Review article
Pediatric emergency in Brazil: the consolidation of an area in the pediatric field
Emergência pediátrica no Brasil: a consolidação da área de atuação para o pediatra
a Universidade Federal do Rio Grande do Sul (UFRGS), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
b Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
c Hospital de Clínicas de Porto Alegre (HCPA), Unidade de Emergência Pediátrica, Porto Alegre, RS, Brazil
d Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Escola de Medicina, Serviço de Medicina Intensiva e Emergência, Porto Alegre, RS, Brazil
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Piva, Patrícia M. Lago, Pedro Celiny R. Garcia" "autores" => array:3 [ 0 => array:3 [ "nombre" => "Jefferson P." "apellidos" => "Piva" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "Patrícia M." "apellidos" => "Lago" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:4 [ "nombre" => "Pedro Celiny R." "apellidos" => "Garcia" "email" => array:1 [ 0 => "celiny@pucrs.br" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Universidade Federal do Rio Grande do Sul (UFRGS), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital de Clínicas de Porto Alegre (HCPA), Unidade de Emergência Pediátrica, Porto Alegre, RS, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Escola de Medicina, Serviço de Medicina Intensiva e Emergência, Porto Alegre, RS, Brazil" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Emergência pediátrica no Brasil: a consolidação da área de atuação para o pediatra" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1104 "Ancho" => 1658 "Tamanyo" => 392721 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Meeting held at the Federal Medical Council (Conselho Federal de Medicina [CFM]) with representatives of the National Medical Residency Commission (Comissão Nacional de Residência Médica [CNRM]) and representatives of 20 Brazilian institutions (medical schools and teaching hospitals),<span class="elsevierStyleSup">a</span> where the residency programs in emergency (adults) and pediatric emergency were defined and approved. (June 2015).</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span> Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS; Hospital de Pronto Socorro, Porto Alegre, RS; Hospital São Lucas, Pontifícia 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; Universidade Estadual de Campinas (UNICAMP), Campinas, SP; Hospital Geral de Nova Iguaçu (HGNI), Nova Iguaçu, RJ; Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG; Hospital de Messejana, Fortaleza, CE; Instituto da Criança, Universidade de São Paulo (USP), São Paulo, SP; Irmandade da Santa 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 Federal de São Paulo (UNIFESP), São Paulo, SP; Hospital das Clínicas, Universidade de São Paulo (USP), São Paulo, SP; Hospital Alemão Oswaldo Cruz, São Paulo, SP; Hospital do Coração (HCor), São Paulo, SP; Hospital de Clínicas Gaspar Vianna, Belém, PA; Hospital Municipal Infantil Menino Jesus, São Paulo, SP; Hospital Infantil Darcy Vargas (HIDV), São Paulo, SP, Brazil.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Starting in the second half of the last century, emergency services in most countries have experienced a substantial increase in their volume of care. The reasons for this increase in demand include rapid access to diagnostic and therapeutic resources; the complexity and resolutiveness of the sector, being an alternative and facilitated route for hospital admission; and, in some cases, access to medical care without costs to the user.</p><p id="par0010" class="elsevierStylePara elsevierViewall">It is estimated that in the United States, over 115 million visits to emergency services are made annually; 10%–12% of them are transported by ambulance. Of this total, 18% are intended for the care of children and adolescents under 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 pediatric patients occur through emergency services.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,2</span></a> In Brazil, there is little data available, but according to the portal of the Ministry of Health, over 300,000 calls were received from patients with some type of urgency between January 2016 and March 2015, during which 72,000 patients were treated in specialized emergency units and 81,000 in emergency units. Around 10% of the total number of visits (approximately 30,000 visits) required observation for more than 24<span class="elsevierStyleHsp" style=""></span>h in a specialized unit. The heterogeneity of prehospital care in Brazil is also noteworthy, as in 6900 cases the care was provided through boats.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Obviously, this complex system, which has become increasingly overloaded, has brought several challenges: organization, size, training of professionals, as well as the regulation of professional practice.</p><p id="par0020" class="elsevierStylePara elsevierViewall">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) was founded; the specialty was recognized in 1979 and issued its first certificate in 1980. After 1982, the minimum requirements for the Residency Program in Emergency Medicine were approved, followed by the first annual fellowship program in 1989. After 2000, emergency medical residency training and the certificate issued by ACEP became prerequisites for clinical practice in emergency services. Even with this recent history, emergency is now one of the largest medical specialties in the United States, with over 25,000 active professionals.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">From the recognition of the specialty, the search for emergency care standardization directed to the pediatric range was natural and obligatory. The death of an 18-year-old adolescent in New York attributed to the lack of adequate emergency care was the trigger for the creation, in 1984, of the Emergency Medical Services for children, aiming to ensure treatment for children and adolescents with severe diseases or victims of trauma, reduce their dysfunctions, prevent death, and promote rehabilitation.