Pediatric Emergency Medicine Global Health Fellowship Curriculum

In collaboration with the Aga Khan University, Karachi, Pakistan, we are developing a research protocol to study the utility of urinary nitric oxide as a biomarker for neonatal sepsis in community-based settings of a developing country. The ultimate significance of this would be in the development and validation of simple, inexpensive urinary test strips for nitric oxide metabolites. These will be effectively utilized by low-literacy, minimally trained community health workers to screen newborn babies in the community at high risk for severe sepsis, so that medical intervention can be sought earlier.

Asad Mian, M.D., Ph.D.

In collaboration with Bookgroup, a non-profit education research organization based in Karachi, Pakistan, we have initiated an internship program that enrolls young high school/college level students in the United States interested in learning about how they can become effective agents of change in the developing world.

One aspect related to global child advocacy will be the development and distribution of bilingual (Urdu-English) books among under-privileged children. This can potentially be used as a tool to spread health literacy in Pakistan.

Over time this program will be opened up to medical students, pediatric residents, and pediatric sub-specialty fellows.

Asad Mian, M.D., Ph.D.

We have developed a training program and supplemental teaching curricula for the WHO Emergency Triage Assessment and Training course. First piloted in Lesotho in 2008, we have been working in Guatemala since 2009 in collaboration with the Texas Children's Hospital and the Pan American Health Organization to develop the program in Spanish (Clasificación, Evaluación y Tratamiento de Emergencias Pediátricas). The goal of the program is to build the capacity of hospitals in Latin America by improving early recognition and stabilization of acute illnesses in children. In the summer of 2011, in conjunction with PAHO and local ministries of health, we began rolling out the training program through Latin America, including Nicaragua, El Salvador and Peru.

To date we have developed locally-led, sustainable, high-quality and effective training programs in these four countries. We have trained 119 facilitators who have subsequently trained 1. 076 local participants. Currently we are collaborating with WHO/PAHO to produce and publish generic CETEP curriculum in Spanish that will be distributed by WHO/PAHO and will be accessible to any Latin American country in the future at no charge (anticipated distribution end of 2015). We have completed four studies looking at quality and effectiveness of the training program, clinical impact of triage processes, and other regional studies, and will have five publications from this work (two published in 2014). CETEP has been introduced into the national medical training norms in Guatemala and El Salvador. Another study evaluating CETEP effect on mortality in El Salvador is pending. This multi-phased project was funded by a combination of a grant from the TCH Office of International Operations as well as two internal TCH Educational Grants.

Heather Crouse, M.D. and Eric Russell, M.D.

We have developed and delivered a Pediatric Emergency Medicine Module for emergency medicine trainees at the University Teaching Hospital of Kigali/University of Rwanda in 2014. In addition, we worked with in-country providers to develop and evaluate simulation curriculum for emergency medicine trainees in resource-limited settings.

Marideth Rus, M.D., M.Ed.

We developed and coordinate the "Foundations in Global Health" lecture series. This 18-month cycling discussion-based didactic curriculum series, developed with the goal of expanding contextual knowledge on major causes of global child and maternal mortality and providing mentorship and collaboration for ongoing global research projects. The series is targeted towards Texas Children's Hospital Pediatrics, OB/GYN and Surgery fellows and faculty actively involved in global health initiatives, and was adapted into the BCM Fellows' College in July 2013.

Heather Crouse, M.D.

We are developing and will be evaluating a pre-travel simulation curriculum for global health trainees at Texas Children's Hospital to improve the comfort and performance of these trainees during their rotations abroad.

Marideth Rus, M.D., M.Ed., Heather Crouse, M.D. and Heather Machen, M.D., M.P.H.

We developed a Pediatric Emergency Medicine CME course for pediatric and emergency medicine healthcare providers at University Hospital in Marrakech, Morocco in collaboration with BIPAI through a Chevron Social Responsibility Grant. Components of the trip included tours, informal evaluation of the Pediatric and Adult ED and PICU and advising on development of ED processes and flow as well as teaching. We delivered a total of 15 hours of lectures and workshops on PEM and Quality Improvement topics to approximately 25 learners (primarily physicians, residents and nurses).

