What Is the Immunization Plan for an Internally Displaced Person from a Natural Disaster?

Patient Presentation
A 10-month-old female came to clinic with a mild cough, runny nose and a fever for 2 days.
The child has recently relocated from the New Orleans area because Hurricaine Katrina had devastated their home.
She was drinking and urinating well, was playful and had no specific ill contacts.
The past medical history revealed a healthy female who had received routine health care up to 6 months of age.
Her immunizations were current.
The pertinent physical exam revealed a playful female with a normal temperature and no tachypnea. She had mild clear rhinorrhea anda small amount of fluid behind her tympanic membranes bilaterally with no injection. Her throat and lungs were normal.
The diagnosis of a viral upper respiratory illness was made. Her parents were told to give symptomatic care and to monitor symptoms. The parents asked what they should do about their child’s immunization schedule because of the hurricaine and the lack of vaccine documentation.
The parents were told that the Centers for Disease Control website had recommended that health care providers assume that patients without documentation of immunization would have had all of their vaccinations and to continue the regularly schedule vaccines at the proper time. They were offered Influenza vaccine in a few weeks when it became available.

Discussion
A humanitarian emergency generally can be described as “an acute situation affecting a large population where through disruption or displacement neither the population nors it’s government is capable of providing for all of the basic needs.”
There can be various inciting events including natural disasters (e.g. hurricanes, droughts, famines, earthquakes, etc.) or manmade disasters (e.g. terrorist attacks, bombings, nuclear explosions, civil war, etc.). The United Nations High Commission for Refugees refers to the individuals affected as “persons of concern.”These persons of concern are either refugees (people who leave and cross an international border to another country) or internally displaced persons (IDPs, people who leave their homes but do not cross an international border and enter another country).
Refugees sometimes maybe better off than IDPs because once a border is crossed then international treaties and laws often apply to their treatment. This is not true for IDPs as a sovereign government needs to accept aid for what is considered an internal problem.

The most vulnerable individuals in humanitarian emergencies are the youngest and oldest of a population. Orphaned and unaccompanied children are even more vulnerable. Women and women-headed households often have less access to relief services. Pregnant and lactating women are also vulnerable because of their increased nutritional needs.

The appropriate emergency response must always be tailored for the disaster.
Ten essential emergency relief measures to evaluate and institute are:

  • Rapid assessment of the situation and the affected population
  • Provide adequate shelter and clothing
  • Provide adequate food – minimun 1900 kcal/person/day
  • Provide elementary sanitation and clean water 3-5 liters/person/day
  • Institute diarrhea control program
  • Immunize against measles and provide Vitamin A supplements
  • Establish primary care medical treatment
  • Establish disease surveillance and a health information system
  • Organize human resources – victims themselves, community leaders, interpreters, surrogates for unaccompanied minors
  • Coordinate activities with local authorities, relief organizations, government agencies, military etc.

Learning Point
The Centers for Disease Control (CDC) has issued recommendations for immunization implementation plans for IDPs of the Hurricaine Katrina and Rita disasters that occurred in the fall of 2005 (see To Learn More). Many medical records were destroyed in these disasters.

  • If medical records are available and the patient has current vaccines, then the patient should continue to receive the proper vaccines on the regular schedule
  • If medical records are available and the patient is missing vaccines, then the patient should receive the proper vaccines on the catch-up schedule.
  • If no medical records are available, then the recommendations are based upon age:
    • <10 years – the patient is assumed to have current vaccines and should receive the proper vaccines for their age based upon the current schedule and state immunization practices. Varicella vaccine should be given unless there is a reliable history of disease.

    • 10-18 years – the patient should receive the adult formulation of diphtheria toxoids and acellular pertussis (Tdap), meningococcal conjugate vaccine (ages 11-12, and 15 years only) and Influenza vaccine if in high risk Tier 1 category.
    • > 18 years – the patient should receive adult formulation of diphtheria toxoids and acellular pertussis (Tdap) if 10 years or more since last tetanus, Pneumococcal vaccine for adults > 65 years, and Influenza vaccine if in high risk Tier 1 category.