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> In the first decade of its implementation, operating norms were defined, funding was allocated to specific projects, and epidemiological knowledge and information were distributed to the entire system. At the end of the first decade, pediatric emergency training programs aimed at medical and non-medical professionals were instituted, including pediatric basic and advanced life support (PALS). In the second decade, protocols for prehospital care were developed, minimum pediatric equipment in the emergency services were defined, and the emergency care was regionalized, with patient referral and transfer, following a logical pattern of increasing complexity.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In Canada, the pediatric emergency field was acknowledged in 1980, while in the United States the training of these professionals became regular and frequent in the 1980s, but it was only defined, regulated, and certified as subspecialty in 1991.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">After its recognition, pediatric emergency became the fastest growing area in the United States – approximately 500% in the period between 1992 and 1999 – and is the second most sought specialty by pediatricians who completed the basic residence, second only to neonatology.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,4</span></a> After an accelerated growth phase in the pediatric emergency residency programs in the United States, a natural stabilization and consolidation was observed, with a reduction in the proliferation of new training programs. Since then, the goal has been to standardize training in the several services and to look forward to the future challenges for the new millennium. In the early 1990s, there was great disparity in training provided by the programs. It was observed that 75% of the first-year residents worked without adequate supervision in the different programs, a percentage that was reduced to less than 20% in 2000. At the end of the first decade of the new millennium, most pediatric emergency residency programs became a three-year program with a minimum-curriculum definition, as well as skills and competences to be achieved.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,2,4–6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Evolution of pediatric emergency in Brazil</span><p id="par0040" class="elsevierStylePara elsevierViewall">In the 1970s and 1980s, Brazil still suffered from the consequences of major and severe epidemics due to the lack of vaccine coverage and, especially, basic sanitation. Even with advances in these areas, pediatric emergency services were still overloaded, as they represented (and still represent) the best option for healthcare access.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Since the 1990s, the Brazilian Society of Pediatrics (Sociedade Brasileira de Pediatria [SBP]) has started a movement to stimulate and regulate training in pediatric areas, such as pediatric intensive medicine, neonatology, pneumology, pediatric nephrology, and pediatric neurology. To meet this demand, it was decided together with the National Commission of Medical Residency (Comissão Nacional de Residência Médica [CNRM]) to accredit some residence programs 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 pediatric residency program, aimed at pediatric emergency, was established in several services and persisted until 2002. In that year, a significant change occurred with the unification of Specialties and Areas of Practice defined by the Brazilian Medical Association (Associação Médica Brasileira [AMB]), CNRM, and the Federal Council of Medicine (Conselho Federal de Medicina [CFM]). For reasons unknown to date, urgency and emergency became an area linked to the internal medicine practice.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> From that moment on, pediatric emergency ceased to be an area of action of pediatrics; this program was no longer recognized by the CNRM and thus the formation of pediatricians with training and qualification in pediatric emergency activity was suspended for over a decade. Evidently, this impossibility in the formation of qualified professionals in pediatric emergency was very harmful to the Brazilian population, to pediatricians, and to teaching and research activities in this country.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Despite the repeated requests by the SBP to the CNRM and AMB, this illogical situation persisted until 2015, when a decisive fact took place that changed the direction and the history of the emergency specialty in Brazil. In June 2015, twenty renowned Brazilian institutions (medical schools and teaching hospitals) met with the CNRM and presented proposals for residency programs in adult emergency (three years) and pediatric emergency area (one year), with detailed programmatic content, as well as skills and competences to be acquired up to the completion of training (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The CNRM, in an innovative and ground-breaking attitude, decided to approve the application for accreditation of 22 residency programs proposed by these entities. Thereafter, the specialty and the area of action were recognized by the scientific council of AMB in August 2015 and formally homologated with the publication of CFM resolution No. 2.149/2016.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8,9</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">A pediatric emergency residency program for Brazil</span><p id="par0055" class="elsevierStylePara elsevierViewall">When proposing a residency program in pediatric emergency to be implemented in Brazil, some guiding assumptions were chosen for the creation of the program content, skills, and competences, as well as training time, among which the following stand out:<span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">“To preview, prepare, and enable their graduates to face the challenges anticipated for the next decades in the services of Pediatric Emergency.”