The 4H and 4T Pediatric Early Acute Support in the Deteriorating Child: Competent Staff Instead Experts Facing the New Threats, and New Approaches Can Reduce Mortality – Experience in Guatemala

Abstract

Pediatric advanced life support courses provide widespread education on recognizing and treating cardiac arrest in children. Their main goal is to teach the cardiopulmonary resuscitation (CPR) sequence and improve early recognition and treatment of leading causes for better survival rates. Initially, there were four “H” and four “T” conditions, but now 12 are recognized. The 12 reversible conditions, categorized as “H’s” and “T’s,” consist of seven starting with “H” and five starting with “T.” The “H’s” include hypovolemia, hypoxia, hydrogen ion excess (acidosis), hypoglycemia, hypokalemia, hyperkalemia, and hypothermia. The “T’s” include tension pneumothorax, tamponade—cardiac, toxins, thrombosis (pulmonary embolus), and thrombosis (myocardial infarction). Finding specific training for these conditions in structured courses can be challenging. However, understanding their physiological basis enables healthcare providers to detect and treat them early, leading to improved outcomes and reduced mortality rates in Guatemala. In response to the COVID-19 outbreak, a regular course on managing these conditions was initiated for pediatric intensivists, pediatricians, and healthcare staff. In 2022, the Continuing Medical Education program at Universidad de San Carlos de Guatemala extended coverage to 134 physicians in rural areas and 50 pediatric intensivists from the Sociedad Latinoamericana de Cuidado Intensivo Pediátrico (SLACIP).

1. Introduction

The widespread education and goals of the pediatric advanced life support (PALS) have been demonstrated as an important competence that implies skills and attitudes related to decision-making and teamwork in the healthcare personnel. In high-income countries, when personnel is hired, this becomes a requirement for the startup and it is expected, as a hospital requirement, to keep and update certification [1, 2, 3, 4, 5].

PALS guidelines published by the American Heart Association (AHA) are designed for resuscitation in a broad range of scenarios and environments. In general, the main goal of several life support courses is to learn the sequence for cardiopulmonary resuscitation; the related algorithm for cardiac arrest evaluation always goes back to the recognition of its leading causes that need rapid assessment and treatment to increase survival. These conditions were initially described as 4 “H” and 4 “T” (H and T are related to the first letter of each of the conditions). Currently, several centers and healthcare providers recognize 12. The 12 H’s and T’s are reversible conditions, of these seven start with H and five start with T. These conditions are:

• H’s: hypovolemia, hypoxia, hydrogen ion excess (acidosis), hypoglycemia, hypokalemia, hyperkalemia, and hypothermia.

• T’s: tension pneumothorax, tamponade—cardiac, toxins, thrombosis (pulmonary embolus), and thrombosis (myocardial infarction).

It is not easy to find specific training for H & T’s conditions in structured courses. Understanding the physiological basis of these conditions can give the healthcare provider the opportunity of an early detection and treatment of these life-threatening conditions.

The required competencies, the understanding, and the metacognition of these conditions need more expertise than “getting the pass score” in the PALS course.

In developing countries, the main barrier to taking the PALS courses is the copyright and the merchandise; this course has been registered as intellectual property implying a payment for using the license. Currently in developing countries, the deployment of basic biological and educational science in the training and performance of the residents is still the focus. The quality assurance knowledge and the adherence to guidelines, protocols, and procedures still require a cultural change and the development of the teamwork concept; this is not only about technology [4].

Even knowing that the basic life support and the advanced life support courses are designed for the early recognition and treatment of the imminent cardiac arrest, the availability in low- and middle-income countries is very limited due to the market implications and subsequent cost, without any consideration about the design or quality of the training during the course. The AHA (American Heart Association) courses are more extended with all the implications already described [1, 2, 3, 4, 5].

Since the 1990s, the cardiopulmonary resuscitation courses in collaboration with colleagues from the USA begun; it was yearly and primarily directed to people who can speak English. Some years, the course was discontinued, and during other years, it was taken by the exact same group due to the English language barrier and consequence never disseminated among others, losing a lot of good opportunities for distributing knowledge to healthcare professionals only due to language barrier that could be easily solved.

