www.jped.com.br
REVIEW
ARTICLE
Pediatric
emergency
in
Brazil:
the
consolidation
of
an
area
in
the
pediatric
field
夽
Jefferson
P.
Piva
a,b,
Patrícia
M.
Lago
b,c,
Pedro
Celiny
R.
Garcia
d,∗aUniversidadeFederaldoRioGrandedoSul(UFRGS),HospitaldeClínicasdePortoAlegre(HCPA),PortoAlegre,RS,Brazil
bUniversidadeFederaldoRioGrandedoSul(UFRGS),PortoAlegre,RS,Brazil
cHospitaldeClínicasdePortoAlegre(HCPA),UnidadedeEmergênciaPediátrica,PortoAlegre,RS,Brazil
dPontifíciaUniversidadeCatólicadoRioGrandedoSul(PUCRS),EscoladeMedicina,Servic¸odeMedicinaIntensivaeEmergência,
PortoAlegre,RS,Brazil
Received23June2017;accepted5July2017 Availableonline1September2017
KEYWORDS
Emergency; Pediatrics; Medicalresidency;
Teachingprogram
Abstract
Objective: Theaimofthisstudywastopresentareviewontheevolution,development,and consolidationofthepediatricemergencyabroadandinBrazil,aswellastodiscusstheresidency programinthiskeyareaforpediatricians.
Datasources: Thiswasanarrativereview,inwhichtheauthorsusedpre-selecteddocuments utilized as the minimum requirements for the Residency Program in Pediatric Emergency Medicineandarticlesselectedbyinterestforthethemedevelopment,attheSciELOandMedline databases,between2000and2017.
Datasynthesis: The historicalantecedentsand theinitial evolution ofpediatric emergency inBrazil,aswellasseveralchallengesweredescribed,regardingtheorganization,thesize, thetrainingofprofessionals,andalsotheregulationoftheprofessionalpracticeinthisnew specialty.Additionally,anew pediatricemergencyresidencyprogram tobeimplementedin Brazilisdescribed.
Conclusions: Pediatricemergencytrainingwillbeapowerfulstimulustoattracttalented indi-viduals,toestablishtheminthiskeyareaofmedicine,wheretheycanexercisetheirleadership bypromotingcarequalification,research,andteaching,aswellasactingdecisivelyintheir management.
©2017SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/ 4.0/).
夽
Pleasecitethisarticleas:PivaJP,LagoPM,GarciaPC.PediatricemergencyinBrazil:theconsolidationofanareainthepediatricfield.
JPediatr(RioJ).2017;93:68---74.
∗Correspondingauthor.
E-mail:[email protected](P.C.Garcia). https://doi.org/10.1016/j.jped.2017.07.005
PALAVRAS-CHAVE
Emergência; Pediatria;
Residênciamédica;
Programadeensino
EmergênciapediátricanoBrasil:aconsolidac¸ãodaáreadeatuac¸ãoparaopediatra
Resumo
Objetivo: Oestudotevecomoobjetivoapresentarumarevisãosobreaevoluc¸ão, desenvolvi-mentoeconsolidac¸ãodaEmergênciaPediátricanoexteriorenoBrasilassimcomodiscutiro programaderesidêncianestaimportanteáreadeatuac¸ãoparaopediatra.
Fontesdosdados: Trata-sedeumarevisãodotiponarrativa,emqueosautoresutilizaram docu-mentospré-selecionadosempregadosnosrequisitosmínimosparaoprogramaemResidênciade MedicinadeEmergênciaPediátricaeartigosselecionandoporinteresseparadesenvolvimento dotemautilizaramasbasesdedadosSciELOeMedlineentre2000e2017.
Si´ntesedosdados: Foramdescritososantecedenteshistóricoseaevoluc¸ãoinicialda Emergên-ciaPediátricanoBrasilediversosdesafios,naorganizac¸ão,nodimensionamento,naformac¸ão deprofissionaise,também,naregulamentac¸ãodoexercícioprofissionaldestanova especial-idade.TambémsedescreveumnovoprogramaderesidênciaemEmergênciaPediátricaaser implementadonoBrasil.
Concluso˜es:A formac¸ão em emergência pediátrica será um poderoso estímulo para atrair indivíduostalentosos,fixá-losnestaimportanteáreadamedicina,ondepoderãoexercersua lideranc¸apromovendoqualificac¸ãonaassistência,napesquisaenoensino,assimcomoatuando decisivamentenoseugerenciamento.
©2017SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Este ´eumartigo OpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4. 0/).