</p></span></p><p id="par0060" class="elsevierStylePara elsevierViewall">In this context, it should be emphasized that pediatricians who are now entering these programs will be working in the care of children and adolescents with acute diseases in the next 30–35 years (<span class="elsevierStyleItalic">i.e.</span>, between 2020 and 2050). Therefore, they will face challenges in care that are very different from those experienced to this day. Some of these future challenges have already been well identified. Studies that analyzed the changes in disease profiles over the last few years suggest that the greatest challenges for pediatricians in the coming decades will be related to adolescent pregnancy, perinatal mortality, urgency medicine, infections (sepsis), external causes (including accidents, alcohol and drug use), chronic diseases, and children with “medical complexity.”<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> Thus, differently from what occurred 20 years ago, there is a growing contingent of pediatric patients with chronic diseases, and even at the final stages of life, being treated in pediatric emergency services. The ability to treat these patients and their families is a priority in the teaching goals of the new programs.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Not only the disease profile tends to change, but also the diagnostic features. Almost all areas of modern medicine incorporate routine echocardiography performed at the bedside, increasing both diagnostic sensitivity and specificity. Specifically, in the emergency service, this possibility has found great applicability.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">12,13</span></a> Of course, this skill becomes an essential requirement for the new pediatricians working in emergency care, representing a great challenge in their formation, because few chief residents currently dominate this technique. Programs should establish partnerships with radiology services or other services so that their residents have a minimum and sufficient training to deal with the most prevalent situations in pediatric emergency.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Model and resources for learning and acquiring skills</span><p id="par0070" class="elsevierStylePara elsevierViewall">As in several countries, the acquisition of knowledge, skills, and competence in pediatric emergency should follow a model based on daily practice, through the discussion and review of more prevalent cases with a preceptor actively involved in the teaching process. The less frequent situations must be experienced through a simulation laboratory or other teaching practices such as films and dramatizations, among others.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">It has been observed that residency programs in pediatrics, neonatology, and pediatric emergency, among others, expose residents to a small number of more complex procedures, less that the amount proposed and considered as the minimum desirable.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">14–17</span></a> In the proposed program, residents to prove their participation and performance with adequate supervision in a minimum of these more complex procedures.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Training leaders to work in pediatric emergency services</span><p id="par0080" class="elsevierStylePara elsevierViewall">In addition to the knowledge, skills, and competences, the graduates of these new programs must be trained to assume the status of leaders of their services, coordinating care and administrative activities.</p><p id="par0085" class="elsevierStylePara elsevierViewall">A question could be raised on whether the adoption of the pediatric residency program in three years would not be sufficient to enable professionals to act as medical leaders at several levels (care, teaching, research, and management) in emergency settings. Even considering that 20–25% of the workload of the three-year general pediatric residency programs occurs in the emergency department, this training is incomplete for what is expected of a professional who leads the process in this important area.</p><p id="par0090" class="elsevierStylePara elsevierViewall">International studies evaluating the abilities and experience of pediatric residence programs (three to four years) developed in large hospitals show that, at the end of the residency, these pediatricians have insufficient exposure to the minimum recommended pediatric emergency situations. In a study evaluating the pediatric residency program (four years) at a large referral center in the United States, it was observed that 89% of pediatric residents were not exposed to the minimum situations recommended by the CNRM in that coutry.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> Another study showed that pediatric residents in their regular emergency department training are exposed to a small number of critical patients (∼14 severe pediatric patients per resident during the training period).<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> These same shortcomings in training and skill acquisition by emergency pediatric residents were also observed in Brazil,<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> as well as through the analysis of their performance at the board certification test promoted by SBP.</p><p id="par0095" class="elsevierStylePara elsevierViewall">These results do not necessarily mean that pediatricians are not capable of working in pediatric emergency services. However, it is imperative to recognize that they prevent these professionals from being a reference, a leader, and an innovative element in this area. The gaps in their skills and abilities in this area require an adequately trained and qualified professional to support and improve their performance while working in a pediatric emergency.