Season of Joy and Trauma
As EMS providers, we are caught in a schizophrenic state between the joys of working with children and the pain of having to witness them in emergency situations — especially during the season of joy; the winter months.
When children are the victims of trauma, our calling is to properly care for them in that moment in order to give them the best chance of surviving and reaching adulthood. In order to maximize their survivability and reduce our stress, we must become life-long students of pediatric trauma care.
Being a proactive pediatric care student begins with a basic fundamental — learning who is at risk and how they are injured. The 2007 Pediatric Trauma Report, from the National Trauma Data Bank, provides insight into the most common causes of pediatric injuries and death.
From 2002 to 2006, NTDB reported 334,095 pediatric injuries, with 94,309 in 2006 alone. From that figure, data shows that boys were about two times more likely to be injured than girls. The breakdown by age and gender is as follows:
|0 – 7 yrs =||40359 (40%)||59882 (60%)||100241|
|8 – 14 yrs =||26739 (31%)||59869 (69%)||86608|
|15 – 19 yrs =||42672 (29%)||104574 (71%)||147246|
According to the NTDB data, the leading cause of pediatric injury is motor vehicle crashes (MVC), reaching a total of 124,337 reported cases for the year. This emphasizes the importance of using car seats for younger children and making sure to regularly check the seat’s condition before use. Other leading causes include falls (79,693), striking injuries (27,801), other transportation modes (25,488), and firearms (17,322). From these mechanisms, the number of deaths equates to 4,307 from MVCs, 2,103 from firearms, and 262 from falls.
This data shows that pediatric injures can come from a variety of sources, each requiring a different approach to treatment. Our knowledge and skills of caring for pediatric trauma victims must be at a mastery level, as opposed to just concentrating on the final stages of care. A trauma registrar once gave me this advice,
“Caring for trauma victims should be similar to how the top ten golfers in the world train. They spend 75 percent of their practice time on the driving range and 25 percent putting, because three of every four strokes are driving the ball to the green. The fourth stroke is for the final cup.”
Unfortunately, many healthcare providers spend 75 percent of their time focusing on the knowledge and skills required for only the bottom 25 percent of life-threatening problems. Mastering the knowledge, skills, equipment and critical-thinking strategies related to trauma are all required to properly care for a child in any emergency situation. Consider the following example:
“Medic 135, respond to the Maverick Skate Park for a child injured.”
You start thinking, “A bunch of kids on skateboards. Were they wearing protective gear, helmet with the chin strap properly secured, gloves, elbow and knee pads?”
Upon arrival, you get your answer. Witnesses meet the ambulance and tell you their friend, 13—year-old Ian, missed his jump at the top of the twelve-foot ramp and augured in. They direct you to the bottom of a concrete ramp where the patient is laying, probably in the same position that he landed in. It is obvious he was not wearing any protective gear.
During your assessment, you find the boy has a decreased response to verbal stimuli, but withdraws from painful stimuli. He has obvious abrasions and contusions about his head, body and extremities, and has significant deformity around the right femur. You ask him his name, but he does not respond with any verbal level of appropriateness. His friends indicate that they don’t know if he has any medical problems besides the obvious — that he’s lying in a pile at the bottom of the jump. They also state that his parents are out of town and no one knows how to get a hold of them. One of the boys mentions the wipe-out will be “gnarly” on YouTube.
C-spine and A, B, C precautions are immediately taken. A cervical collar is measured for correct sizing and applied, as assurances for a patent airway are confirmed. The patient is breathing adequately and has good central and distal pulses. His distal circulation, sensation, and motion are also checked prior to applying the device and prior to placing him on the backboard. Ian’s pulmonary and circulatory status appears accelerated, but within normal compensation ranges for a 13-year-old, except for the circulation in his right foot.
Ian is correctly log-rolled, his back is checked for injuries, and he is correctly log-rolled back onto the backboard, providing additional care relative to his injured right leg. Straps, head-bed and padding are placed to complete the spinal motion restriction precautions. The secondary survey confirms the patient has a decreased level of consciousness and continues to have reduced quality of pulses in his injured right leg and foot.
His vital signs are checked with the following results:
- Respiratory rate: 32 per minute and regular
- Heart rate: 130 beats per minute and regular
- Best Motor Response: Withdraws from pain
- Age adjusted Sacco Score = 9
- Weight: 50 kilograms (approximately)
As a prehospital provider, you understand that the mechanism of injury required to fracture Ian’s femur is sufficient to cause him to be in shock, specifically hemorrhagic shock. You further understand how Ian, an otherwise young, healthy adolescent, is able to compensate despite potentially life-threatening injuries. You hope for the best as you prepare for the worst. As nearly an afterthought, you ask Ian’s friend for the video camera they were using to record the skating tricks, so that you could see the mechanism of injury for yourself. He complies.
Your treatment regiment includes high-flow, high-concentration oxygen at 12 L/minute via non-rebreather mask, establishing vascular access preferably a large bore, and keeping the fluid at a TKO if his vital signs remain at their current levels. En route to the hospital, a 20 mL/kg (1000 mL) fluid bolus must be considered if there is any indication that Ian is starting to decompensate.
During transport you re-evaluate the patient, including his neurological status. Consideration must be made to further stabilize Ian’s right leg. A traction splint may be applied and distal circulation, sensation and motion are checked both before and after applying the device. Distal circulation in the right foot increases with the application of the traction splint and the amount of pain decreases.
During transport, the EKG monitor shows a sinus tachycardia, pulse oximetry on ambient air is at 93 percent, and blood glucose is at 84. Transport is facilitated in a prompt and safe manner to a definitive care hospital approved to care for children.
The patient’s level of consciousness improves to the point that he is able to answer most of your questions. A prompt and concise patient report is provided to the receiving hospital. Ian continually asks what happened and is occasionally confused as to his surroundings. He complains of spasms in his right leg and tells you, “This thing in my groin is really uncomfortable.”
Upon arrival at the hospital, Ian’s care is transferred to the receiving nurse and a full report is given. As you complete the transfer of care to the ED staff, a clerk tells you that they have contacted the parents and have received permission to treat.
Over the next several hours Ian is evaluated by both the ED physician and orthopedist. X-rays confirm a displaced mid-shaft femur fracture without proximal or distal joint involvement. Ian’s parents agree that surgical intervention is required and he is taken to the operating suite for an open repair. Within 24 hours the rehabilitation process begins and Ian is soon attempting “crutch stunts.”
For your consideration
EMS continues to be called on to care for children engaged in recreational activities. It is estimated that nearly 3 million children will be seen in emergency departments and approximately 2,500 will die before the start of school next fall.
EMS providers must be prepared for the increased potential for pediatric trauma during the winter months. It is cardinal for quality prehospital care to properly assess, provide on-scene interventions when life is threatened, assure prompt interventions during transport, and provide safe transport to a facility capable of caring for the traumatized child.