In 2003, at the Pediatric Intensive Care Unit in Hospital General San Juan de Dios, we started endorsing and implementing standard guidelines for pediatric traumatic brain injury and goal-directed therapy, using validated protocols, guidelines, and quality assurance in the formation of human resources and for clinical management. Between 1995 and 2003, a very high mortality rate in 12-bed wards in the national reference hospital in Guatemala was reported; the mean Pediatric Risk of Mortality score—PRISM III was 6–9 points in deceased patients.

In 2009, the RIBEPCI (Red Iberoamericana para el Estudio de la Parada Cardiorrespiratoria en la Infancia) started working with us in Guatemala; this group endorsed the Grupo Guatemalteco de Reanimación Avanzada Pediátrica (GRAP) GUATEMALA, who can keep in a local manner a regular structure and education of the Health Care Staff Spanish and with nonprofit purposes. This course gives the possibility to the healthcare providers of delivering these courses to their own staff once they are certified. The RIBEPCI courses are based on and endorsed by the European Resuscitation Council (ERC).

In 2009, the Postgraduate course of Pediatric Intensivists began with the endorsement of the Universidad de San Carlos de Guatemala.

The RIBEPCI experience and GRAP GUATEMALA experience in the Hospital General San Juan de Dios were combined and led to the creation of SOYUTZ Pediatric Emergencies Simulation Center in 2014. The word soyutz, it is a mixed word from Russian Soyuz that means “union” and Utz in quiche Mayan language that means “good” and the word soyutz means good union, this is representing teamwork).

There is an important need of retaining trained staff and of maintaining them updated, this will allow an integrated flow in the scope of an attention model based on decision-making process sharing for optimizing the time-sensitive interventions. The fragmentation of healthcare in several specialized medicine fields results very frequently in an orphan patients; these “orphan” patients are in the middle of several medical specialties and even with an overlapping attention, the decision-making is not shared and could become a great conflict. The artificially separated attention of patients who need noninterventional attention and the patients that could require a surgical intervention becomes a problem in facilities of developing countries; in this kind of setting, we can find a primary care physician able to solve several conditions; and the level of the University hospitals would be very important that surgery, orthopedics, trauma anesthesia, pediatrics, emergency, and pediatric intensive care residents share the algorithms for recognition and treatment, no matter if these belong to the pediatric field or to the primary care field [6].

The classical approach for diagnosing sepsis, trauma, burns, surgical conditions, pneumonia, dengue, hypovolemic shock caused by diarrhea, diabetic ketoacidosis, and even COVID-19, among others, using the construction of a concept adding signs and symptoms with some grade of sensibility and specificity, could lead to diagnostic criteria with a high level of uncertainty; this also generates important delays for patient stabilization in emergency departments and hospitalization wards. This situation plus, the decision-making about referring a patient to a healthcare facility without solving access barriers like distance and quality of the roads, constitute a model of delays avoiding a fast-track process of recognition–stabilization, increasing the negative impact of hypoxia, ischemia, and reperfusion injury [7, 8, 9].

Patients with trauma or requiring surgery, could also have a congenital condition or an oncologic diagnosis; these adaptative conditions related to the disease, their related treatment, and potential complications should be considered before the surgery due to their very high possible relationship with deterioration and cardiac arrest when these are underestimated. In the perioperative environment, most of the arrests are witnessed, the patients are being monitored at the time of arrest, and the reason for the arrest may be related to the intervention or treatment. In this chapter, the perioperative period is defined as the period in which the patient is cared for by the anesthesia team and focuses on events that occur in the operating room, procedural areas, and diagnostic imaging areas from the moment that the patient is seen for the first time by the anesthesia team until the patient is transferred to another service or is discharged to home or to another facility. Cardiac arrest is defined as a “no-flow” state requiring chest compressions (open or closed chest) or failure to wean from cardiopulmonary bypass.

The cardiac arrest is categorized as out-of-hospital cardiac arrest (OOHCA) or in-hospital cardiac arrest (IHCA), both requiring a structured attention, using good quality cardiopulmonary resuscitation; the issue with this is that both conditions imply a pulseless event or a life-threatening condition. The cardiac arrest has three phases, and these phases have important implications for therapeutic actions. The cardiopulmonary resuscitation utilizes a rhythm-based approach, and the problem is that this action only considers the time elapsed after the onset of cardiac arrest. The cardiac arrest is addressed using the three-phase time-dependent model. This model is clearly time-dependent considering for clinical evaluation “0 min” as the startup [10].