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In Brazil, the need for a vocational and acknowledged speaker in this area has been observed, to be an interlocutor in both the intra-hospital and extra-hospital discussions aimed at the implementation of management policies and care in pediatric emergency.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">To expand the offer of emergency pediatricians in the short-term</span><p id="par0105" class="elsevierStylePara elsevierViewall">After more than a decade without providing residency programs in pediatric emergency, qualified professionals are needed in all regions of the country. Even considering the most optimistic calculations, there will be a great gap to be filled in the several services of the country. In this context, the proposal for the next years is that the residence programs in emergency pediatrics will be conducted over the course of one year, complementing the three years of residence in pediatrics. It was understood at the time of the proposal presentation that this policy would allow the fulfillment, in a maximum of one decade, of the main positions of leadership and coordination of pediatric emergency in Brazil. Thereafter, a new level will be established, developing the program into a two-year training period, as in other pediatric areas (pediatric intensive medicine and neonatology, among others).</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Development of pediatric emergency research</span><p id="par0110" class="elsevierStylePara elsevierViewall">In an attempt to prepare themselves for this new scenario, the US National Health Institute (NHI) has recently chosen three priority fields for the development and stimulation of pediatric research: pediatric intensive care, pediatric emergency and rehabilitation of children suffering from acute or chronic diseases. Research in the pediatric emergency area has been relegated and poorly developed, requiring, in addition to research resources, the training of skilled researchers with interest and knowledge in this area.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">18,19</span></a> Therefore, among the challenges for the next decades, emergency medicine should be considered as a priority in research on children and adolescents’ health.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Due to the aforementioned reasons, the authors believe that pediatric emergency training will be a powerful stimulus to attract skilled individuals, to establish them in this important area of medicine, where they can exercise their leadership by promoting qualification in care, research, and teaching, as well as decisively working in its management.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Residency program in emergency and pediatric emergency area</span><p id="par0120" class="elsevierStylePara elsevierViewall">Approved by CNRM in August 2015:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1-</span><p id="par0125" class="elsevierStylePara elsevierViewall">Duration: one year</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2-</span><p id="par0130" class="elsevierStylePara elsevierViewall">Number of openings: the minimum opening number was defined as two per service, while the maximum number of residents will be defined according to the volume and facilities offered by the service</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3-</span><p id="par0135" class="elsevierStylePara elsevierViewall">Workload: 60<span class="elsevierStyleHsp" style=""></span>h per week according to CNRM recommendations, including 30-day vacations.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Objectives of the professional to be trained:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">–</span><p id="par0145" class="elsevierStylePara elsevierViewall">To deepen the knowledge, skills, and competences in the area of pediatric emergency in its several scenarios.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">–</span><p id="par0150" class="elsevierStylePara elsevierViewall">To develop the capacity to generate knowledge within four components: clinical skills, research, education, and management.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">–</span><p id="par0155" class="elsevierStylePara elsevierViewall">To train leaders who can influence and have an impact on the care, management and planning of the sector, including leadership roles in multiprofessional teams.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">–</span><p id="par0160" class="elsevierStylePara elsevierViewall">Training of professionals who are able to contribute to the creation of solutions aligned with the healthcare policy needs of their region.</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">5-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Training sites<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">–</span><p id="par0170" class="elsevierStylePara elsevierViewall">Pediatric Emergency Service with a minimum of 50,000 annual outpatient visits.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">–</span><p id="par0175" class="elsevierStylePara elsevierViewall">The care complexity should ensure a minimum demand close to 10% of patients classified as up to second level on the priority scale (five levels)</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">–</span><p id="par0180" class="elsevierStylePara elsevierViewall">Intra and extra-hospital transportation</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">–</span><p id="par0185" class="elsevierStylePara elsevierViewall">Pediatric intensive care unit (at least ten beds).</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">–</span><p id="par0190" class="elsevierStylePara elsevierViewall">Anesthesiology and surgery (imaging services with anesthetic procedures/surgical center/anesthetic recovery).</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">–</span><p id="par0195" class="elsevierStylePara elsevierViewall">Trauma service.