Kevin R. Schwartz

Imported pediatric malaria presenting to an urban pediatric emergency department: a case series.

Objective The objective of this study was to identify common presenting signs, symptoms, and laboratory findings of imported pediatric malaria presenting to a US pediatric emergency department (ED). Methods This is a retrospective chart review of all patients presenting to an urban pediatric ED between July 1, 2004, and July 1, 2011, who were assigned an ED or inpatient discharge diagnosis of “malaria” and had a confirmed blood smear demonstrating plasmodium species. Results There were 21 patients included in this study (median age, 12 years; range, 19 months to 22 years). A total of 15 (71%) were infected with Plasmodium falciparum subtype of malaria. Patients presented to the ED between 1 day and 2 years after return from a malaria-endemic area. All 21 patients (100%) reported a history of fever, but only 9 (43%) had a fever documented in the ED. Of the patients, 14 (66%) complained of headache, 13 (62%) complained of anorexia, 11 (52%) complained of chills, and 10 (48%) complained of abdominal pain. The most common sign was tachycardia, present in 18 patients (86%). Consistent with other studies, thrombocytopenia was the most frequently observed laboratory abnormality, present in 16 patients (76%). Conclusions The presenting signs and symptoms of imported pediatric malaria are nonspecific and inconsistently present, underscoring the importance of maintaining a high index of suspicion for this diagnosis in any patient returning from a malaria-endemic region.

Simulation in Pre-departure Training for Residents Planning Clinical Work in a Low-Income Country

Introduction Increasingly, pediatric and emergency medicine (EM) residents are pursuing clinical rotations in low-income countries. Optimal pre-departure preparation for such rotations has not yet been established. High-fidelity simulation represents a potentially effective modality for such preparation. This study was designed to assess whether a pre-departure high-fidelity medical simulation curriculum is effective in helping to prepare residents for clinical rotations in a low-income country. Methods 43 pediatric and EM residents planning clinical rotations in Liberia, West Africa, participated in a simulation-based curriculum focused on severe pediatric malaria and malnutrition and were then assessed by survey at three time points: pre-simulation, post-simulation, and after returning from work abroad. Results Prior to simulation, 1/43 (2%) participants reported they were comfortable with the diagnosis and management of severe malnutrition; this increased to 30/42 (71%) after simulation and 24/31 (77%) after working abroad. Prior to simulation, 1/43 (2%) of residents reported comfort with the diagnosis and management of severe malaria; this increased to 26/42 (62%) after simulation and 28/31 (90%) after working abroad; 36/42 (86%) of residents agreed that a simulation-based global health curriculum is more useful than a didactic curriculum alone, and 41/42 (98%) felt a simulator-based curriculum should be offered to all residents planning a clinical trip to a low-income country. Conclusion High-fidelity simulation is effective in increasing residents’ self-rated comfort in management of pediatric malaria and malnutrition and a majority of participating residents feel it should be included as a component of pre-departure training for all residents rotating clinically to low-income countries.

Developing and Implementing a Pediatric Emergency Care Curriculum for Providers at District Level Hospitals in Sub-Saharan Africa: A Case Study in Kenya

Introduction Emergency medicine is a relatively new field in sub-Saharan Africa and dedicated training in pediatric emergency care is limited. While guidelines from the African Federation of Emergency Medicine (AFEM) regarding emergency training exist, a core curriculum in pediatric emergency care has not yet been established for providers at the district hospital level. Methods The objective of the project was to develop a curriculum for providers with limited training in pediatric emergencies, and contain didactic and simulation components with emphasis on treatment and resuscitation using available resources. A core curriculum for pediatric emergency care was developed using a validated model of medical education curriculum development and through review of existing guidelines and literature. Based on literature review, as well as a review of existent guidelines in pediatric and emergency care, 10 core topics were chosen and agreed upon by experts in the field, including pediatric and emergency care providers in Kenya and the United States. These topics were confirmed to be consistent with the principles of emergency care endorsed by AFEM as well as complimentary to existing Kenyan medical school syllabi. A curriculum based on these 10 core topics was created and subsequently piloted with a group of medical residents and clinical officers at a community hospital in western Kenya. Results The 10 core pediatric topics prioritized were airway management, respiratory distress, thoracic and abdominal trauma, head trauma and cervical spine management, sepsis and shock, endocrine emergencies, altered mental status/toxicology, orthopedic emergencies, burn and wound management, and pediatric advanced life support. The topics were incorporated into a curriculum comprised of ten 1.5-h combined didactic plus low-fidelity simulation modules. Feedback from trainers and participating providers gave high ratings to the ease of information delivery, relevance, and appropriateness of the curriculum. Conclusion We present here a core curriculum in pediatric emergency care for district hospital level providers in Kenya which can be used as a framework for further development and implementation of training programs throughout sub-Saharan Africa.

Pediatric Acute Promyelocytic Leukemia Presenting to the Emergency Department as Refusal to Ambulate

A previously healthy 10-year-old girl presented to the emergency department (ED) with a headache and vomiting which resolved with oral NSAIDs. The patient returned two days later unable to ambulate with mental slowing and lower extremity bruising. Labs demonstrated marked leukocytosis, severe anemia and thrombocytopenia, and disseminated intravascular coagulation (DIC). Brain MRI showed multiple intracranial hemorrhages. A peripheral blood smear demonstrated blasts with many Auer rods. A diagnosis of acute promyelocytic leukemia (APL) was made and therapy including all-transretinoic acid (ATRA) was initiated. Neurologic status returned to baseline within 1 week in the pediatric intensive care unit.