It is privilege to be invited to join the team at St Emlyn’s as a Visiting Professor. However, you might ask (and I have asked myself) why am I here? Perhaps I don’t really belong; paediatric trauma is arguably no place for a Paediatric Surgeon. Ten years ago the majority of paediatric trauma teams, if such teams even formally existed, were run by Paediatric Surgeons. My thesis is that the role of paediatric surgeons in paediatric trauma has changed dramatically in this last decade.
This blog is based on a talk I gave at the London Trauma Conference in December 2015. You can listen to a summary of that talk by clicking on the link below from the St.Emlyn’s podcast.
Where previously the majority of experience and practical wisdom in the topic rested with those in possession of a Fellowship from one of the ancient Royal Colleges this has now changed to those in possession of a Fellowship from a new Royal College. As a paediatric surgeon I am increasingly minded that paediatric trauma is now the domain of Emergency Physicians and is no place for a Paediatric Surgeon; we simply don’t know very much and have even less experience.
Trauma is the biggest killer of children (3) over the age of one year. The sadness is that the majority of death occurs at the scene and as clinicians all we can do to change this is be involved in injury prevention projects. In those transferred to hospitals what is required is expertise in rapid triage, assessment and primary therapy. The reality is that paediatric trauma is actually vanishingly rare representing less than 1% of significantly injured patients. Consequently bravado and firm opinions of surgeons in the past about what to do and not to do made little impact on the outcomes. Times have changed and professional resuscitationists have stepped into this void with wisdom and experience gained in adult practice.
The debate around whether a paediatric trauma patient is a small adult is one specifically reserved for the pub. The average paediatric major trauma patient is seven years old and clearly not an adult. The commonest mechanism of injury is road traffic accident, the same as adults, but importantly the majority of children are struck by a car as opposed to the majority of adult trauma patients who suffer injury within the car. Even comparison of injuries sustained by the same specific mechanism of injury show that adults are relatively less injured and with a different trauma pattern. Children are not small adults. And yet the reality is that assessing a child clinically in the same way you assess an adult clinically will deliver a good result (4). Administering airway support, fluid and analgesia in the same way as one does to an adult will bring about a good result for an injured child. They can be considered a small adult.
What role does a paediatric surgeon offer in paediatric major trauma? It is clear that trauma teams need effective members and paediatric surgeons have many specific and valuable skills to offer such a team. Technical expertise in assessing an abdomen is shown to be of significant value in management of paediatric trauma as the recent PECARN study highlighted. Operative skills for procedures such as chest drain insertion/thoracostomy, local control of haemorrhage and suturing are within the remit of most ED staff: surgeons simply have more experience. Mostly, paediatric surgeons offer a reasoned response to the “needs surgery” worry around major trauma patients. The reality is that damage control surgery in paediatrics is an exceptionally rare occurrence and that conservative management of significant blunt abdominal trauma has a lower morbidity, mortality, blood usage, intensive care requirement and ultimately discharge time. Confidence in the technique coupled with the willingness to intervene if appropriate are definitely the preserve of paediatric surgeons.
The reality of paediatric trauma however is that with its rarity and the fact that emergency surgeons have many other roles within the hospital, paediatric surgeons are seldom free to attend every trauma call and leave their other responsibilities. This has led to many centres moving the surgeon to second tier call on the majority of trauma cases. A surgeon will be sought if a specific action is required, analogous to the neurosurgeons. Over 75% of major trauma involves significant head injury but neurosurgeons are not part of the majority of teams.
Paediatric major trauma needs to be managed by experts. Paediatric surgeons have less and less experience of this and more and more responsibilities elsewhere in the hospital. There are specific tasks a surgeon should be involved in and the astute trauma team leader will call a surgeon to be directly involved as required. Trust me, if you call, we will come, running, if a little nervously. We will come and we will play our part, but as for leading from the front? That’s no place for a paediatric surgeon.
(1) Identifying children at very low risk of clinically important blunt abdominal injuries.
Holmes JF1, Lillis K, Monroe D, Borgialli D, Kerrey BT, Mahajan P, Adelgais K, Ellison AM, Yen K, Atabaki S, Menaker J, Bonsu B, Quayle KS, Garcia M, Rogers A, Blumberg S, Lee L, Tunik M, Kooistra J, Kwok M, Cook LJ, Dean JM, Sokolove PE, Wisner DH, Ehrlich P, Cooper A, Dayan PS, Wootton-Gorges S,Kuppermann N; Pediatric Emergency Care Applied Research Network (PECARN). Ann Emerg Med. 2013 Aug;62(2):107-116.e2. doi: 10.1016/j.annemergmed.2012.11.009. Epub 2013 February
(2) Curr Opin Pediatr. 2005 Jun;17(3):402-6. Outcomes from pediatric solid organ injury: role of standardized care guidelines. Stylianos S1.
(3) Why Children Die: RCPCH http://www.rcpch.ac.uk/improving-child-health/child-mortality/child-mortality
(4) Children are just small adults. http://www.stemlynsblog.org/children-are-just-little-adults-st-emlyns-2/
7 thoughts on “Paediatric Trauma is no place for a Paediatric Surgeon. Ross Fisher joins St.Emlyn’s”
But a paediatric surgeon, Dr. Warwick Teague at SMACC Chicago did make a compelling argument that whilst trauma resuscitation can occur in a variety of settings, the best place for comprehensive trauma care is still currently in a dedicated paediatric hospital.
Whilst I agree with the general comments that trauma is best managed by specialist trauma doctors (regardless of what college they are affiliated to) an important aspect I believe Professor Fisher has not explored is what happens to these young patients after the ED phase of their care.
Are they to admitted to an ED paeds ward for necessary observation (do any exist?), discharged home, admitted to general paeds ward, under whose care? Chest drains and haemostatic dressings are within the skill of ED to be sure but who is then to decide when to remove the drains or manage the wounds further. I am not suggesting this is the domain purely of the paediatric surgeon but of the inpatient paediatric trauma care specialist who can be surely be anyone; surgeon, anaesthetist, intensivist, emergency physician or paediatrician who is appropriately trained and experienced working with appropriate nursing staff and therapists to provide necessary inpatient care.
I also have a theory that in paediatric trauma patients with intermediate risk of isolated head or abdominal injury, they are more likely to be exposed to non-ionising radiation in a non-paeds centre because the skill and resources for prolonged serial observation are absent.
Apart from the clinical and technical aspects of ongoing management little people, there are also other psychological aspects of care including the environment that aid in the assessment, management and recovery of these patients.
Resuscitation and stabilisation of critically injured children should ideally be available in multiple settings but trauma care extends long past the acute phase.
I do agree that paediatric patients are best resuscitated and managed in paediatric centres.
J Emerg Med. 2009 Nov;37(4):359-68. Epub 2007 Nov 26.
Emergency department children are not as sick as adults: implications for critical care skills retention in an exclusively pediatric emergency medicine practice.
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