Introduction
Startingin thesecond halfofthe lastcentury,emergency
services in most countries have experienced a
substan-tial increasein theirvolumeof care.The reasons for this increaseindemandincluderapidaccesstodiagnosticand therapeuticresources;thecomplexityandresolutivenessof thesector,beinganalternativeandfacilitatedroutefor hos-pitaladmission;and,insomecases,accesstomedicalcare withoutcoststotheuser.
ItisestimatedthatintheUnitedStates,over115million visits to emergencyservices are made annually;10%---12% of themaretransportedby ambulance.Of thistotal,18% areintendedforthecareofchildrenandadolescentsunder
15 years of age, and 75% of these services are provided
in emergency services located in general hospitals. It is
also estimated that 40% of hospital admissions of
pedi-atricpatientsoccurthroughemergencyservices.1,2InBrazil,
thereislittledataavailable,butaccordingtotheportalof theMinistryofHealth,over300,000callswerereceivedfrom patientswithsometypeofurgencybetweenJanuary2016 andMarch2015,duringwhich72,000patientsweretreated in specialized emergency units and 81,000 in emergency units. Around 10% of the total number of visits (approxi-mately30,000visits)requiredobservationformorethan24h inaspecializedunit.Theheterogeneityofprehospitalcare inBrazilis alsonoteworthy, asin6900 casesthecarewas providedthroughboats.3
Obviously, this complex system, which has become increasingly overloaded, has brought several challenges: organization,size,trainingofprofessionals,aswellasthe regulationofprofessionalpractice.
The development of the emergency specialty is very recent in most countries, with a very similar history of development and recognition among them. In 1968, in the United States, the American College of Emergency
Physicians(ACEP)wasfounded;thespecialtywasrecognized in1979andissueditsfirstcertificatein1980.After1982,the minimumrequirementsfortheResidencyProgramin Emer-gencyMedicinewereapproved,followedbythefirstannual fellowshipprogramin 1989.After 2000,emergency medi-cal residency training and the certificate issued by ACEP becameprerequisitesforclinicalpracticeinemergency ser-vices.Evenwiththisrecenthistory,emergencyisnowone ofthelargestmedicalspecialtiesintheUnitedStates,with over25,000activeprofessionals.1,4
From the recognition of the specialty, the search for emergency care standardization directed to the pedi-atric range was natural and obligatory. The death of an 18-year-oldadolescentinNewYorkattributedtothelackof adequateemergencycarewasthetriggerforthecreation,in 1984,oftheEmergencyMedicalServicesforchildren, aim-ingtoensuretreatment for childrenandadolescentswith severediseasesorvictimsoftrauma,reducetheir dysfunc-tions, preventdeath, and promote rehabilitation.5 In the
firstdecade of itsimplementation, operatingnorms were defined,fundingwasallocatedtospecificprojects,and epi-demiologicalknowledge and informationwere distributed totheentiresystem.Attheendofthefirstdecade, pedi-atric emergency training programs aimed at medicaland non-medicalprofessionals wereinstituted,including pedi-atricbasicandadvancedlifesupport(PALS).Inthesecond decade,protocolsforprehospitalcareweredeveloped, min-imumpediatricequipmentintheemergencyserviceswere defined, and the emergency care was regionalized, with patientreferralandtransfer,followingalogicalpatternof increasingcomplexity.4
After itsrecognition, pediatric emergencybecame the fastestgrowingareaintheUnitedStates--- approximately 500%intheperiodbetween1992and1999---andisthe sec-ondmostsought specialtybypediatricianswhocompleted thebasicresidence,secondonlytoneonatology.1,4Afteran
acceleratedgrowthphaseinthepediatricemergency resi-dencyprogramsintheUnitedStates,anaturalstabilization andconsolidationwasobserved,withareductioninthe pro-liferationofnewtrainingprograms.Sincethen,thegoalhas beentostandardizetrainingintheseveralservicesandto lookforward tothefuturechallenges forthe new millen-nium.Intheearly1990s,therewasgreatdisparityintraining providedbytheprograms.Itwasobservedthat75%ofthe first-yearresidentsworkedwithoutadequatesupervisionin thedifferentprograms,apercentagethatwasreducedto less than 20% in 2000. At the end of the first decade of thenew millennium, most pediatric emergency residency programsbecame a three-yearprogram with a minimum-curriculumdefinition,aswellasskillsandcompetencesto beachieved.1,2,4---6
Evolution
of
pediatric
emergency
in
Brazil
Inthe1970sand1980s,Brazilstillsufferedfromthe conse-quencesofmajorandsevereepidemicsduetothelackof vaccinecoverageand,especially,basicsanitation.Evenwith advancesintheseareas,pediatricemergencyserviceswere stilloverloaded,as theyrepresented(and stillrepresent) thebestoptionforhealthcareaccess.