It is important for health care providers not only to document the immunizations given, but also to document that the decision for the immunization plan was based upon the natural disaster recommendations from the CDC or other agency. This can prevent possible confusion in the future for the other health care providers who may not know of these recommendations and to prevent unnecessary vaccine duplication.
As for school requirements, the CDC has stated,”States affected by Hurricane Katrina had immunization requirements for school and daycare and it is likely that children enrolled prior to the disaster would be vaccinated appropriately. It is not necessary to repeat vaccinations for children displaced by the disaster, unless the provider has reason to believe the child was not in compliance with applicable state requirements.”

People living in crowded group conditions should be immunized for Influenza, Varicella, MMR and Hepatitis A according to the CDC guidelines.

Questions for Further Discussion
1. What are some of the mental health needs of refugees and IDPs?
2. What is the relationship between governmental agencies and non-governmental organizations in disasters?
3. What is your own role in providing help during a local diaster?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for these topics: Traveling with Small Children and Colds / Upper Respiratory Infection (URI)

To view current news articles on this topic check Google News.

Uniformed Services University of the Health Sciences, Department of Pediatrics. Military Medical Humanitarian Assistance Course. October 2003. pp. 3-24.Available from the Internet at http://www.pedsedu.com/course_manual.htm (rev. 9/8/05, cited 10/17/05).

Centers for Disease Control. Interim Immunization Recommendations for Individuals Displaced by Hurricane Katrina.
Available from the Internet at http://www.bt.cdc.gov/disasters/hurricanes/katrina/vaccrecdisplaced.asp (cited 10/17/05).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    October 31, 2005

  • What are the Treatment Recommendations for Acne?

    Patient Presentation
    A 19-year-old female comes to clinic for her health maintenance examination. She has had mild acne in the past, mainly comedones and some papules, that has responded to oral antibiotics and benzoyl peroxide/clindamycin. Over the past 2 months her acne has gotten worse on these medications with more pustules and some nodules.
    She is concerned about her appearance. She denies new soaps, lotions, haircare products or cosmetics. She wears a sunscreen recommended by her mother’s dermatologist.
    The family history reveals ‘bad’ acne in her mother who continues to have occasionally acne problems that are related to her menstrual cycle.
    The pertinent physical exam shows a healthy adolescent with normal growth parameters. She has about 75 total lesions mainly around her forehead, cheeks and around the nose. Most are comedomal, but there are ~10 lesions that are pustular and ~5 that are nodular.
    She also has ~10 lesions on her upper back/neck area that are pustular.
    The diagnosis of moderate acne was made that is failing past treatment. The patient, mother and physician agreed that a consultation with a dermatologist may be helpful considering the progression of symptoms, moderate psychological stress to the patient and the mother’s history. The patient was prescribed Retin-A® to use in the evening along with the benzoyl peroxide/clindamycin in the morning in the meantime.
    The patient’s clinical course showed some improvement with the Retin A® and benzoyl peroxide treatment by the time of her dermatology appointment. The dermatologist also suggested possible oral contraceptive treatment now and possible Accutane® treatment if there was failure. The patient decided to try the oral contraceptives which also markedly improved her acne.

    Discussion
    Acne vulgaris is the most common skin disease with about 17 million people in the US affected. It commonly occurs in adolescents and young adults. The exact mechanism is unknown but combinations of bacteria (Propionibacterium acnes, an anaerobic bacterium), increased sebum production caused by increased androgens, and increased keratinocytes all appear to be partially responsible.
    Acne affects the areas of the face, the upper part of the chest, and the back which have the densest population of sebaceous follicles.

    Some external factors may cause acne to become worse and these include:

    • Some cosmetic agents and hair care products

    • Medications – i.e. steroids, lithium, some antiepileptics, and iodides.
    • Endocrine disorders with increased androgen production – i.e. congenital adrenal hyperplasia, polycystic ovary syndrome

    Descriptive definitions of acne lesions include:

    • Closed comedone (whitehead): non-inflamed (non-red) follicular opening containing a keratotic plug with a thin overlying epidermal membrane
    • Open comedone (blackhead): non-inflamed (non-red) follicular opening containing a keratotic plug that appears black
    • Papule: small round to oval red elevation of the skin (1-4 mm)
    • Pustule: resembles a papule with a central pocket of pus
    • Nodule/Cyst: poorly marginated, red, tender, sometimes draining 0.2- to 3.0-cm indurated mass in the skin

    Figure 27 – Cross section of normal skin

    Figure 28 – Cross section of closed comedone

    Figure 29 – Cross section of open comedone

    Acne has different severity grades depending on the reference. A recent guideline uses a practical 3-step grading scale:

    • Mild – predominance of comedones (fewer than 20), or fewer than 15 inflammatory papules, or a comedone/papule count of fewer than 30 on the face.
    • Moderate – predominance of papules and pustules (about 15-50 lesions) with comedones and rare cysts. Total lesion (comedone, papule, pustule) count may range from 30 to 125 on the face.
    • Severe – primarily has inflammatory nodules and cysts. Also present are comedones, papules, and pustules or total lesion count of greater than 125 on the face.