The three phases in this model are:

1. First phase (electrical): Begins with the onset of cardiac arrest and lasts for about 5 min; the therapeutic gold standard for this phase is early and rapid defibrillation.

2. Second phase (circulatory): Exists between 5 and 10 min after the initiation of arrhythmic cardiac arrest. The treatment objective in this phase should be the maximization of blood flow to the myocardium.

3. Third phase (metabolic): Begins 10 min after the initiation of cardiac arrest and is related in proportion to high mortality.

It is very important to understand that the underlying processes of cardiac arrest and the related physiological conditions could start several minutes before [10].

The overall goal of all perioperative resuscitative efforts or stabilization like the golden hour in medical conditions is to minimize this no-flow period and to maximize the chance of spontaneous circulation return. Whereas the indications for resuscitation outside of the operating room may be simple (loss of consciousness, loss of pulse, etc.), the indications in the perioperative period may be more complex. They may include inadequate heart rate or blood pressure based on age, inadequate minute ventilation, cyanosis, failure of noninvasive blood pressure monitoring or pulse oximetry, loss of arterial waveform, or a sudden change in the end-tidal carbon dioxide (ETCO2) waveform or value.

For understanding the physiological instability, it is necessary to understand how the body’s dynamic balance is related to a predetermined range of values in healthy conditions, and the most common for age and gender (e.g., perfusion, level of consciousness, blood pressure, work of breathing, and metabolic state) with or without clinical intervention.

The approach to organ dysfunction or failure cannot be done when one or more vital organ dysfunction or failure is due to chronic adaptation, with or without severe impairment, dysfunction, or external support. In fact, the main cause of an imminent life-threatening condition is the unrecognized process of deterioration due to treatment failure and deficient monitoring with the addition of poor knowledge of any chronic adaption of the patient. High accuracy and low opportunity (HALO) are required for improving any time-sensitive intervention. The HALO applicability will require at the same time healthcare workers with enough skills and with strong commitment and knowledge for decision-making and execution of any needed action in all patients, requiring or not an intervention [11, 12, 13, 14, 15]. The early approach is based on the probability and uncertain odds of potential reversibility. The recognition is time-sensitive, and this could help a situation may be reversible with defined goals and objectives of directed management. Sometimes, the organ dysfunction may persist and develop to adaptative physiology in case leading to a condition that could be technology-dependence or chronic. Is there when Sir William Osler’s quote describes the everyday practice of medicine “A science of uncertainty and an art of probability” [16].

There is a need for developing acute care in any place; the recognition and evaluation of the acute patient have common bases and could be done in any location outside the emergency department (ED) or the pediatric intensive care unit (PICU); sometimes could be related with surgical process (before operating room and recovery room). For making possible acute care independent of the location, teamwork has the most important role in recognizing, approaching, treating, and monitoring any pediatric patient.

It is important to recognize that the location sometimes is not designed and equipped with the optimal resources. The attention of the patient will be resource-availability independent. In the developing countries’ settings, attention is based on the equipment and facilities that are more focused on diagnostic or laboratory resources with a lot of delays, omissions, and pitfalls in attention [17, 18, 19].

The education process from basic concepts and its evolution is needed for allowing the growth of the healthcare worker in autonomy and responsibility. This process is a shared pathway that needs the supervision of a mentor; at some point, new mentors will be formed, able to train and able to work and educate as peers. In this moment, the student reaches the finest level of competence: the leadership. In the everyday teamworking process, the importance of the followership is growing; this very important and special skill is based in the capability of putting aside ego, seniority, and hierarchy for promoting the empowerment from the rest of the team. The competence model based on the Dunning–Kruger effect promotes self-confidence by using the capability to respond with responsibility. Based on Miller’s Pyramid, Bloom’s Taxonomy, and the International Pediatric Simulation Society, we can build an education matrix for learning process presented in Table 1.

