Getting medical care for your kid in remote locations
What is available for milder illnesses & what is available if my child is very sick?
What is available for milder illnesses & what is available if my child is very sick?
In far western NSW, kids and their families can access health care with nurses and/or doctors in their home town.
Care will be provided by:
a nurse practitioner (INSERT ROSTER OF WHICH NURSE IS ROSTERED ON VIA NSW HEALTH INTRANET -NOT PUBLIC ACCESS)
a general practitioner (INSERT ROSTER OF WHICH DOCTOR IS ON CALL IN WHICH TOWN-NSW HEALTH INTRANET)
VRGS is Virtual Rural General Service: if you do not have a GP in your home town, your nurse may call an on call doctor for a virtual, online consultation.
If your GP or your VRGS has concerns after speaking to your about your child, and thinks they need an admission to Dubbo , we recommend your GP call NETS.
NETS - this is service for assessing and transporting children who may have more serious illnesses (including life- threatening conditions). NETS have access to helicopters and planes and can decide if a doctor and nurse need to fly to your home town to support your local team
If the NETS doctor believes that the best plan is for your child to move to Dubbo, then the NETS doctor will ring the paediatrician on call 0408 487 724 from 0800 until 2200. If there is a paediatric bed, then your child will be moved to Dubbo by ambulance (road or flight), or by private vehicle if your child is not too unwell. If available, consider adding in the paediatric registrar in the conference call, as they will examine the child, once ED has done the primary assessment.
Overnight (2200-0800) the NETS consultant can ring the paediatric registrar on call on 0437 143 344 to arrange a transfer to Dubbo. If it is a tricky case, and there are concerns about diagnosis , safety both consultant and registrar can conference call with NETS,
If the patient is a chronic and complex patient, and the NETs consultants wants more information on the patient, the ringing the on call consultant, or registrar is recommended.
At this point it is also recommend that the ED admitting be made aware of the patient coming to the ED, by the paediatric registrar.
The vCare nurse will put the patient on the patient portal for expects
For surgical problems, it is recommended your GP attempt to ring the general surgical, gynaecological , ear nose and throat or orthopaedic surgeon on call in Dubbo.
If you attempt to ring the surgical registrar on call , and are unable to contact them, it is reasonable to ring the NETS to assess fitness for transfer to Dubbo hospital
Note Dubbo does not have an ophthalmology service on call on Dubbo, the nearest service is at Orange hospital.
Not all towns in Far Western NSW have a doctor in it and even with the VRGS it may still mean your child may need a medical review that , unfortunately, can not be done in your local town.
Proposal for a minimum level of care prior to DBH paediatric consultation
Give it a name that all will understand:
E.g. A paediatric medical consultation “a PMC” (a virtual or in person) for rural and remote patients
e.g.: vRGS is calling you regarding a paediatric medical consultation.
MEDICAL ASSESSMENT
a) History of present illness
b) Main parental concern(s) and is this a representation
c) Any current medications, any current treatments?
d) Past Medical History- any chronic illnesses that require specialist input, or influence current illness?
e) Immunisations: are they up to date?
f) Examination: are the vital signs between the flags? Are the vital signs seriously abnormal and do we need to escalate immediately to NETS and/or vCare.
If vital signs are abnormal then repeating the vital signs to see trends
Document: vital signs, BP, BSL, urinalysis if possible (as this will help with planning the next 24 hours of treatment)
Identify what parts of examination are incomplete, and if this poses medical risks to the child.
g) Main working diagnoses and differential diagnoses
h) Treatments proposed, any interventions done after presentation? Have they been effective?
LOGISTICAL PLANNING
i) In the event a deficiency in examination is identified, where is the nearest doctor?
j) Who is the nearest doctor, and are they willing and able to see the patient within the 2 hour period?
k) Is there a high likelihood of a double movement from the patient having a diagnosis that needs to come to DBH?
l) Are the patient’s family willing and able to drive to nearest doctor for examination completion?
Then call the Paediatrician if the nurse and doctor on call are unable to reach agreement on an appropriate plan.
DBH PD, estimates that such PMCs would take 10-15 minutes if done properly.
LIMITATIONS of TELEMEDICINE in PAEDIATRIC MEDICAL CONSULTATION
Having outlined what DBH PD believes are the minimum needs of a PMC, we believe we need to state what is not known after a virtual PMC.