    It is important to assess the psychological impairment acne causes for the patient. Often the psychological stress necessitates more aggressive treatment than the objective grading of the acne. It is important to educate the patient and family about the treatment options, the proper way to use the medications prescribed, and especially the natural history.
    Often acne becomes initially worse with the treatment before improvement is seen. Also, use of the medication often requires 8-12 weeks of treatment before improvement is actually seen. If patient’s do not understand this time course, they may discontinue treatment as they feel it is ineffective.

    Learning Point
    An algorithm for the evaluation and treatment of acne is available from the Institute for Clinical Systems Improvement.

    Mild acne is often initially treated with benzoyl peroxide or benzoyl peroxide/topical antibiotic (combination product) once or twice a day. This can also be used with or without a topical retinoid.
    If using a topical retinoid it used, use it in the evening and use the benzoyl peroxide product in the morning.

    Topical Medications

    • Over the counter medications
      • Benzoyl peroxide – ex. Clearasil®, Desquam®, works by decreasing lipid formation and free fatty acids and causing mild desquamation, may be a single product or in combination with antibiotics (ex. Benzaclin®, Benzamycin®), products have concentrations up to 10%
      • Salicylic acid – works by keratolysis, products have concentrations of 0.5-2%
      • Other products – ex. glycolic acid, sulfur, resorcinol
    • Prescription medications
      • Topical retinoids – ex. Diffren® and Retin A®, works by increasing the turnover of follicular epithelial cells, promoting drainage of comedones, and inhibiting new comedone formation, generally used in the evening.
      • Azelaic Acid – antibacterial and comedomal medication
      • Topical Antibiotics- ex. clindamycin, erythromycin, sulfacetamide, works by decreasing Propionibacterium acnes within follicles and also may also possess direct anti-inflammatory effects
    • Systemic medications
      • Oral antibiotics – ex. erythromycin, doxycycline, minocycline, tetracycline are generally the first line antibiotics; clindamycin and Bactrim® are second line.
      • Oral retinoids – Accutane® – works by reducing sebum secretion, can cause severe birth defects and therefore its use is restricted to certified dermatologists
      • Oral contraceptives – ex. Ortho Tri-Cyclen® and Estrostep® have FDA approval for acne treatment, works by modulating androgen
      • Spironolactone – works by anti-testosterone effect
    • Other treatments
      • Intralesional corticosteroid injections
      • Blue light – ex. ClearLightTM approved by FDA for moderate acne

    Questions for Further Discussion
    1. What are the indications for referral to a dermatologist?
    2. What steps and certification are required to prescribe Accutane?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Acne.

    To view current news articles on this topic check Google News.

    National Institute of Arthritis and Musculoskeletal and Skin Diseases. Questions and Answers About Acne. Available from the Internet at http://www.niams.nih.gov/hi/topics/acne/acne.htm (rev.10/2001 cited 8/25/05).

    Institute for Clinical Systems Improvement (ICSI). Acne management. Bloomington (MN): 2003 Sep. 32 p. Available from the Internet at http://www.guideline.gov/summary/summary.aspx?doc_id=4164&nbr=3189&string=acne (rev.9/2003 cited 8/25/05).

    Harper JC, Fulton J Jr. Acne Vulgaris. eMedicine.
    Available from the Internet at http://www.emedicine.com/derm/topic2.htm (rev. 7/29/04, cited 8/25/05).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused case is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    October 17, 2005

  • How Come I’m Still Shorter Than the Other Guys?

