For the world's children — from Russia with love
For 20 years a unique paediatrics team from Russia has provided a significantly welcome presence at natural and man-made disasters worldwide. During our interview with Professor Leonid Roshal MD, Executive Director and Chief of the Scientific and Research Institute for Children's Emergency Surgery and Traumatology, in Moscow, he recollected areas in which the team's assistance provided medical aid and pointed out ways in which countries worldwide could improve disaster care for the children of today and those of the future. Journalists have dubbed him `The Children's Doctor of the World´.
"Our institute for Children's Emergency Surgery and Traumatology, which also includes neurotrauma, trauma, resuscitation, intensive care and others, has a unique character", Prof Roshal explained.
‘There are no others of its kind, either in Russia or, actually, the rest of the world. Our equipment is state-of-the-art; we have at our disposal CT and MR tomography with imaging at 3-tesla. We examine traumas using all functional methods. We devote particular attention to problems concerning severe traumatic pathologies. We also treat acute diseases in children, for example peritonitis. In 98% of these cases we use laparoscopy. We have achieved a very high level in treating craniocerebral trauma, and know a lot about crush syndrome, having accumulated a profound experience in the treatment of this condition.’
The institute could and should become a centre of education and training for emergency medical assistance for children, not only in Russia, but also for personnel in countries worldwide, he suggested. ‘We can carry out seminars and conferences
on all these subjects. I have already started on this endeavour. Within the framework of the World Association for Disaster and Emergency Medicine (WADEM) congress, held every two years, we hold specialised sessions to consider and discuss related problems. Called Children in Disasters and Wars, these sessions have been held for many years on our initiative. We began with one session, now there are two. Nevertheless, to my mind the initiatives taken are far from sufficient to solve the problems existing in this specialised field. Focused education and training is needed, and we are ready to provide such training; we are available and have top-rank experts at the Institute. The bulk (99%) of the international medical team who assist at disaster sites are our specialists. Because this is part of our Institute’s activity, we have several emergency teams. Practically every day we deal with emergency cases in Moscow; it is our routine work and we have enough staff on the spot to carry it out. In the meantime our medical teams set off to give help at emergency sites anywhere. Their complement varies; perhaps 10 or maybe 14 people. We also replace people if necessary. For example one group returns and another departs for the emergency site.’
The Institute first provided assistance following an earthquake in Armenia in 1988. Since then it has been a notable presence at disaster and earthquake sites in Georgia, Russia, Algeria, Egypt, Turkey, Iran, India, Pakistan, Japan, three times in Afghanistan, and for a month recently was present in Indonesia. ‘We have actually walked the whole equator from west to east,’ Prof. Roshal remarked. ‘At first, it was only my hypothesis. Then I came to a firm opinion that highly skilled paediatric specialists could help children more efficiently compared with physicians for adults. Children have particularities that need special attention. In treating them, our experience has totally demonstrated that the death toll as well as disablements is approximately twice lower when our paediatric team is doing the relief work.’
For many years, Prof Roshal has been on the Board of the WADEM. ‘It is from this position that I engage in providing assistance to children whenever emergencies arise. And it has become clear to me that we need a united, efficient structure that can organise emergency aid for children throughout the world. We do not have this. I would prefer this structure to be created under the aegis of the World Health Organisation. The WHO has its specific features; all participating countries pay for the implementation of its concrete programmes. To my regret, a programme to render services to children in emergency situations is not provided for. Nonetheless, I hope that possibilities can be found in this direction. I’m not even contemplating this problem from the point of view of financing the scheme. The main thing is the overall organisational work – throughout the world.
‘Teams to provide medical service to children should be formed on the national basis, for which the Russian experience could be put to good use. A team can include neurosurgeons, traumatologists, specialists in burns, plastic surgeons, intensive care and reanimation and paediatric surgeons as well as paediatricians, but it should be staffed according to the nature and scale of a disaster. Such are the principles under which our mobile teams work. That practical experience has proved the expediency of forming emergency teams of this kind at a national level.’ When a disaster occurs, particularly on a large-scale, he pointed out, ‘… we are confronted by a deficiency in highly qualified personnel.’
