on personal clinical
experience, various real anecdotal accounts are presented reflecting how
culture and beliefs influence Child Health practices.
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Jem Osman, Jo Cole & Jill Wood |
Taking Injury Prevention Into Schools
Dr Jeremy Osman, Consultant in Emergency Paediatric Medicine, will open
the workshop with an overview of attendances from the Accident and
Emergency Department in Hull. This will be followed by examples of two
effective injury prevention interventions:
– Injury Minimisation Programme for Schools (IMPS) targeting 10/11
year old children
– Focus On Safety Award Scheme aimed at Nurseries / Pre-Schools
Children from Newington Primary School will demonstrate their skills
learnt on the IMPS programme. Question and Answer session to finish.
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Nicholas Maurice
Bridging Lives - North/South Community Links for Learning |
In these days of globalisation, to misquote John Donne “No
country is an island...”. But while there is a commercial and
technological globalisation, “human globalisation” has a lot of catching
up to do.
One way of achieving this is through community linking. There are many
such links; towns, schools, local authorities, faith, diaspora and
professional links between communities in the North and in developing
countries (the South). Hospitals and increasingly hospices and health
professionals are developing links with counterparts in the South.
Would the invasion of Iraq have taken place if there had been closer ties
and learning at community level? While there is an ever-widening gap
between the rich and the dispossessed, between the powerful and the
powerless, we have a recipe for increasing fundamentalism, tension and
institutionalised terrorism. There is a self- interest for all in
developing these ties.
There are certain principles involved in linking lives- principles of
reciprocity and mutual learning. It is not about “us the rich giving to
them the poor”, but a recognition that we all have wealth and poverty,
strengths and weaknesses. How can we learn and benefit from each other?
Increasingly, people in the South are saying that they are “fed up with
being the recipients of charity and dancing to the development tune of
Northern agencies, accountability to you, measuring impact for you”. “We
are looking for sustained partnerships of equality where there is giving
and receiving”.
We have increasingly been brought up in a culture of rights.
Responsibilities seem to have taken a back seat. How can we reverse the
trend?
We cannot do this alone as a profession but in partnership and
collaboration with other agencies.
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Jodie McVernon
Conjugate Vaccines in the Developed and Developing World |
Conjugate vaccine technology has made possible safe and
effective immunisation against many causes of meningitis and serious
invasive bacterial infections. The first of these vaccines to be licensed,
against Haemophilus influenzae type b (Hib) has been widely used in the
developed world for the past ten years with great effect. Unfortunately,
barriers to implementation of this vaccine in the developing world have
led some to estimate that only 6% of all classical invasive Hib infections
are currently being prevented globally. Some of these barriers, and
suggested approaches to overcome them are explored. More positively, the
recent model for development of meningococcal A and C conjugate vaccine
for Africa, involving a range of public sector organisations in
collaboration with industry partners, is discussed.
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Margaret Mishra
Screening Newborns for Hearing in the USA: Why, How, and Outcomes |
All levels of hearing impairment may affect long term
development of language as well as global development of the growing
child. Determination of hearing impairment done via objective
physiological testing is necessary to provide early intervention to
enhance hearing. Interventions are essential for facilitating speech,
language, and cognitive skills, social-emotional development, and academic
achievement. It is known that a child diagnosed with a hearing impairment,
who receives amplification and habilitation services by six months of age
develop language equal to a hearing infant. (Yoshinago-Itano 1997)
Congenital hearing impairment occurs 1:1000 in the normal newborn
population. That rate increases to 1:600 in infants sick enough to be
admitted to an Neonatal Intensive Care. (Northern, 1994). Objective
automated brain stem responses technology testing at 35 dB was developed
in 1989. Automated otoaccoustical emissions screening developed later.
With the advent of reliable automated inexpensive testing all newborns in
the
state of Georgia and 35 other states in the United States are provided
with screening prior to hospital discharge.
This presentation will amplify the reasons for newborn hearing screening,
discuss the technology readily available for screening, and the outcomes
of newborns diagnosed with hearing impairments, in various settings in the
USA and habilitation methods.