Since the 1990s, the Brazilian Society of Pediatrics
(SociedadeBrasileiradePediatria[SBP])hasstarteda move-menttostimulateandregulatetraininginpediatricareas, such as pediatric intensive medicine, neonatology, pneu-mology, pediatric nephrology, and pediatric neurology. To meetthisdemand,itwasdecidedtogetherwiththeNational
Commission of Medical Residency (Comissão Nacional de
ResidênciaMédica[CNRM])toaccreditsomeresidence
pro-grams to offer the optional third year of the residency
program in pediatrics for training in the specific area. Within this context, the third optional year in the pedi-atricresidencyprogram,aimedatpediatricemergency,was establishedinseveralservicesandpersisteduntil2002.In that year, a significant change occurred withthe unifica-tion of Specialties and Areas of Practice defined by the BrazilianMedicalAssociation(Associac¸ãoMédicaBrasileira
[AMB]),CNRM, andthe Federal Council of Medicine
(Con-selhoFederaldeMedicina[CFM]).Forreasonsunknown to
date, urgency and emergency became an area linked to
the internal medicine practice.7 From that moment on,
pediatric emergency ceased to be an area of action of pediatrics;this program wasno longer recognizedby the CNRM andthus the formation of pediatricians with train-ing and qualification in pediatric emergency activity was suspended for over a decade. Evidently, this impossibil-ityin theformation of qualified professionalsin pediatric emergencywasveryharmfultotheBrazilianpopulation,to pediatricians,andtoteachingandresearchactivitiesinthis country.
Despitethe repeatedrequests bytheSBPtotheCNRM andAMB,thisillogicalsituationpersisteduntil2015,when a decisive fact took place that changed the direction
Figure1 MeetingheldattheFederalMedicalCouncil (Con-selhoFederaldeMedicina[CFM]) withrepresentativesofthe NationalMedicalResidencyCommission(ComissãoNacionalde ResidênciaMédica[CNRM])andrepresentativesof20Brazilian institutions (medicalschools andteaching hospitals),a where the residency programs in emergency (adults) and pediatric emergencyweredefinedandapproved.(June2015).
aHospitaldeClínicasdePortoAlegre(HCPA),Universidade
Fed-eraldoRioGrandedoSul(UFRGS),PortoAlegre,RS;Hospital deProntoSocorro,PortoAlegre,RS;HospitalSãoLucas, Pon-tifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS; Irmandade Santa Casa de Misericórdia de Porto Alegre (ISCMPA), Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS; Universi-dadeEstadualdeCampinas(UNICAMP),Campinas,SP;Hospital Geral de NovaIguac¸u (HGNI),NovaIguac¸u, RJ;Universidade FederaldeMinasGerais(UFMG),BeloHorizonte,MG;Hospital de Messejana, Fortaleza, CE; Instituto da Crianc¸a, Universi-dadedeSãoPaulo(USP), SãoPaulo, SP;IrmandadedaSanta Casa de Misericórdia de São Paulo, São Paulo, SP; Hospital Santa Marcelina, São Paulo,SP; Hospital Infantil Sabará,São Paulo, SP; Universidade de São Paulo (USP), Ribeirão Preto, SP; Universidade Federalde SãoPaulo(UNIFESP),SãoPaulo, SP;HospitaldasClínicas,UniversidadedeSãoPaulo(USP),São Paulo,SP;HospitalAlemãoOswaldoCruz,SãoPaulo,SP; Hospi-taldoCorac¸ão(HCor),SãoPaulo,SP;HospitaldeClínicasGaspar Vianna, Belém, PA;Hospital Municipal Infantil Menino Jesus, SãoPaulo,SP;HospitalInfantilDarcyVargas(HIDV),SãoPaulo, SP,Brazil.
A
pediatric
emergency
residency
program
for
Brazil
Whenproposingaresidencyprograminpediatricemergency tobeimplementedinBrazil,someguidingassumptionswere chosenforthecreationoftheprogramcontent,skills,and
competences, as well as training time,among which the
followingstandout:
‘‘Topreview,prepare,andenabletheirgraduatestoface thechallenges anticipated for thenextdecades in the servicesofPediatricEmergency.’’