Level	Novice	Advanced	Competent	Competent advanced	Expert
Miller’s pyramid	Know	Know how	Show how	Do	Teach others
Bloom’s taxonomy	Remember enlist	Explain interpret	Apply solve	Predict criticize	Planify design
Challenges			+	+++	++++
Cultural competencies		+	+++	++++	+++
Esencial competencies	+	+++	++++	+++	++
Skills	+++	++++	+++	++
Knowledge	++++	+++	++

Table 1.

Education matrix for learning process.

2. Academic content

2.1 Dominion level

It is necessary to understand, in the education settings for medical students, nurses, and residents, how to have more operative performance to deploy anywhere the capabilities and response. The impact of the trained freshmen physicians is based on the opportunity to do appropriate and opportune interventions, the use of the resources, the proportionality of care, and the monitoring and treatment interventions.

It is different to define the sailing course and the destination of navigation, in this part, it is important to define routes and could be important to understand the steps and the sequence and the consequences of each step in order to teach the approach. The SODOTO methodology (See One, Do One, Teach One) for teaching and learning skills not necessarily is accurate when we review the cumulative sum analysis of the learning curve, based on patient safety. The cumulative supervised task requires enough amount for receiving the feedback and promoting the feedforward for making with reduced error any procedure or decision-making process. The experience of the 10,000 hours to reach mastery and the assessment using risk matrices is focused on the practice time using the most frequent scenarios in daily practice and the evaluation of the consequences of different decisions and their impact.

In PICU setting, is very important to know, to teach, to audit, to improve, and to learn step by step any process. A sequence of steps using mandatory commands (written process with sequences in programming imperative commands START, IF THEN, YES, NO, AND, OR FINISH) instead of flowcharts that could be confusing, the addition of the critical path method to distribute tasks and the crew resource management methodology for distributing the workload are the rules. All these allow the staff to track all the processes. The importance of having the algorithms using commands and tracked standard operative procedures (SOPs) is a blueprint for educative and performance purposes [20, 21, 22].

Nowadays is very frequent to find in our ward complex patients or technology dependent, medical education is based on diagnosis, syndromes, and diseases but not on ongoing processes and the tag to define one of those is not clear in the adaptative balance of the patient in these conditions.

It is very important to speed the early recognition of the signs of deterioration instead of being worried about the speed of the appearance of the signs of deterioration; this is the reason why monitoring is the basic recognition tool of a patient in a deteriorating process, with an apparent acute or sudden onset of illness in the settings of the compensated or decompensated shock, respiratory arrest, and cardiopulmonary arrest. Patients with chronic conditions who develop acute critical illness/deterioration needs more close monitoring. This may include patients with chronic conditions (e.g., cerebral palsy, chronic renal disease, etc.) who develop acute critical illness when the basic start is not necessarily healthy.

Potential reversibility is a very common attribute of critical illness in pediatric patients with suspected, probable, or at risk of critical illness; they may have one or more abnormal physiological parameters or vital signs compared to healthy children.

The evaluation of the deteriorating process instead of the cut-point of failure, or the diagnosis itself of disease is more important. In pediatric patients, trying to define the persistence of a condition for more than 60 min (1 h) based on the physiological parameters or vital signs, that are references from previous healthy children like >95th or < 5th percentile, or > 2 or < 2 SD for age and gender, could be risky when the monitoring and the consecutive evaluations are hourly. The changes of the trends of the vital signs are very important for recognizing the acute deterioration and could be necessary to have reevaluations at least every 15 min.

Qualitative and clinical physiological parameters or vital signs may include the pediatric assessment triangle and/or any pediatric early warning score or scale to promote early recognition and subsequent interventions. The used signs are mentioned in the following findings:

Central nervous system: Level of consciousness and response to external stimulus (awake, verbal response, pain response, or unresponsiveness) AVPU/Glasgow Coma Scale, pupils’ size/reactivity-fixed, asymmetry.

Respiratory: Clinically, the breathing needs to be wide (lung expansion), correct (inflate in inspiration, deflate in expiration), and depth (enough volume and flow to expand the thorax). Signs of airway obstruction and respiratory distress, respiratory rate and effort, and the work of breath related to the respiratory pattern or mental status. Oxygen saturation is a measure to move the subjective evaluation of cyanosis.