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Jackie Moores
Community Dietetics in UK and Indonesia |
Growth problems related to food and feeding practices are
commonplace throughout the world. After working with Failure to Thrive
Children in the UK for 10 years, an opportunity to work in Indonesia for
voluntary service overseas arose. The three-year placement enabled
projects on Food Security to be undertaken jointly with Indonesian Health
Workers and the Community.
Short-term improvements in weight, of over 60% of children were achieved,
somewhat different to the clinic stats in the UK! So what’s the secret?
This workshop will look at working practices in both settings and
elucidate what we can learn from these situations, ultimately trying to
improve effectiveness and working practice.
Slides of life and work in Indonesia will be shown and discussed.
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Kavery Nambisan
Surgery in Rural India |
Dr Kavery Nambisan has worked in rural India for 20 years:
from crime-infested Bihar where she was busy treating gun-shot injuries in
the middle of the night, to UP, Tamil Nadu and Karnataka. She has worked
in varied milieu. In each place the problems were different and she had to
do many other things beside surgery: she helped start a successful nursing
school, set up physiotherapy departments, trained health workers, junior
surgeons and theatre staff. She has also found time to pursue her
favourite pastime, of writing fiction.
Dr Nambisan talks about the problem of medical care in rural India; about
the Association of Rural Surgeons and scores of doctors like herself who
have taken on the responsibility of reaching out to the villages where 70%
of the country's population lives. She highlights the work of some of the
rural surgeons and makes a plea for addressing issues which affect the
poor in all parts of the world.
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David Southall
Emergency Maternal and Child Health Care (EMCH)
An Educational Approach That Addresses Team-Working And Resources |
The management of obstetric, neonatal and paediatric
emergencies must be coordinated and effective if avoidable deaths and
long-term or permanent disability is to be avoided.
Management in the first hour or two of the presentation of an emergency is
a major determinant of outcome.
A programme utilizing an educational approach based on the transference of
skills by an expert working alongside local healthcare staff during real
life emergencies provides the core of the training. Scenarios, skill
stations, and small seminars as in the Advanced Paediatric Life Support (APLS)
course widely practiced in well-resourced countries will supplement this.
The Advanced Life Support Group and Child Advocacy International, two
charities based in the United Kingdom, with experience in this form of
medical education, are developing the course.
Prior to the 7 day course, candidates, who will be doctors, nurses,
midwives and traditional birth attendants, will receive the following
educational materials: 1) a reference manual containing in basic terms
proportionate to the resources available in that country a “how to do it”
guide to the management of all obstetric, neonatal, and paediatric
emergencies including serious local problems such as malaria and severe
malnutrition, 2) a more basic manual containing essential knowledge,
especially designed for the generalist doctor or nurse working in poorly
resourced district hospitals. 3) CD ROMs of both paediatric, neonatal and
obstetric emergency care, each of which will include more than 200 videos
of live patients undergoing emergency care, especially emergency
procedures.
After they have had a chance to read through the manuals and use the CD
ROMs, candidates will then join a course where the instructor to candidate
ratio is high, basically 1 : 3 or 4. Two types of courses will be run, the
first in tertiary hospitals where there are specialist paediatricians,
obstetricians, midwives and children’s nurses. The second in district
general hospitals where there are usually generalist doctors and nurses
and traditional birth attendants. The courses will be adjusted to the
different levels of specialty. In the course for non-specialists all
aspects of obstetrics, paediatrics and neonatal emergency care will be
taught because an integration of these 3 managements is regarded as
essential. In the specialist course, there will be part of the course for
both paediatric and obstetric staff and part where they will be instructed
separately.
Since many of the hospitals in which this course will be held have very
limited, emergency resources, each course will be accompanied by a
donation of essential drugs, medical supplies and basic equipment.
Specially trained volunteers from the United Kingdom will initially prime
instructors but the aim is for local instructors to be identified as soon
as possible in the targeted countries so that they can pass on their
skills in a sequential fashion to as many healthcare staff as possible.
Each time a hospital becomes involved, the aid package for emergency care
as outlined above will be provided. In particular, the emergency drugs and
medical supplies which are not particularly expensive will be earmarked
for the poorest of patients and systems will be put into place to ensure
that they are indeed used only in the State sector and not transferred to
the private sector.
