Most Children Get Sick At Night, When The Day Clinic Is Closed
Claude’s 4 year-old son Frantz had been coughing all day but he decided to wait it out and see if the toddler would improve on his own. But as evening came on Frantz became feverish and the cough persisted. Claude was particularly worried because Frantz’s medication had run out. At this point it was too late in the day for Claude to bring his son to any of the area clinics so he called MotoMeds, a new nighttime pediatric healthline he had heard about on the radio.
Claude’s call was answered by Wylmerlaine, a MotoMeds nurse who was staffing the call center that evening. Wylmerlaine asked Claude a series of questions about his son’s illness and past medical history and determined he needed an inhaler for his respiratory distress along with acetaminophen for his fever. A MotoMeds motorcycle driver was then dispatched to deliver the medications to Claude’s house, averting a potentially life-threatening respiratory emergency in a setting where emergency care is prohibitively expensive and for the most part inaccessible at night.
MotoMeds was launched by Dr. Eric Nelson, MD, PhD, and his team at the University of Florida to address the lack of access to basic healthcare at nighttime in resource limited settings. The idea originated from Dr Nelson’s experience responding to the 2010 cholera outbreak in Haiti where he repeatedly treated children presenting at the clinic in the morning with severe dehydration – a life-threatening medical crisis for children. Had these children received oral rehydration solution (ORS) at night when the symptoms began, he reasoned, it’s likely many of them wouldn’t have become severely dehydrated by morning. Dr. Nelson began brainstorming a way to get children the basic care they need at night before their problems became severe.
Little did he expect his service would soon be serving children suffering from both medical and social crises.
Social Determinants Of Health
Since July 2018, Haiti has been in the throes of significant political unrest, sparked initially by a dramatic increase in fuel prices that soon led to an outraged public inciting frequent protests against the country’s leadership. Using physical barricades like burning tires to block roads all across the country, these protests frequently result in a total disruption of public transportation for days on end, forcing services like schools and health centers to close because neither the employees nor the patrons can safely travel. At the same time, the economy has been deteriorating, leaving the population with a decreased resiliency and ability to buffer themselves from the chaos. Families that might normally take their child to the local clinic in the afternoon can no longer do so and other families delay seeking care in the hopes of avoiding the high healthcare costs, which exacerbates the illness.
Yet thanks to MotoMeds, families that otherwise would’ve had no options for pediatric care are now finding house calls just a phone call away.
Adapting Clinical Guidelines to a Mobile World
MotoMeds was launched in September 2019 in Gressier, Haiti, as part of a pre-pilot feasibility study funded by the National Institutes of Health. One of the principle goals of this project is to develop telehealth guidelines for pediatric call centers. Using World Health Organization clinical guidelines that are currently only available for inpatient and in-person outpatient pediatric care, the MotoMeds project is adapting the guidelines to a call center setting, essentially extending avaialble services into the nighttime. The call center itself is run out of the MotoMeds office, where nurses begin work at 6pm after the local clinics close, and remain available to take calls until 5am when the clinics open back up again.
The MotoMeds pediatric healthline uses novel technologies that work off the local telecommunications infrastructure: Parents of sick children reach the on-call nurses by dialing an easy-to-remember phone number provided by Digicel Haiti, which then forwards these calls to the Twilio Flex platform, a cloud-based call center management software that allows the nurses to answer the incoming calls through basic laptop computers connected to the Internet.
Once connected, the nurses follow MotoMeds guidelines to ask the parents targeted questions about the child’s symptoms and triage the illness in case they need to be routed directly to a hospital. Following triage, the parents are asked to assist in assessing vital signs like heart rate and respiratory rate. The next step is to obtain more details about the chief complaint through problem-specific questions such as how many times the child has vomited or if there is pain with urination. The assessment is wrapped up with a review of current medications and past medical history, and the nurse reviews the information and develops a treatment plan, reaching out to a local on-call physician if any uncertainty exists. If basic medications or fluids are needed, a nearby MotoMeds delivery driver is alerted via text message through Trek Medics’ Beacon Emergency Dispatch platform to coordinate transport for the medication delivery, or even to take the nurses along to visit the children’s homes in some cases.
Leveraging Available Resources to Strengthen Local Capacity
During the day, MotoMeds delivery drivers operate as motorcycle taxis, shuttling children to school and transporting village women to and from the market with their goods. Their expert knowledge of the area allows them to locate households with no addresses making them a vital part of the operation. The drivers initially expressed security concerns about working at night, not only because of current political crises, but also because of the common-held belief that people who are out after dark are usually up to no good. To reassure their safety, two drivers respond to deliveries after 9 PM or in areas with particularly difficult terrain. The service is so novel that families continue to appear shocked when a driver actually shows up at their house with their MotoMeds delivery after dark.
To date over 130 children 0-10 years have received lifesaving medication deliveries for illnesses ranging from fever to diarrhea to asthma, usually arriving at the patients’ homes in less than an hour after the call was placed. The political and economic climate in which MotoMeds was launched has both highlighted the need for such a service and the unique ways in which it overcomes many of the common barriers to accessing basic healthcare. Following continued iteration of the call center processes MotoMeds can begin scaling to serve a larger area within Haiti and expand to other countries with limited access to healthcare at nighttime.
Motomeds is designed to avoid emergencies by reaching patients early at home. This model can serve many purposes, including decentralizing care to households when situations like cholera, ebola or even coronavirus necessitate more telemedicine and less centralized clinic visits.
To learn more about the MotoMeds Pediatric Healthline, contact Molly Klarman, Program Director