Cardiovascular: Heart rate, systolic blood pressure, shock index (heart rate/systolic blood pressure; normal value considered <1), capillary refill time, quality of central/ peripheral pulses, skin (temperature/color/perfusion), urine output, etc.

Nutritional problems could affect the clinical interpretation as in the case of core temperature, hepatomegaly, and signs of dehydration (e.g., sunken eyes, tears, dry mucosa), several studies report the bias in the accurate interpretation and pitfalls in the treatment of malnourished patients.

In terms of education, it is very important to share the decision-making process. The training should go from basic knowledge concepts to metacognition in explicit knowledge.

Human-dependent assessment can include but is not limited to vital signs, and the human-dependent monitoring/assessment needs an educational approach. The experience of COVID-19 in campaign hospitals demonstrated the urgency of competent staff instead of some experts.

The workload of the human-dependent assessment and monitoring of acute, critical, chronic, technology-dependent patients, requires a great number of hours/shift but the pathway to reach and expert level is not always possible due to the high demands.

The approach of a suspected versus a confirmed diagnosis is quite different, in this case, the cut-point or the sum of the criteria sometimes could delay the treatment; other times, the syndromic approach could be useful for the recognition of patterns; this kind of pattern recognition is the base used for algorithms development, including artificial intelligence.

In statistics, likelihood is not the same as probability; we are performing for taking decisions in high uncertain, dynamic, and complex clinical scenarios with the addition of the technology and the devices that sustain a chronic patient. At this point, we need to teach critical thinking and the pattern recognition first and in a second step, make sure to teach also the adaptative physiology related to the medical device plus the function and programming of the medical device itself, including noninvasive or invasive mechanical ventilation. This technology is also related to resources for follow-up monitoring like X-rays, arterial blood gases, oximetry, end-tidal CO2, and others.

Pediatric patients with suspected, probable, deteriorating, or with critical illness may need frequent clinical evaluation and decision-making about the different trends or changes in patients’ patterns. It is more important time-sensitive hands-on interventions instead of repetitive obtention of laboratory or diagnostic test. Those activities could be directed to the therapeutic interventions not only mobilization, suctioning, review of the tube’s fixations, mouth care, repositioning, tracheostomy care, cold sponge bathing for fever, cleaning and dressing wounds/burns, or close follow,up of the fluids balance.

There is also a special group of patients who are in deterioration or at high risk related to traumatic or surgical conditions.

The priority in recognition is focused on pediatric patients with suspected, probable, or high risk for deterioration and evidence of critical illness; they may need time-sensitive life-supporting intervention, based on objectives and goals.

3. Children with comorbidities or preexisting conditions

The survival of patients from the Neonatal Intensive Care Unit (NICU), with congenital surgical or medical conditions is improving in developing countries. For this, recognition of co-morbidities and high-risk conditions is crucial.

In the PICU, the recognition of the risk of deterioration and/or exacerbation of any condition, or changes in the adaptative physiology is very important. Added malnutrition, obesity or overweight, congenital heart disease, oncologic diseases, primary immunosuppression or acquired immunosuppression like HIV/AIDS, transplant patients among others could increase the mortality rate in these patients.

Another important factors are the chronic pathologies with neurological disability, like cerebral palsy or neural tube defects and the use or dependence of invasive devices like shunt. These conditions imply adaptation of the patient’s physiology. In these cases, the information given by the caregiver is fundamental for understanding the real changes of the mental status and behavior of the patient.

4. Essential and optimal resources for educational competencies and performance

Many times, the governance bodies believe that the growth in infrastructure and the recruitment of freshmen doctors are the solutions to the healthcare system; it is very common to think that hierarchy will give a person “magically,” the required competencies, experience, and level of responsibility.

The definition of “Medical Attention Quality” will imply structure, process, and outcome. Any improvement of technology needs to be based on the comprehensive understanding of any tool as a resource (drug, device, laboratory test, X-ray, CT scan, among others) and is mandatory to understand any connected point as a chain of decision and iterative evaluations.