    Patient Presentation
    A 15-year-old male came to clinic for a sports physical. He and his father had no concerns but the patient wanted to know when he was going to grow taller.
    The past medical history showed that he had always been smaller than his peers.
    The family history revealed that his father was a ‘late-bloomer” and the patient’s brother had his growth spurt around 15-16 years of age too. Mother’s puberty history was unavailable.
    The review of systems was negative.
    The pertinent physical exam revealed a healthy male. Weight is 42.3 kilograms (<3% and equal to 12.5 years ) His height is 151.5 cm (<3% and equal to 12.5 years ). His growth in the past year was 2.3 cm which is below the usual 4-5 cm/year before adolescence. Tanner 3 male. The rest of his examination was normal.
    The chart review showed that the estimated mid-parental height should be ~180 cm and the patient’s height was not within 5 cm of this prediction (see Figure 25).
    As the adolescent had a family history of late puberty and had a growth pattern consistent with constitutional growth delay, the physician felt that this was the most common diagnosis. However, the adolescent was already Tanner stage 3 and appeared to have a decrease in his growth
    velocity in the past year. Therefore a radiologic evaluation of the hand and wrist for a bone age was completed and showed a bone age of 13 years with a standard deviation of 8.9 months.
    The diagnosis of constitutional growth delay was confirmed and the patient will be monitored.

    10-10-05Figure25GrowthChart.jpg:
    Figure 25 -Growth chart for the patient showing short stature.


    Figure 26 – AP radiograph of the left hand showing that the patient’s bone age is greater than two standard deviations below his chronological age, according to the method of Gruelich and Pyle.

    Discussion
    Normal growth patterns in children and adolescents are good signs for both parents and health care providers to see, as they often are reassuring evidence that the child is healthy. When abnormal growth rates or patterns are seen, this is a cause for concern.
    Generally if there is a problem, the growth parameters will be affected in the following order: weight before height before head circumference. The differential diagnosis is dramatically different based upon if one, two or all three growth parameters are affected.

    Primary evaluation for linear growth problems includes a growth and pubertal history of the parents and siblings, the patient’s prenatal and perinatal history and developmental milestones, and a careful evaluation of previous growth measurements.
    Sometimes previous growth measurements are not available and some indications can be obtained from group photographs or changes in clothing and shoe size.

    Normal growth rate is 5 cm/year for ages 2 – puberty onset. The peak linear growth is Tanner 2-3 for girls (9 cm/year) and Tanner 3-4 for boys (10 cm/year). The potential for achieving additional growth after Tanner 4-5 (full maturity) is small as this correlates with epiphyeseal closure.
    A bone age radiograph is very helpful in determining how skeletally mature the adolescent is compared to their chronological age.

    Learning Point
    The most common causes of short stature in adolescence are consititutional growth delay, familial/genetic short stature and chronic illness (in this order). Short stature in adolescence includes:

    • Constitutional growth delay (chronological age > bone age) – These patients are small in the first few years then have an average growth rate. Puberty is late and the growth spurt occurs later. These adolescents catch up with their peers and have a normal range of stature in adulthood.
      If no signs of puberty emerge by 15 for females and 16 for males, an endocrine consultation is recommended.

    • Familial or genetic short stature (chronological age = bone age) – These patients are small at birth and remain so throughout childhood. They enter puberty at an average age and remain short relative to their peers and are short in adulthood.
    • Chronic illness
    • Endocrine abnormalities
      • Cortisol excess

      • Growth hormone deficiency – These patients have marked dwarfism (i.e. usually 3-4 standard deviations below the mean). Growth is normal for the first 1-2 years of life and then a decrease in height velocity is seen. Physical signs include infantile features and body proportions, weight age > height age, and delayed puberty.
      • Hypothalamic disorders
      • Hypothyroidism
    • Genetic syndromes (i.e. Turner’s Syndrome, Russell-Silver syndrome, Albright’s hereditary osteodystrophy, Down’s syndrome, Prader-Willi syndrome, etc.)
    • Nutritional abnormalities – (i.e. Anorexia nervosa, Inflammatory bowel disease, etc.)
    • Psychosocial dwarfism
    • Skeletal dysplasia

    FDA approved indications for growth hormone treatment in children includes:

    • Growth hormone deficiency

    • Turner syndrome
    • Chronic renal insufficiency
    • Small for gestational age or intrauterine growth retardation
    • Prader-Willi Syndrome
    • Continued height deficit in puberty

    Questions for Further Discussion
    1. What is included in the differential diagnosis of a child with short stature and decreased weight?
    2. What is included in the differential diagnosis of a child with short stature and macrocephaly?
    3. What psychosocial evaluation should be done for an adolescent with short stature?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    To view current news articles on this topic check Google News.