In this context,it shouldbe emphasizedthat pediatri-cianswhoarenowenteringtheseprogramswillbeworking inthecareofchildrenandadolescentswithacutediseases in the next 30---35 years (i.e., between 2020 and 2050). Therefore,theywillface challengesin carethat arevery differentfromthoseexperiencedtothisday.Someofthese futurechallengeshavealreadybeenwellidentified.Studies thatanalyzedthechangesindiseaseprofiles overthelast few years suggest that the greatestchallenges for pedia-triciansinthecomingdecadeswillberelatedtoadolescent pregnancy,perinatalmortality,urgencymedicine,infections (sepsis),external causes (includingaccidents, alcohol and drug use), chronic diseases, and children with ‘‘medical complexity.’’10 Thus, differently from what occurred 20
yearsago,thereisagrowingcontingentofpediatricpatients withchronic diseases,andevenatthefinalstagesof life, beingtreatedinpediatric emergencyservices.Theability totreatthesepatientsandtheirfamiliesisapriorityinthe teachinggoalsofthenewprograms.11
Not only the disease profile tends to change, but also the diagnostic features. Almost all areas of modern medicineincorporateroutineechocardiographyperformed at the bedside, increasing both diagnostic sensitivity and specificity.Specifically,intheemergencyservice,this pos-sibilityhasfoundgreatapplicability.12,13Ofcourse,thisskill
becomesanessentialrequirementforthenewpediatricians workinginemergencycare,representingagreatchallenge in their formation, because few chief residents currently dominatethistechnique.Programsshouldestablish partner-shipswithradiologyservicesorotherservicessothattheir residents have a minimum and sufficient training to deal withthemostprevalentsituationsinpediatricemergency.
Modelandresourcesforlearningandacquiring skills
Asinseveralcountries,theacquisitionofknowledge,skills,
and competence in pediatric emergency should follow a
modelbasedondailypractice,throughthediscussionand review of moreprevalent caseswith apreceptor actively involved in theteachingprocess. The less frequent situa-tionsmustbeexperiencedthroughasimulationlaboratory orotherteachingpracticessuchasfilmsanddramatizations, amongothers.14
It has been observed that residency programsin pedi-atrics,neonatology,andpediatricemergency,amongothers, exposeresidentstoa smallnumberof morecomplex pro-cedures, less that the amount proposed and considered as the minimum desirable.14---17 In the proposed program,
residentstoprovetheirparticipationandperformancewith adequatesupervisioninaminimumofthesemorecomplex procedures.
Trainingleaderstoworkinpediatricemergency services
Inadditiontotheknowledge,skills,andcompetences,the graduatesofthesenewprogramsmustbetrainedtoassume thestatusofleadersoftheirservices,coordinatingcareand administrativeactivities.
Aquestioncouldberaisedonwhethertheadoptionofthe pediatricresidencyprograminthreeyearswouldnotbe suf-ficienttoenableprofessionalstoactasmedicalleadersat severallevels(care,teaching,research,andmanagement) inemergencysettings.Evenconsideringthat20---25%ofthe workloadofthethree-yeargeneralpediatricresidency pro-gramsoccursintheemergencydepartment,thistrainingis incompleteforwhatisexpectedofaprofessionalwholeads theprocessinthisimportantarea.
Internationalstudiesevaluatingtheabilitiesand experi-enceofpediatricresidenceprograms(three tofouryears) developedin large hospitalsshow that,at the endof the residency,thesepediatricianshaveinsufficientexposureto
theminimumrecommendedpediatricemergencysituations.
Inastudyevaluatingthepediatricresidencyprogram(four years)atalargereferralcenterintheUnitedStates,itwas observedthat89%ofpediatricresidentswerenotexposedto
theminimumsituationsrecommendedbytheCNRMinthat
coutry.16 Anotherstudyshowedthatpediatric residentsin
theirregular emergencydepartment training areexposed toasmallnumberofcriticalpatients(∼14severepediatric
patients per resident during the trainingperiod).17 These
sameshortcomingsintrainingandskillacquisitionby emer-gencypediatricresidentswerealsoobservedinBrazil,15 as
well as through the analysis of their performance at the boardcertificationtestpromotedbySBP.
Theseresultsdonotnecessarilymeanthatpediatricians arenotcapableofworkinginpediatricemergencyservices. However,it is imperative to recognize that they prevent theseprofessionalsfrombeingareference,aleader,andan innovativeelementinthisarea.Thegapsintheirskillsand abilitiesinthisarearequireanadequatelytrainedand qual-ifiedprofessionaltosupportandimprovetheirperformance whileworkinginapediatricemergency.
