Even though accidents are the major cause of death among small children, many Japanese hospitals are woefully unprepared to deal with such cases.
Among 13 major nations, Japan ranks third-worst in terms of the mortality rate for infants between 1 and 4, according to statistics compiled by the World Health Organization (WHO).
While emergency care in Japan in general is in dire straits, with more doctors moving away from the strenuous work, the paucity of such care for children is even more serious.
One of the few pediatric intensive care units (PICU) in Japan is at Shizuoka Children's Hospital.
In early November, a so-called Doctor-Heli landed on the roof of the hospital. A 2-year-old girl was placed on a stretcher. She was bleeding from her mouth and chest, her blood pressure was low and she was unconscious.
The girl fell from the second story of her home and was taken by ambulance to a general hospital. Doctors there determined that she had hit her head and chest hard and that surgery might be required if there was bleeding in her brain.
Doctors at the general hospital called Shizuoka Children's Hospital, located about 50 kilometers away.
The PICU had doctors who specialized in intensive care for children as well as brain surgeons and plastic surgeons. Although it would have taken an ambulance about an hour to transport the girl, the Doctor-Heli did the job in 10 minutes.
Ikuya Ueta, who heads the pediatric intensive care center at the children's hospital, gave out instructions to the doctors and nurses gathered around the girl.
He asked that the girl's blood pressure be monitored and that an IV drip be injected into her foot.
A tube inserted into her respiratory passages that measured only 5 millimeters in diameter was connected to a respirator. Needles were injected into her foot for blood transfusions and IV drips.
The initial stages of treatment were over in about 30 minutes. There was no damage to the brain or internal organs, so doctors were relieved that she had emerged from a worst-case scenario.
The PICU at Shizuoka Children's Hospital was established in June 2007. The 14 doctors work in two shifts. The two Doctor-Helis in Shizuoka Prefecture along with ambulances bring in children in critical condition from both within and outside the prefecture on a 24-hour a day basis. Different knowledge set
Dealing with children in critical condition requires a new set of knowledge because they cannot be treated in the same manner as adults.
The effects of having a PICU have been documented.
Since 2004, the emergency and critical care center at the Nippon Medical School Chiba Hokuso Hospital in Inba, Chiba Prefecture, has been transporting children under 15 in critical condition by Doctor-Heli to the PICU at the National Center for Child Health and Development in Tokyo's Setagaya Ward, about a 15-minute flight away.
Including the period when the Doctor-Heli was not used, 11 children were transferred between 2001 and 2006. Only one died.
Of the 22 children who were not transferred, close to a third, or six, died.
Even an emergency and critical care center may not be enough to save children's lives.
Kenkichi Takei, the doctor at Chiba Hokuso Hospital who compiled the study, said, "I was very surprised that even children who we thought could not be saved because of a major injury were saved at the PICU."
According to the Japanese Society of Intensive Care Medicine, there are 18 PICUs in Japan. There are a total of about 120 beds at all those units.
In Europe, based on the incidence of children in critical condition, a PICU with 10 beds is set up for every 400,000 or so children.
If that standard was used in Japan, there would be a need for about 50 PICUs, with a total of about 500 beds.
Another problem in Japan is that most PICUs can only handle post-operative care or sudden changes in the conditions of children already hospitalized for cancer, heart disease and other illnesses. Those PICUs do not accept children with major injuries stemming from falls or traffic accidents.
In such cases, those children have to be taken to emergency and critical care centers for adults. But such centers often refuse to see the children.
One emergency care doctor admitted, "If possible, I do not want to see a small child with a major injury. Only a pediatrician can adequately handle such cases. To be honest, I would be afraid of taking on such cases."
Youngest most vulnerable
Such conditions are behind the high mortality rate for Japanese infants. While Japan's rate falls below the average in the WHO study in all other age groups, the rate is above average for children between 1 and 4.
Hirokazu Sakai, who heads the comprehensive care department at the National Center for Child Health and Development, said, "The leading cause of death for that age group is accidents. However, many pediatricians refuse to treat such children. It is as if those children were being left to die."
One reason behind such a situation is the advanced differentiation within pediatric care. Because emergency and intensive care requires that doctors examine the entire body, it has not been covered in the current medical specialization system, which is classified based on the organ being examined.
For that reason, Japanese medical schools do not have a systematic curriculum that allows students who have completed pediatric care training to undergo training in intensive care for children.
There are only between 20 to 30 doctors in Japan who specialize in pediatric emergency and intensive care.
To change that situation, the Japanese Society of Intensive Care Medicine, the Japan Pediatric Society and a research group with the Ministry of Health, Labor and Welfare compiled standards for PICUs in 2007. The PICU was clearly defined as "a place to treat all children whose lives are in danger, including emergency patients."
A pressing issue in increasing the number of PICUs is training doctors to work in those units. Specialists are taking time out of their busy schedules to help with that training.
Veteran pediatric intensive care specialists formed a nonprofit organization in 2005 that has conducted two-day workshops every fall for young doctors and nurses. This year, about 600 people took part, indicating that some effort is just now beginning to help save more children's lives.
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