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*Dr Deepak Upadhyay, **Dr Ranendra Shrestha, ***Dr
Martin Samuels
Critical Care For Developing Countries: Making A Difference |
*Women and Children’s Hospital, Hull, UK
**Kanti Children’s Hospital, Kathmandu, Nepal
***North Staffordshire Hospital, Stoke on Trent, UK
The provision of facilities for intensive care in areas where there is
high infant mortality associated with communicable diseases, malnutrition
and lack of other basic health care infrastructure could be considered
esoteric and a waste of limited resources. Whilst there is the challenge
of preventing and treating common diseases like infections, diarrhoea,
acute respiratory illness and malnutrition, there are fair numbers of
critically ill children, many of whom are rescuable even with meagre
resources. We argue that it is of benefit to commit resources to this
latter group of children, as the benefits help not only the sickest
children, but also raise the standards of care for all ill and injured
children. This arises through the training and improved resources that
this tertiary level of care brings with it.
It is feasible to set up a small high dependency / intensive care unit in
a teaching hospital or tertiary hospital setting, and this can help in the
training of nursing and medical staff:
Kanti Children’s Hospital (KCH) is the only paediatric hospital in Nepal
with developing sub-speciality facilities. It is a 280-bedded teaching
hospital for the Institute of Medicine, the latter based at an adjacent
hospital. Critical care began in 1983 with one newborn incubator and 2
nursing staff. Japanese aid grants led to full-fledged NICU and PICU in
1986 and 1994 respectively. In the 12 months to April 2000, the PICU had a
total of 130 admissions (64% males). The majority of patients were infants
58(45%), followed by 1-5y age group 37 (28%) and >5y 35 (27%). The mean
stay in the unit was 7.4 days. The 4 main causes of admissions were
pneumonia 44 (33.8%), bacterial meningitis 18 (13.8%), poisoning 8 (6.2%)
and encephalitis 6 (4.6%). Twenty-four patients (18.4%) needed
ventilation, of which 79% died. The main reasons for ventilation were
meningitis 9 (37.5%) and pneumonia 6 (25%). Of all admissions, 71 (54.6 %)
improved and 50 (38.5%) died. Excluding manpower costs, the average cost
of treating each patient was £31.60, compared to £750-1000 per patient for
patients at the Apollo Hospital, a private hospital, in Delhi and
£2483-4463 in a US PICU inclusive of manpower cost in the latter two.
In 2001, a modified advanced Paediatric life support (APLS) course was
introduced which has contributed towards further supporting the critical
care in KCH. The aim was to train medical and nursing staff in how to
recognise and treat seriously ill and injured children. This began with
five 3-day modified Advanced Paediatric Life Support courses (NPLS)
between May 2001 and August 2002. In the first five courses, 71 out of 74
candidates (63 doctors, 11 nurses) from 6 different hospitals in Kathmandu
passed. The course was rated high and a large demand subsequently
developed , and it is hoped that the Ministry of Health will incorporate
the course into a national training program. The project including the
supply of additional equipment was funded by Child Advocacy international
(UK) for less than £ 6000. Subsequent courses are being supported by
Carmel Dersch and friends of Kanti from Liverpool who have been
instrumental in maintaining Paediatric Oncology Link between KCH and
Alderhey Children’s Hospital , Liverpool
The development of PICU and APLS programmes in Kanti Children’s Hospital
are examples of how critical care can be introduced into a resource-poor
country and how moderate resources allow valuable training and equipment
to be introduced successfully. We consider that there should not be a
debate as to whether critical care is needed for developing countries, but
what can be done with the limited resources. Every country, however poor,
should have access to facilities for its critically ill children. This
will be further aided by links between hospitals in poor and rich
countries.
References
1. Razzak JA, Kellerman AL. Emergency medical care in developing
countries: is it worthwhile? WHO Bulletin 2002; 80:(11) 900-905
2. Sachdeva RC. Intensive Care – a cost effective option for developing
countries? Indian Journal of Paediatrics 2001; 68(4):339-42.
3. Armaganidis A. Intensive care in developed and developing countries:
are comparisons of ICU performance meaningful? Intensive Care
Medicine1998; 24:1126-1128. |
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