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">–</span><p id="par0200" class="elsevierStylePara elsevierViewall">Imaging area (radiology and ultrasound)</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">–</span><p id="par0205" class="elsevierStylePara elsevierViewall">Complementary options (<span class="elsevierStyleItalic">e.g</span>., otorhinolaryngology, cardiology, pneumology, burn unit, poisoning, accidents with venomous animals, among others)</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">6-</span><p id="par0210" class="elsevierStylePara elsevierViewall">Cognitive goals of the program</p><p id="par0215" class="elsevierStylePara elsevierViewall">A minimum of 10% of the workload should be allocated to theoretical activities, either as classes, seminars, clinical discussions, and article reviews, among others. The theoretical-practical basis should cover the main acute situations in Pediatrics, such as those listed below, but not restricted only to these:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">a.</span><p id="par0220" class="elsevierStylePara elsevierViewall">Cardiopulmonary resuscitation.</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">b.</span><p id="par0225" class="elsevierStylePara elsevierViewall">Rapid sequence intubation.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">c.</span><p id="par0230" class="elsevierStylePara elsevierViewall">Shock (septic, hypovolemic, cardiogenic).</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">d.</span><p id="par0235" class="elsevierStylePara elsevierViewall">Acute respiratory failure.</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">e.</span><p id="par0240" class="elsevierStylePara elsevierViewall">Severe acute asthma</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">f.</span><p id="par0245" class="elsevierStylePara elsevierViewall">Basic notions o mechanical ventilation.</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">g.</span><p id="par0250" class="elsevierStylePara elsevierViewall">Upper airways emergencies.</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">h.</span><p id="par0255" class="elsevierStylePara elsevierViewall">Meningoencephalitis.</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">i.</span><p id="par0260" class="elsevierStylePara elsevierViewall">Status epilepticus</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">j.</span><p id="par0265" class="elsevierStylePara elsevierViewall">Sedation and analgesia.</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">k.</span><p id="par0270" class="elsevierStylePara elsevierViewall">Diabetic ketoacidosis.</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">l.</span><p id="par0275" class="elsevierStylePara elsevierViewall">Initial care to the polytraumatized and cranial trauma.</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">m.</span><p id="par0280" class="elsevierStylePara elsevierViewall">Exogenous poisoning.</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">n.</span><p id="par0285" class="elsevierStylePara elsevierViewall">Accidents with venomous animals.</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">o.</span><p id="par0290" class="elsevierStylePara elsevierViewall">Anaphylaxis.</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">p.</span><p id="par0295" class="elsevierStylePara elsevierViewall">Hypertensive urgencies.</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">q.</span><p id="par0300" class="elsevierStylePara elsevierViewall">Syncope and coma</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">r.</span><p id="par0305" class="elsevierStylePara elsevierViewall">Congestive heart failure and cyanosis crisis.</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">s.</span><p id="par0310" class="elsevierStylePara elsevierViewall">Heart rhythm disturbances.</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">t.</span><p id="par0315" class="elsevierStylePara elsevierViewall">Hydroelectrolytic and acid-base disorders.</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">u.</span><p id="par0320" class="elsevierStylePara elsevierViewall">Ethical and legal aspects of care in emergency services</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">v.</span><p id="par0325" class="elsevierStylePara elsevierViewall">Basic concepts in management and administration of emergency services.</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">w.</span><p id="par0330" class="elsevierStylePara elsevierViewall">Notions in scientific methodology for research in emergency.</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">x.</span><p id="par0335" class="elsevierStylePara elsevierViewall">Catastrophe care.</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">y.</span><p id="par0340" class="elsevierStylePara elsevierViewall">Emergency surgical pathologies</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">z.</span><p id="par0345" class="elsevierStylePara elsevierViewall">Ultrasound at the bedside (point of care).</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">7-</span><p id="par0350" class="elsevierStylePara elsevierViewall">Competences<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">a.</span><p id="par0355" class="elsevierStylePara elsevierViewall">To recognize signs of severity and the acute diseases in children and adolescents treated at emergency/urgency units and the adequate implementation of the respective protocols.</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">b.</span><p id="par0360" class="elsevierStylePara elsevierViewall">To promptly establish urgency lines of care.</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">c.</span><p id="par0365" class="elsevierStylePara elsevierViewall">To assist in the care of patients with specific needs and dependent on technology.</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">d.</span><p id="par0370" class="elsevierStylePara elsevierViewall">Capacity for autonomy and leadership</p></li><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">e.