Heather Crouse, M.D., Ben Choi, M.D., Nick Glomb, M.D., M.P.H. and Binita Patel, M.D.

In collaboration with decision-makers, agency representatives, and other recognized experts in the field we developed an after-action reporting tool to better gauge the effectiveness of disaster response. The final tool will be able to describe the inputs, activities, outputs, outcomes, and impact of a disaster response.

Rajesh Daftary, M.D., MPH (fellow 2010-2013), Andrea Cruz, M.D., MPH (current faculty), and Paul Sirbaugh, D.O. (current faculty)

We have faculty members who have been selected to participate on a pediatric-specific disaster response team. This collaborative effort between the American Academy of Pediatrics, the Centers for Disease Control and Prevention, the National Association of Children’s Hospitals and Related Institutions and the National Disaster Medical System is being developed to deliver clinical care to pediatric patients during declared disasters both in the US and internationally. Through hospital support, we provided patient care in Pisco, Peru after the earthquake in 2007.

Heather Crouse, M.D. (current faculty and fellow 2005-2009), Andrea Cruz, M.D., MPH (current faculty), Brent Kaziny, M.D., Heather Machen, M.D., MPH (current faculty), Paul Sirbaugh, D.O. (current faculty)

Our faculty hold administrative positions for disaster response including the Chief Medical Officer for disaster preparedness for Texas Children’s Hospital and a position on the NACHRI disaster response advisory group.

Paul Sirbaugh, D.O. (current faculty) and Brent Kaziny, M.D. (current faculty)

Tuberculosis (TB):

Due to governmental concerns of limited pediatric tuberculosis diagnostic activities in the country, we collaborated with the Botswana National Tuberculosis Programme, Centers for Disease Control and Prevention, and the Botswana-UPenn Partnership to roll-out improved diagnostic strategies for pediatric tuberculosis. An initiative to improve access to sputum induction and gastric aspirates was started in 2008. Data generated from this roll-out provided information on the burden of pediatric TB in the country, capturing the utility and safety of sputum inductions and gastric aspirates, and informed the development of a Botswana-based pediatric TB diagnostic algorithm. This project was funded by a grant from the Center for Disease Control and Prevention.

Paul Mullan, M.P.H.

Two additional TB projects involve expanding tuberculosis diagnostics for HIV-infected children in Botswana through the use of two additional methodologies. The first, microscopic-observation drug susceptibility testing, uses a relatively low technology, low cost liquid culture methodology to simultaneously grow the TB bacteria and check for drug resistance. In an era of increasing drug resistance globally, this methodology offers a sustainable, timely intervention allowing optimization of individual patient care. A second methodology will determine the utility of interferon gamma release assays, which test for immune response to TB proteins, in children in the same setting, in an attempt to augment diagnosis and targeting of preventive therapy to high-risk children in a setting with tuberculosis hyperprevalence. These projects are being funded by the Thrasher Pediatric Research Foundation Grant.

Andrea Cruz, M.D., M.P.H.

We have worked with or are working with partners at hospitals in Antigua, Guatemala, Lilongwe, Malawi, and the Oriental region of El Salvador to develop and implement triage systems in their emergency departments. We have researched and published the clinical uptake and impact of these triage systems. The project in Guatemala was funded internally through a TCH Educational Grant and in Malawi the project was funded internally through Baylor Pediatric AIDS Initiative (BIPAI)

Heather Crouse, M.D. and Sue Torrey, M.D.

We worked with a multi-disciplinary team of local healthcare workers to develop and implement a new triage system in the Accident & Emergency Department at Princess Marina Hospital in Gaborone, Botswana. The triage system was successfully launched in April 2010 and clinical outcomes evaluated and published in 2013. The project was funded internally by the TCH Section of Emergency Medicine.