    Hofmann AD, Greydanus DE. Adolescent Medicine. 1983. 243-246.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1-6.

    American Association of Clinical Endrocrinologists Medical Guidelines for Clinical Practice. Growth Hormone Use for Adults and Children.
    Endocrine Practice. 2003:9;64-76. Available from the Internet at http://www.aace.com/clin/guidelines/ (cited 8/23/05).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    9. Patient-focused case is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    October 10, 2005

  • What are the Salter-Harris Fracture Types?

    Patient Presentation
    A 12-year-old female came to clinic because of pain in her distal great toe. Last evening she stubbed it on the floor as she was raising her leg for a kick in a martial arts class.
    She had immediate pain and swelling. She has iced it several times, but it continues to swell, and has become ecchymotic and she is having some minor problems walking.
    The pertinent physical exam reveals a pre-teen in no acute distress. She has significant swelling and ecchymosis of the great toe, with point tenderness at the distal phalyngeal joint. The rest of the examination was normal.
    The radiologic evaluation confirmed the diagnosis of a Salter-Harris II fracture of the distal phalynx of the great toe.
    The patient was treated by ‘buddy-taping’ the great toe to the second toe as a splint, and placed into a cast boot to aid support. She obtained some immediate relief with these measures. She was also instructed to rest, ice, and elevate her foot and use ibuprofen for pain control. The patient was to follow-up in approximately 1 week.

    Figure 23 – AP (left) and lateral (right) radiographs demonstrate a subtle Salter-Harris Type II fracture of the distal phalanx of the first toe.

    Discussion
    Toe and metatarsal fractures are common in children. For toe fractures that are non-displaced or minimally angulated, they can be adequately treated by buddy-taping the toe, and placement in a a hard-soled shoe using crutches. Sometimes a bulky splint can also be applied.
    Fractures of the great toe and the metatarsals can have higher risks of complications. For example, intrarticular fractures of the proximal great toe may need surgical pinning and a 5th metatarsal fracture (Jones Fracture) has a high rate of non union.

    Learning Point
    Drs. Robert Salter and William Harris classified injuries inolving the epiphyseal plate in their article from the Journal of Bone and Joint Surgery in 1963. Because Salter-Harris fractures involve the physis (i.e. growth plate) they are unique to pediatrics.
    The classification has 5 types with the risk of complications increasing with the level. This is because Type III and IV have intraarticular components and Type V crushes the physis (i.e. growth plate) itself.

    The Salter-Harris Classification is:

    • Type I – fracture through the physis (widened physis)
    • Type II – fracture partway through the physis extending up into metaphysis
    • Type III – fracture partway through the physis extending down into the epiphysis
    • Type IV – fracture through the metaphysis, physis, and epiphysis — can lead to angulation deformities when healing
    • Type V – crush injury to the physis

    Figure 24 – Diagram showing the Salter-Harris Fracture Classification System. M = Metaphyseal involvement, E = Epiphyseal involvement, ME = Metaphyseal and Epiphyseal involvement.

    Overall, only 30% of Salter-Harris fractures cause growth disturbance and 2% have significant functional problems. Generally plain radiographic examination is all that is needed to diagnose the fracture. Computed tomography can be used for surgical planning.

    Questions for Further Discussion
    1. What are the indications for an orthopaedics consultation for a fracture?
    2. What does the acronym RICE stand for?
    3. How long should ice be applied to a musculoskeletal soft tissue injury?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for these topics: Fractures and Dislocations and Casts and Splints.

    To view current news articles on this topic check Google News.

    Salter RB Harris WR. Injuries Involving the Epiphyseal Plate. J. Bone Joint Surg. 1963:45A:587-622.

    Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:688.

    Moore W, Smith TH. Salter-Harris Fractures. eMedicine.
    Available from the Internet at http://www.emedicine.com/radio/topic613.htm (rev. 05/20/03, cited 8/11/05).

    D’Alessandro MP. Fracture, Epiphyseal Plate (Salter Harris) Paediapaedia: Musculoskeletal Diseases. Available from the Internet at: http://www.vh.org/pediatric/provider/radiology/PAP/MSDiseases/FxEpiphyseal.html. (cited 8/11/05).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competency performed.

  • Medical Knowledge
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    October 3, 2005