</span><p id="par0375" class="elsevierStylePara elsevierViewall">To propose and develop a research project (monograph)</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">f.</span><p id="par0380" class="elsevierStylePara elsevierViewall">To demonstrate the ability to manage the unit's administrative processes (cost management, human resources allocation and flows) and the relationship with municipal and state health networks.</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">g.</span><p id="par0385" class="elsevierStylePara elsevierViewall">To participate in the management tool implementation (care protocols and quality indicators, among others)</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">h.</span><p id="par0390" class="elsevierStylePara elsevierViewall">To be familiar with the priorities and national/regional healthcare policies with emphasis in the area of pediatric emergency.</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">8-</span><p id="par0395" class="elsevierStylePara elsevierViewall">Skills<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0275"><p id="par0400" class="elsevierStylePara elsevierViewall">A minimum set of skills will be required, as follows:</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">a.</span><p id="par0405" class="elsevierStylePara elsevierViewall">Peripheral and central venous access (including umbilical catheter) – minimum of six accesses each; arterial access (minimum six);</p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">b.</span><p id="par0410" class="elsevierStylePara elsevierViewall">Intraosseous access – minimum of four accesses;</p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">c.</span><p id="par0415" class="elsevierStylePara elsevierViewall">Airway access – minimum of twelve;</p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">d.</span><p id="par0420" class="elsevierStylePara elsevierViewall">Invasive and non-invasive ventilatory support;</p></li><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">e.</span><p id="par0425" class="elsevierStylePara elsevierViewall">PALS or equivalente;</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">f.</span><p id="par0430" class="elsevierStylePara elsevierViewall">Minimum of invasive procedures: lumbar (twelve), suprapubic (twelve), thoracic (four) punctures;</p></li><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">g.</span><p id="par0435" class="elsevierStylePara elsevierViewall">Identification of alterations and major acute diseases in imaging tests (echography, radiography, CT, and/or MRI);</p></li><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">h.</span><p id="par0440" class="elsevierStylePara elsevierViewall">Experience in applying priority care classification systems (“risk classification”);</p></li><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">i.</span><p id="par0445" class="elsevierStylePara elsevierViewall">Presentation of a free theme or submission of an article to a journal</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">9-</span><p id="par0450" class="elsevierStylePara elsevierViewall">Description of activities</p><p id="par0455" class="elsevierStylePara elsevierViewall">The activities will be carried out in the unit itself and other places (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">10-</span><p id="par0460" class="elsevierStylePara elsevierViewall">Assessment</p><p id="par0465" class="elsevierStylePara elsevierViewall">Residents will be assessed on the following aspects every six months:</p><p id="par0470" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Attitudes</span><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">-</span><p id="par0475" class="elsevierStylePara elsevierViewall">Posture, communication, and integration, among others</p><p id="par0480" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Knowledge and skills</span></p></li><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">-</span><p id="par0485" class="elsevierStylePara elsevierViewall">Domain of contents of the area and protocols, among others</p></li><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">-</span><p id="par0490" class="elsevierStylePara elsevierViewall">Research project (Term Paper)</p><p id="par0495" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Skills</span></p></li><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">-</span><p id="par0500" class="elsevierStylePara elsevierViewall">Check list of acquired skills</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">11-</span><p id="par0505" class="elsevierStylePara elsevierViewall">At the end of the internship, the professional should be able to:<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">a.</span><p id="par0510" class="elsevierStylePara elsevierViewall">Identify, diagnose, and treat the main acute situations in Pediatrics according to the best scientific evidence (protocols).</p></li><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">b.</span><p id="par0515" class="elsevierStylePara elsevierViewall">Identify, diagnose, and start treatment based on the best scientific evidence (protocols) of the main emergency situations in the pediatric specialties (<span class="elsevierStyleItalic">e.g</span>., otorhinolaryngology, ophthalmology, orthopedics, neurology, and neurosurgery, among others).</p></li><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">c.</span><p id="par0520" class="elsevierStylePara elsevierViewall">Correctly interpret the usual imaging tests in the main pediatric emergency situations.</p></li><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">d.</span><p id="par0525" class="elsevierStylePara elsevierViewall">Perform key emergency procedures.</p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">e.</span><p id="par0530" class="elsevierStylePara elsevierViewall">Lead the medical and multiprofessional team in the area of pediatric urgency and emergency.</p></li><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">f.</span><p id="par0535" class="elsevierStylePara elsevierViewall">Understand regional health policies and the hospital referral system;</p></li><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">g.