Paul Mullan, M.D., MPH

We are working in collaboration with the Ministry of Health of Botswana to create a simulation-based training program for pre-hospital providers in Botswana on a review of most common response calls recorded in their log books. The first course will be delivered in September 2015. Pre- and post-training self-evaluation by training participants will be conducted. All MOH pre-hospital providers will receive baseline training in the AAP's Pediatric Educations for Pre-Hospital Providers (PEPP) curriculum prior to being enrolled in the simulation program. A $40,000 TCH Educational Award was awarded to support this effort.

Nick Glomb, M.D., M.P.H., Cara Doughty, M.D., M.Ed., Deola Kosoko, M.D., Marideth Rus, M.D. and Manish Shah, M.D.

We have been working clinically in Gaborone, Botswana since spring 2014 laying the groundwork for possible development of a formal academic partnership between the University of Botswana, Princess Marina Hospital, Baylor College of Medicine/Texas Children's Hospital Section of Emergency Medicine in order to effectively improve the management and care of acutely ill patients in Botswana and to develop long-term capacity building for sustainable training programs in country. We will be conducting a formal site assessment in October 2015 to determine feasibility of a formal academic partnership including understanding opportunities for collaboration, investigating possible funding models and development of a partnership structure for staffing, education/research support and administrative support. Beginning October 2015 we will pilot a program of capacity building through direct teaching/training and development of PEM-based educational curricula and support provision of care for acutely ill children via five PEM faculty/fellows rotating at Princess Marina Hospital during the 2015 - 2016 year.

Heather Crouse, M.D., Nick Glomb, M.D., M.P.H., Rebecca Chancey, M.D, M.P.H., Amber Hathcock, M.D., M.P.H. (current Global Health Fellow), Deola Kosoko, M.D. and Marideth Rus, M.D., M.Ed.

We worked with our partner hospital in Antigua, Guatemala to scale-up ETAD/CETEP trainings locally for pediatric healthcare providers from referral health centers, health posts, ambulances and the fire department in the region of Sacatepequez, Guatemala. The program included training in pediatric evaluation and management with ETAT/CETEP, the development of local triage processes, and assistance in the formalization of referral and counter-referral systems in the region. Internal funding was secured through a TCH Educational Grant.

Heather Crouse, M.D. and Rupa Kapoor, M.D.

We are working in Entebbe, Uganda in collaboration with an NGO to construct a pediatric emergent and urgent care facility in collaboration with local personnel and officials in a rural village in Uganda where advanced medical care is not already available, with an overall goal of education and sustainability. A publication describing how the formal needs assessment with local, surrounding health center, community leaders, medical community leaders, and officials form the Ministry of Health advised the facility's construction and processes is pending. We will bring providers to construct ETAT trainings with healthcare providers on site in January 2016 as the clinic is set to open.

Carol Chen, M.D.

We are working in La Guajira, Colombia in collaboration with Chevron and the BIPAI SAIL program (Health and Indigenous Self-Sufficiency) aimed at improving the health of a migrant indigenous community in a remote part of the country. In 2015 we sent six PEM faculty/fellows to provide pediatric care for area children for one week per month for a period of three months in April, May and June during a gap in their program's pediatric coverage. Cumulatively, we saw over 500 patients, the majority of which had malnutrition, and have plans to begin collaborating with the program in the coming months to support their efforts. Anticipated projects include ETAT/CETEP trainings for health promoters and personnel in the local health centers and hospitals and a collaborative project to improve the referral/counter-referral system in the region.

Heather Crouse, M.D., Eric Russell, M.D., Elsa Haddad, M.D., Esther Sampayo, M.D., M.P.H., Claritsa Santos-Malave, M.D., and Manish Shah, M.D.

In collaboration with Rice University, we are developing an inexpensive, durable, easy to use device to provide bubble continuous positive airway pressure to provide respiratory support to infants and young children in resource-limited settings. The device and accompanying educational program was piloted in Malawi starting fall 2011 and is being expanded throughout Africa. The project is funded by a U.S. Agency for International Development/Gates Foundation grant.

Heather Machen, M.D., MPH (current faculty)