In Brazil, theneed for a vocational and acknowledged speakerinthisareahasbeenobserved,tobean interlocu-torinboththeintra-hospitalandextra-hospitaldiscussions aimedattheimplementationofmanagementpoliciesand careinpediatricemergency.
Toexpandtheofferofemergencypediatriciansin theshort-term
Aftermorethanadecadewithoutprovidingresidency pro-grams in pediatric emergency, qualified professionals are neededinall regionsofthe country.Evenconsidering the mostoptimistic calculations, therewillbe agreat gap to befilledintheseveralservicesofthecountry.Inthis con-text,theproposalfor thenextyearsisthattheresidence
thecourseof oneyear,complementingthethreeyearsof residenceinpediatrics.Itwasunderstoodatthetimeofthe proposalpresentationthatthispolicywouldallowthe
fulfill-ment,inamaximumofonedecade,ofthemainpositions
of leadership and coordinationof pediatric emergency in Brazil.Thereafter,anewlevelwillbeestablished, develop-ingtheprogramintoatwo-yeartrainingperiod,asinother pediatricareas(pediatricintensivemedicineand neonatol-ogy,amongothers).
Developmentofpediatricemergencyresearch
Inanattempttopreparethemselvesforthisnewscenario, theUSNationalHealthInstitute(NHI)hasrecentlychosen threepriorityfieldsforthedevelopmentandstimulationof pediatricresearch:pediatricintensivecare,pediatric emer-gencyandrehabilitationofchildrensufferingfromacuteor chronicdiseases.Researchinthepediatricemergencyarea hasbeenrelegatedandpoorlydeveloped,requiring,in addi-tiontoresearchresources,thetrainingofskilledresearchers with interest and knowledge in this area.18,19 Therefore,
among the challenges for the next decades, emergency medicineshouldbeconsideredasapriorityinresearchon childrenandadolescents’health.20
Duetotheaforementionedreasons,theauthorsbelieve thatpediatricemergencytrainingwillbeapowerful stim-ulus to attract skilled individuals, to establish them in this important area of medicine, where they can exer-cise their leadership by promoting qualification in care, research,andteaching,aswellasdecisivelyworkinginits management.
Residency
program
in
emergency
and
pediatric
emergency
area
ApprovedbyCNRMinAugust2015:
1- Duration:oneyear
2- Numberofopenings:theminimumopeningnumberwas
definedastwoperservice,whilethemaximumnumber ofresidentswillbedefinedaccordingtothevolumeand facilitiesofferedbytheservice
3- Workload:60hperweekaccordingtoCNRM recommen-dations,including30-dayvacations.
4- Objectivesoftheprofessionaltobetrained:
--- To deepen the knowledge,skills, and competences intheareaofpediatricemergencyinitsseveral sce-narios.
--- To develop the capacity to generate knowledge
within four components: clinical skills, research,
education,andmanagement.
--- To train leaders who can influence and have an
impactonthecare,managementandplanningofthe sector,includingleadershiprolesinmultiprofessional teams.
--- Trainingofprofessionalswhoareabletocontribute tothecreationofsolutionsalignedwiththe health-carepolicyneedsoftheirregion.
5- Trainingsites
--- Pediatric Emergency Service with a minimum of
50,000annualoutpatientvisits.
--- The care complexity should ensure a minimum
demandcloseto10% ofpatientsclassified asupto secondlevelonthepriorityscale(fivelevels) --- Intraandextra-hospitaltransportation
--- Pediatric intensive care unit (at least ten
beds).
--- Anesthesiology and surgery (imaging services with
anesthetic procedures/surgical center/anesthetic
recovery). --- Traumaservice.
--- Imagingarea(radiologyandultrasound)
--- Complementary options (e.g., otorhinolaryngology, cardiology, pneumology,burn unit, poisoning,
acci-dentswithvenomousanimals,amongothers)
6- Cognitivegoalsoftheprogram
Aminimumof10%oftheworkloadshouldbeallocated to theoretical activities, either as classes, seminars, clinical discussions, and article reviews, among oth-ers. The theoretical-practical basis should cover the mainacutesituationsinPediatrics,suchasthoselisted below,butnotrestrictedonlytothese:
a. Cardiopulmonaryresuscitation. b. Rapidsequenceintubation.
c. Shock(septic,hypovolemic,cardiogenic). d. Acuterespiratoryfailure.