</span><p id="par0540" class="elsevierStylePara elsevierViewall">Lead and organize a pediatric emergency care service.</p></li></ul></p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0545" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres938166" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Data sources" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Data synthesis" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec911908" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres938165" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Fontes dos dados" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Si¿ntese dos dados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Concluso¿es" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec911907" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Evolution of pediatric emergency in Brazil" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "A pediatric emergency residency program for Brazil" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Model and resources for learning and acquiring skills" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Training leaders to work in pediatric emergency services" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "To expand the offer of emergency pediatricians in the short-term" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Development of pediatric emergency research" ] ] ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Residency program in emergency and pediatric emergency area" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-06-23" "fechaAceptado" => "2017-07-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec911908" "palabras" => array:4 [ 0 => "Emergency" 1 => "Pediatrics" 2 => "Medical residency" 3 => "Teaching program" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec911907" "palabras" => array:4 [ 0 => "Emergência" 1 => "Pediatria" 2 => "Residência médica" 3 => "Programa de ensino" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to present a review on the evolution, development, and consolidation of the pediatric emergency abroad and in Brazil, as well as to discuss the residency program in this key area for pediatricians.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Data sources</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This was a narrative review, in which the authors used pre-selected documents utilized as the minimum requirements for the Residency Program in Pediatric Emergency Medicine and articles selected by interest for the theme development, at the SciELO and Medline databases, between 2000 and 2017.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Data synthesis</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The historical antecedents and the initial evolution of pediatric emergency in Brazil, as well as several challenges were described, regarding the organization, the size, the training of professionals, and also the regulation of the professional practice in this new specialty. Additionally, a new pediatric emergency residency program to be implemented in Brazil is described.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pediatric emergency training will be a powerful stimulus to attract talented individuals, to establish them in this key area of medicine, where they can exercise their leadership by promoting care qualification, research, and teaching, as well as acting decisively in their management.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Data sources" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Data synthesis" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O estudo teve como objetivo apresentar uma revisão sobre a evolução, desenvolvimento e consolidação da Emergência Pediátrica no exterior e no Brasil assim como discutir o programa de residência nesta importante área de atuação para o pediatra.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Fontes dos dados</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Trata-se de uma revisão do tipo narrativa, em que os autores utilizaram documentos pré-selecionados empregados nos requisitos mínimos para o programa em Residência de Medicina de Emergência Pediátrica e artigos selecionando por interesse para desenvolvimento do tema utilizaram as bases de dados SciELO e Medline entre 2000 e 2017.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Si¿ntese dos dados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Foram descritos os antecedentes históricos e a evolução inicial da Emergência Pediátrica no Brasil e diversos desafios, na organização, no dimensionamento, na formação de profissionais e, também, na regulamentação do exercício profissional desta nova especialidade. Também se descreve um novo programa de residência em Emergência Pediátrica a ser implementado no Brasil.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Concluso¿es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A formação em emergência pediátrica será um poderoso estímulo para atrair indivíduos talentosos, fixá-los nesta importante área da medicina, onde poderão exercer sua liderança promovendo qualificação na assistência, na pesquisa e no ensino, assim como atuando decisivamente no seu gerenciamento.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Fontes dos dados" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Si¿ntese dos dados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Concluso¿es" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Piva JP, Lago PM, Garcia PC. Pediatric emergency in Brazil: the consolidation of an area in the pediatric field. J Pediatr (Rio J). 2017;93:68–74.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1104 "Ancho" => 1658 "Tamanyo" => 392721 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Meeting held at the Federal Medical Council (Conselho Federal de Medicina [CFM]) with representatives of the National Medical Residency Commission (Comissão Nacional de Residência Médica [CNRM]) and representatives of 20 Brazilian institutions (medical schools and teaching hospitals),<span class="elsevierStyleSup">a</span> where the residency programs in emergency (adults) and pediatric emergency were defined and approved. (June 2015).