The physiology is the same in developing and developed countries, but to be effective, efficient, and explicit it is mandatory to be familiar with the local resources not only in the context of the access to some drugs (i.e., Amiodarone in several countries is substituted by Lidocaine, but Aminophylline is also widespread in some countries instead intravenous salbutamol and phenytoin used instead phosphenytoin). This is why we need to understand the reality of the environment where the educational process is being developed; in a first-level setting with fewer available resources, it could be more relevant to teach early noninvasive ventilation and bag-mask oxygenation instead of endotracheal intubation.

The essential resources that are known to be required in the health facilities besides the knowledge to solve medical problems and interventions including monitoring are enlisted but not reduced in the list below:

Central nervous system: Rewarming/cooling (targeting normothermia or therapeutic hypothermia), antidotes (naloxone and in the rural places consider acute or subacute organophosphates poisoning), first- and second-line antiepileptics, hyperosmolar therapy (mannitol/hypertonic saline), cerebrospinal fluid drainage or shunt for raised intracranial cerebral pressure (ICP), decompressive surgery, etc.

Respiratory: Continuous nebulizers, noninvasive/invasive ventilatory support from the high-flow nasal cannula (HFNC), bilevel positive airway pressure (BI-PAP), continuous positive airway pressure (CPAP) to the intubation drugs and supplies and mechanical ventilation as minimum, and thoracostomy tube.

Cardiovascular: Vascular access, intraosseous access, crystalloids, colloids, inotropes, vasopressors, vasodilators, cardiopulmonary resuscitation, pericardiocentesis, and blood products.

Metabolic: Feeding tubes, dextrose, bicarbonate, sodium, potassium, calcium, phosphorus, magnesium, and insulin.

Additional thrombolytics, heparin, and the supplies to make invasive procedures, and personal protective equipment for the health personnel.

5. Conclusions

Since 2003, the implemented educational process at the PICU in the Hospital San Juan de Dios in Guatemala showed a clear improvement in the medical attention and very clear impact on the mortality rate reduction. It is important to highlight that, during these years (from 2003 until now), we kept experiencing several economic constraints. Even with some improvements in equipment and resources, the major reason for the improvement has been the educational activities directed to the human resources at PICU.

On 2003, with a 12-bed PICU facility, 620 admissions per year were registered with 165 deaths; on 2022, with a 49-bed PICU, 99 deaths were reported. Currently, even the patients with the worst prognostic (average PRISM III score of 27 in 2022 compared to the average score of 9 in 2003) have better chances of survival. The 2019 COVID-19 pandemic gave us the opportunity of improving the on-site training and the virtual education using videos, simulation, remote training, and other resources.

Another important aspect during the pandemic was to increase the empathy for attending family and parents’ needs. Situations like restricted access and the curfew among other conditions related to the pandemic were faced using different strategies like “phone access” and special support in cases of withholding and withdrawing treatment when parents were away and not easy to reach (i.e., living in remote areas).

After the COVID-19 pandemic in 2020, we started a regular course for teaching the management of H & T’s for the pediatric intensivists, the pediatricians and the physicians, or health staff who need to be aware about the recognition and treatment of H & T’s. In 2022, 134 physicians located in rural healthcare facilities were enrolled, the specialties of these physicians are anesthesiology, surgery, orthopedics, emergency care, and pediatrics, nurses were included. At the level of the Latino American Society of Pediatric Critical Care (Sociedad Latinoamericana de Cuidado Intensivo Pediátrico, SLACIP), 50 pediatric intensive care physicians were trained. This training now has the endorsement of the Continued Medical Education Department of the Universidad de San Carlos de Guatemala.

We believe that, worldwide, it is not only about improving the infrastructure, and the equipment, or purchasing new technology, or hiring more personnel; all these for sure are very valuable strategies; but also without education, none of this will work.

We need well-trained healthcare personnel; the key to this always will be education; we need to educate for improving the performance and the decision-making process; we need to track the improvement of the team. Negotiation, decision-making process, and teamwork are fundamental skills under the concept of command incidents system, knowing this, we could add another H and another T: Humanization and Teamwork.

Acknowledgments

We are thankful for the contribution of Jesús López-Herce MD, MSc, Raffo Escalante-Kanashiro MD, MSc, Hugo Loayza MD Msc, Carlos Román-Ramos MD, MSc and Manuel Correa, MD Msc. in the development of this approach and diffusion of the related knowledge.