e. Severeacuteasthma
f. Basicnotionsomechanicalventilation.
g. Upperairwaysemergencies.
h. Meningoencephalitis. i. Statusepilepticus j. Sedationandanalgesia. k. Diabeticketoacidosis.
l. Initial care to the polytraumatized and cranial
trauma.
m. Exogenouspoisoning.
n. Accidentswithvenomousanimals.
o. Anaphylaxis.
p. Hypertensiveurgencies.
q. Syncopeandcoma
r. Congestiveheartfailureandcyanosiscrisis. s. Heartrhythmdisturbances.
t. Hydroelectrolyticandacid-basedisorders.
u. Ethical and legal aspects of care in emergency
services
v. Basicconceptsinmanagementandadministrationof emergencyservices.
w. Notions in scientific methodology for research in emergency.
x. Catastrophecare.
y. Emergencysurgicalpathologies
z. Ultrasoundatthebedside(pointofcare).
7- Competences
a. To recognize signs of severity and the acute
diseases in children and adolescents treated at
emergency/urgencyunits andtheadequate
imple-mentationoftherespectiveprotocols. b. Topromptlyestablishurgencylinesofcare. c. Toassistinthecareofpatientswithspecificneeds
e. To propose and develop a research project (monograph)
f. To demonstrate the ability to manage the unit’s
administrativeprocesses(costmanagement,human
resourcesallocationandflows)andtherelationship withmunicipalandstatehealthnetworks.
g. Toparticipateinthemanagementtool implementa-tion(care protocolsand qualityindicators, among others)
h. To be familiar with the priorities and national/ regional healthcare policies with emphasis in the areaofpediatricemergency.
8- Skills
Aminimumsetofskillswillberequired,asfollows:
a. Peripheral and central venous access (including
umbilicalcatheter)---minimumofsixaccesseseach; arterialaccess(minimumsix);
b. Intraosseousaccess---minimumoffouraccesses; c. Airwayaccess---minimumoftwelve;
d. Invasiveandnon-invasiveventilatorysupport; e. PALSorequivalente;
f. Minimum of invasive procedures: lumbar (twelve),
suprapubic(twelve),thoracic(four)punctures; g. Identificationofalterationsandmajoracutediseases
inimagingtests(echography,radiography,CT,and/or MRI);
h. Experienceinapplyingprioritycareclassification sys-tems(‘‘riskclassification’’);
i. Presentationofafreethemeorsubmissionofan arti-cletoajournal
9- Descriptionofactivities
Theactivitieswillbecarriedoutintheunititselfand otherplaces(Table1).
10- Assessment
Residents willbeassessed onthe following aspects everysixmonths:
Attitudes
- Posture,communication,andintegration,among oth-ers
Knowledgeandskills
- Domainofcontentsoftheareaandprotocols,among others
- Researchproject(TermPaper)
Skills
- Checklistofacquiredskills
11- Attheendoftheinternship,theprofessionalshouldbe ableto:
Table1 Descriptionofactivities.
Location Workload(%)
Pediatricemergencyservice/unit 50%---70% Pediatricintensivecareunit 5%---10%
Transportation 5%---10%
Imaging 5%---10%
Trauma 5%---10%
Surgeryandanesthesia 5%---10%
Optional 5%---10%
Thisdistributiondoesnotnecessarilyimplyafixeddivisioninto
blocks.
a. Identify,diagnose,andtreat themainacute situa-tions in Pediatrics according tothe best scientific evidence(protocols).
b. Identify, diagnose, and start treatment based on
thebestscientificevidence(protocols)ofthemain emergency situations in the pediatric specialties (e.g.,otorhinolaryngology,ophthalmology, orthope-dics,neurology,andneurosurgery,amongothers). c. Correctly interpret the usual imaging tests in the
mainpediatricemergencysituations.
d. Performkeyemergencyprocedures.
e. Leadthemedicalandmultiprofessionalteaminthe areaofpediatricurgencyandemergency.
f. Understandregionalhealthpoliciesandthehospital referralsystem;
g. Lead and organize a pediatric emergency care
service.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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![Figure 1 Meeting held at the Federal Medical Council (Con- (Con-selho Federal de Medicina [CFM]) with representatives of the National Medical Residency Commission (Comissão Nacional de Residência Médica [CNRM]) and representatives of 20 Brazilian instituti](https://thumb-eu.123doks.com/thumbv2/123dok_br/14994803.513254/3.918.479.847.85.328/medicina-representatives-residency-commission-comissão-residência-representatives-brazilian.webp)