</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span> Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS; Hospital de Pronto Socorro, Porto Alegre, RS; Hospital São Lucas, Pontifícia 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; Universidade Estadual de Campinas (UNICAMP), Campinas, SP; Hospital Geral de Nova Iguaçu (HGNI), Nova Iguaçu, RJ; Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG; Hospital de Messejana, Fortaleza, CE; Instituto da Criança, Universidade de São Paulo (USP), São Paulo, SP; Irmandade da Santa 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 Federal de São Paulo (UNIFESP), São Paulo, SP; Hospital das Clínicas, Universidade de São Paulo (USP), São Paulo, SP; Hospital Alemão Oswaldo Cruz, São Paulo, SP; Hospital do Coração (HCor), São Paulo, SP; Hospital de Clínicas Gaspar Vianna, Belém, PA; Hospital Municipal Infantil Menino Jesus, São Paulo, SP; Hospital Infantil Darcy Vargas (HIDV), São Paulo, SP, Brazil.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">This distribution does not necessarily imply a fixed division into blocks.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Location \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Workload (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pediatric emergency service/unit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50%–70% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pediatric intensive care unit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5%–10% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Transportation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5%–10% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Imaging \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5%–10% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trauma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5%–10% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgery and anesthesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5%–10% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Optional \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5%–10% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1586517.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Description of activities.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <span class="elsevierStyleInterRef" id="intr0010" href="http://www.nap.edu/catalog/11655.html">http://www.nap.edu/catalog/11655.html</span> [accessed 01.06.17]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Emergency care for children: growing pains" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Committee on the Future of Emergency Care in the United States Health System" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2007" "editorial" => "National Academies Press" "editorialLocalizacion" => "Washington, DC" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0110" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Best educational practices in pediatric emergency medicine during emergency medicine residency training: guiding principles and expert recommendations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "R.L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 4 | 7 |
| 2024 October | 23 | 35 | 58 |
| 2024 September | 29 | 37 | 66 |
| 2024 August | 45 | 34 | 79 |
| 2024 July | 37 | 32 | 69 |
| 2024 June | 20 | 14 | 34 |
| 2024 May | 25 | 14 | 39 |
| 2024 April | 22 | 26 | 48 |
| 2024 March | 22 | 22 | 44 |
| 2024 February | 15 | 26 | 41 |
| 2024 January | 18 | 22 | 40 |
| 2023 December | 18 | 22 | 40 |
| 2023 November | 21 | 30 | 51 |
| 2023 October | 27 | 38 | 65 |
| 2023 September | 24 | 39 | 63 |
| 2023 August | 18 | 14 | 32 |
| 2023 July | 18 | 17 | 35 |
| 2023 June | 14 | 5 | 19 |
| 2023 May | 18 | 18 | 36 |
| 2023 April | 16 | 10 | 26 |
| 2023 March | 39 | 19 | 58 |
| 2023 February | 15 | 10 | 25 |
| 2023 January | 15 | 22 | 37 |
| 2022 December | 47 | 23 | 70 |
| 2022 November | 22 | 26 | 48 |
| 2022 October | 47 | 46 | 93 |
| 2022 September | 23 | 41 | 64 |
| 2022 August | 30 | 36 | 66 |
| 2022 July | 26 | 33 | 59 |
| 2022 June | 18 | 37 | 55 |
| 2022 May | 20 | 30 | 50 |
| 2022 April | 46 | 41 | 87 |
| 2022 March | 30 | 39 | 69 |
| 2022 February | 12 | 26 | 38 |
| 2022 January | 10 | 19 | 29 |
| 2021 December | 9 | 19 | 28 |
| 2021 November | 6 | 12 | 18 |
| 2021 October | 5 | 9 | 14 |
| 2021 September | 6 | 14 | 20 |
| 2021 August | 6 | 11 | 17 |
| 2021 July | 2 | 1 | 3 |
| 2021 June | 10 | 5 | 15 |
| 2021 May | 14 | 15 | 29 |
| 2021 April | 4 | 17 | 21 |
| 2021 March | 11 | 19 | 30 |
| 2021 February | 4 | 6 | 10 |
| 2021 January | 3 | 5 | 8 |
| 2020 December | 8 | 7 | 15 |
| 2020 November | 10 | 13 | 23 |
| 2020 October | 3 | 5 | 8 |
| 2020 September | 12 | 13 | 25 |
| 2020 August | 2 | 4 | 6 |
| 2020 July | 7 | 7 | 14 |
| 2020 June | 6 | 5 | 11 |
| 2020 May | 2 | 4 | 6 |
| 2020 April | 7 | 10 | 17 |
| 2020 March | 2 | 3 | 5 |
| 2020 February | 8 | 12 | 20 |
| 2020 January | 11 | 10 | 21 |
| 2019 December | 8 | 8 | 16 |
| 2019 November | 6 | 8 | 14 |
| 2019 October | 7 | 14 | 21 |
| 2019 September | 6 | 8 | 14 |
| 2019 August | 10 | 13 | 23 |
| 2019 July | 6 | 6 | 12 |
| 2019 June | 5 | 11 | 16 |
| 2019 May | 8 | 14 | 22 |
| 2019 April | 7 | 8 | 15 |
| 2019 March | 2 | 4 | 6 |
| 2019 February | 6 | 9 | 15 |
| 2019 January | 5 | 10 | 15 |
| 2018 December | 6 | 7 | 13 |
| 2018 November | 14 | 4 | 18 |
| 2018 October | 116 | 14 | 130 |
| 2018 September | 25 | 13 | 38 |
| 2018 August | 7 | 8 | 15 |
| 2018 July | 7 | 2 | 9 |
| 2018 June | 8 | 11 | 19 |
| 2018 May | 4 | 29 | 33 |
| 2018 April | 6 | 14 | 20 |
| 2018 March | 14 | 6 | 20 |
| 2018 February | 8 | 4 | 12 |
| 2018 January | 9 | 3 | 12 |
| 2017 December | 5 | 2 | 7 |
| 2017 November | 6 | 4 | 10 |
| 2017 October | 1 | 12 | 13 |
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