1) Febrile child PMC
We need to have sufficient nursing vital signs checks (or any other features of the PMC as listed above). 2-3 over 60 minutes.
A proportion of these will have sepsis and need to be on the sepsis treatment pathway
These children should self-declare with abnormal vital signs on BTF. eg high pulse rate often in the red zone.
If it is fever and vomiting on history- differentials are broad
If it is fever and cough- may be URTI or LRTI
Examination on video
This of itself needs improvement and needs more attention from staff prior to calling the GP (+/- NETS , +/- Dubbo paediatrician).
Calm the child down, give it a cuddle, sit the child under 4 years on carer’s lap
Then turn camera on. Distract the child with video on smart phone.
Pulse oximeter on, what are the vital signs?
Check the blood sugar/ BP prior to turning camera on.
For children with respiratory distress, if prepubertal, if not too cold, lift the shirt, so that work of breathing may been seen.
What is general condition of the child?
Is the child active and moving about easily?
Can the child walk? Is there leg/back/abdominal pain with walking?
Is the child alert and talking to carer? Or if not verbal behaving as per normal?
Examination deficiencies
a) Throat ( ? tonsillitis ? quinsy)
b) Ears ( ? otitis media)
c) Heart (? Murmur)
d) Chest (? crepitation or signs of effusion)
e) Abdomen (?guarding or other signs of peritonism)
f) Urine ( ? leucocytes or red blood cells or nitrates)
So after a PMC on the febrile child, in most cases, where there is no local doctor or nurse practitioner, what the diagnosis is. As such planning for the next 24 hours is very difficult.
PROPOSAL by DBH PD
In the event that the febrile child is not showing signs of sepsis , and the child is otherwise well (“walking, talking, eating and drinking) then the nurse and/or virtual doctor determine where and when the child will have an in person PMC.
The logistical planning is documented in the EMR.
In the event that the family are unable to travel to have the medical examination, then the hospital look at patient transport or the ambulance service to perform the PMC.
The family are given red flags to watch for and the ED staff make a judgement as to parental competency.
ASSESSING THE CHILD WITH SHORTNESS OF BREATH
The vast majority of children with acute onset of shortness of breath will have a bronchiolitis, viral or bacterial pneumonia.
If a child has respiratory distress, and cannot be discharged home then a NETS consultation is warranted.
A decision on sepsis features needs to made, and whether an IV can be sited, but nurse or ambulance staff.
NOISY BREATHING and shortness of breath
For younger children this can be tricky if the nurse/ virtual doctor are unable to examine the child and describe it
Sometimes the telemedicine phone can be held next to the patient to determine
a) Is it mostly noisy breathing in called “stridor” , i.e. croup or baby with croup
b) Is it mostly noisy breathing out , wheeze in baby and wheeze in older child
c) Is it snoring (“stertor”) ?
d) Noisy breathing in and out? Or can’t tell
Note that treatments will differ according to the above diagnosis
ABDOMINAL PAIN
In the child under 5 years of age with abdominal pain DBH PD believes that after the PMC the paediatrician and, ideally surgeon on call should be rung.
DBH PD recommends that if the pain is ongoing, and the cause is not known, then the child is referred to DBH ED for assessment.
DBH PD believes that for children 5 to 14 years (or children who are pre-pubertal), with ongoing pain need a surgical opinion.
Our stated preference is for the DBH Surgical department to be rung first and case discussed with them and the Emergency Admitting Officer.
If then the belief is that a paediatric consultation is desired prior to transfer, the on call paediatrician can be rung
We note that vCare has frequently consulted DBH PD as the initial medical opinion (before the surgical team).
We believe there are a few reasons this
a) Potential for missed medical diagnosis egg pneumonia, DKA, UTI
b) Fluid management
c) Pain management
Nevertheless DBH PD maintains that if common sense prevails and
a) an abdominal pain guideline is follower
b) sepsis is watched for
c) IV fluids given appropriately
Then the child is fit for transfer and paediatrics can consult after arrival (if needed)
Note if the BTF is persistently abnormal, paediatrics should be consulted, as they may well be involved upon arrival.
Background information on VRGS- Dr Shannon Nott presentation
CCAS video URL in Western LHD Intranet (note open in Internet Explorer , as it will not open in Chrome)
If your child has a serious illness that requires emergency care , your team at your town may call a NETS specialist. The NETS specialist is our state expert on taking care of critically unwell children.
NETS guidelines (hospital access only)