The Russian team does not engage directly at an emergency site, he added. ‘We don’t stand near houses waiting for our patient to be rescued from the debris. This important and hard task is accomplished by pre-hospital relief teams, by mobile clinics, not to forget Medicines sans Frontières, the Red Cross, and so on. We concentrate our efforts at the hospital stage of children’s treatment. For example, after the Pakistan earthquake, we arrived by air in Islamabad, settled down in the major children’s hospital there and began to collect the children with the gravest problems, such as crush syndrome, crush kidney, and craniocerebral trauma, to tend these small patients in hospital.’
Along with his belief that specialised emergency medical teams for children should be organised at a national level, he also believes it necessary to form such emergency teams on the basis of geographical regions, taking advantage of their resources. ‘In the case of an extremely large number of injured in a certain country and its own insufficient resources, medical aid ought to be covered at a regional level. Besides this, a special international structure should exist; teams of physicians should be able to arrive by air in the disaster site – and here, the coordination of efforts among different organisations involved is the crucial point. Additionally, in a medical emergency it is essential to evaluate the number of injured and the scale of devastation. The kind of specialists needed at the scene needs to be clear in order to deploy the staff adequately – perhaps five or 10 traumatologists should be sent, but no neurosurgeons or reanimation specialists are needed. It is of major importance that information comes very quickly and is precise. At present, there is no effective information on the necessary medical aid for children at emergency sites; this is a weak point.’
There is another highly important point: ‘There are always many volunteers who wish to help, but not everyone who comes to a site with a kind heart is qualified enough to cope with the tasks. It’s the skilled personnel who are needed, with licenses and a good training. Only a professional workforce can really help.’ He emphasised two principal factors as to children necessary to manage disaster medical care to children: timely intervention of high-skilled personnel.
Four days before our interview, the team had applied to China’s government (via the Chinese Embassy in Russia) to enter the country’s earthquake region and join the medical teams there. ‘The Russian Embassy in China has also applied to China’s Ministry of Foreign Affairs,’ Prof Roshal said. ‘From our experience and calculations we can expect 80,000 injured from the death toll of 20,000. Hence, based on the adult/children ratio, we can calculate the number of injured children; we can also estimate the rate of injured children who definitely need hospital treatment – it should be 20%.
We also expect among hospitalised patients a number of children suffering very severe conditions, such as crush syndrome, craniocerebral trauma as well as extensive wounds. We have physicians at our disposal who specialise in treating extensive wounds complicated by fractures. If we can go to the site, how it should be handled will be clear to us. However, we have not received any answer from the Chinese authorities. Meanwhile time flows away; in ten days we shall be hardly any use: amputations will already have been performed, and it is probable that a number of children could already have died.
‘Actually, reviewing in my memory of the emergency cases in which we provided medical assistance, I cannot recollect a single occasion when a country accepted our offer to give help at once. National peculiarities connected with sovereignty come to the fore. At first, we are always confronted by refusals. This has been the case everywhere – Japan, India, Indonesia. They said they preferred to manage by themselves. But once we were at the site and working it usually took only an hour or two to clarify who was who, if I may put it that way; our role changed rapidly – we became leaders of fashion. Our work done, we’ve been rewarded with gratitude from each government.’
Children have physiological as well as psychological peculiarities that must be considered when treating them, he stressed. ‘Proceeding from this assumption, the necessity of building up a structure for an emergency medical service exclusively for children really does exist.’
Asked how long he has worked for children we discovered this is a landmark year for Prof Roshal. After graduating in paediatrics 50 years ago he worked for some time as a paediatrician before becoming a paediatric surgeon. ‘I’ve mainly engaged in emergency paediatric surgery, always based in Moscow, but I have worked throughout the world.’
Fifty years of dedication to saving children. We congratulated him and expressed hope for his good health to continue.
‘Thank you for your good wishes,’ replied Prof Roshal. ‘As far as my jubilee is concerned, I’d say 75 is no age at all.’
01.07.2008
