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Preparing to care for paediatric trauma patients
  1. Paula Pearce
  1. Correspondence to Maj Paula Pearce, Defence Medical Group South, Portsmouth, Cosham PO6 3LY, UK; ppearce80{at}hotmail.co.uk

Abstract

Introduction Considerable evidence has discussed the significant workload and advances in clinical care by UK Defence Medical Services (DMS) during recent conflicts in Iraq and Afghanistan. Although the DMS is not doctrinally staffed to deal with children on operations, severely ill and injured paediatric casualties continue to present to military medical facilities; therefore, staff must be competent to deliver the appropriate level of care. This paper reports the paediatric presentations to the emergency department (ED), at the Role 3 Medical Treatment Facility (MTF) in Camp Bastion, Afghanistan, over a 21-month period. The aim was to provide quantitative, statistical data of paediatric presentations seen by deployed ED nurses, to identify whether the current training was appropriate and to make recommendations for further training requirements for DMS ED nurses.

Method All paediatric presentations to the MTF ED between January 2011 and September 2012 were analysed. The following aspects of the admission were analysed: date of admission, mechanism of injury, injury sustained, discharge, length of stay in the ED and length of stay in the R3.

Results There were 159 paediatric presentations to the ED in 2011 of which 56% warranted admission to the intensive treatment unit (ITU). In contrast, over the shorter period in 2012, 79% of 73 paediatric presentations were admitted to the ITU. The most common mechanism of injury was hostile action. 13% of the patients who presented to the ED in 2011 did not survive to discharge, compared with 11% the following year.

Conclusion Although the exposure to paediatric polytrauma during the conflicts in Afghanistan and Iraq is not replicated in peacetime roles, it is likely that wherever emergency nurses are deployed the treatment of children will continue. Analysis of the service evaluation has led to the recommendations for specific skills that emergency nurses could develop during the pre-deployment phase to better prepare for caring for such patients. These include recognition of the sick child/triage, paediatric drug calculations, awareness of the massive transfusion requirements for children and skills to gain intravenous/intraosseous access in a child.

  • ACCIDENT & EMERGENCY MEDICINE
  • EDUCATION & TRAINING (see Medical Education & Training)
  • paediatric trauma
  • emergency nursing
  • Military
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Key messages

  • Severely ill and injured paediatric casualties continue to present to military medical facilities; therefore, staff must be competent to deliver the appropriate level of care.

  • Military personnel face significant challenges in gaining the experience of managing major paediatric trauma in peacetime environments as relevant opportunities within the UK are limited

  • Specific skills required, such as approaches to vascular access and the administration of blood products, may not trans late from adults to paediatrics.

  • Recommendations are made for specific skills emergency nurses should develop during the pre-deployment phase to allow them to feel more competent treating paediatric trauma patients.

Introduction

From 2001 to 2014, UK Defence Medical Services (DMS) personnel have treated casualties from high-intensity operations in Iraq (Op TELIC) and Afghanistan (Op HERRICK). Sadly, children have also been the unintended victims of war fighting and during these campaigns large numbers of injured children have been treated at British medical facilities. Incomplete data collection due to the varying intensity of operations explains the inconsistency in reporting the exact number of paediatric patients seen in each theatre of operations, but it is known that paediatric patients have always accounted for a fairly predictable proportion of the operational workload.1

Trauma is the leading cause of death in children aged >1 year in England and Wales2 and caring for critically ill and injured children requires specific paediatric nursing knowledge and skills.3 Exposure to such patients, especially those caused by conflict, can be daunting and typically causes anxiety based on the lack of experience and or training. It has been evident during pre-deployment training and on deployment, that emergency department (ED) nursing colleagues often lacked confidence in treating children. In order to provide data to inform paediatric pre-deployment training and/or identify any further requirements that would better equip ED nurses to deal with the challenge of paediatric patients, a service evaluation of the paediatric presentations to the Role 3 Medical Treatment Facility (MTF) ED in Camp Bastion (BSN), Afghanistan, was undertaken.

Methods

Authority was obtained from the deployed medical director to undertake a retrospective evaluation of all the paediatric presentations to the ED from January 2011 to October 2012. Data were collated by conducting a search of the electronic patient-tracking system Whole Hospital Information System (WHIS). Potential data input errors were identified and corrected by comparing the results from the WHIS search with the ED admissions register.

Results

In 2011, there were 159 paediatric presentations to the ED, of which 89 (56%) were severely injured/ill enough to warrant admission to the intensive therapy unit (ITU), compared with 122 paediatric admissions to BSN R3 ED in 2012. Complete ITU admission data were only available until 30 September 2012, however, by which time 57/73 (79%) paediatric admissions were admitted to ITU. Sadly, 21 of the patients (13%) in 2011 who presented to the ED did not survive to discharge (Figure 1).

Figure 1

Paediatric admissions to Camp Bastion ED from 1 January 2011 to –30 September 2012. ED, emergency department.

Although the number of paediatric patients admitted in 2012 had reduced, a greater proportion required ITU admission (79% vs 59%), suggesting a higher burden of disease or injury.

Figure 2 shows the distribution of the paediatric mortality across the Field Hospital, categorised by department. Most paediatric patients presented to the ED BSN following hostile action injuries such as blasts and burns from improvised explosive devices and gunshot wounds (Figures 3 and 4). A small number were admitted as a result of non-hostile action caused by road traffic accidents, drowning or animal bites, leading to severe poisoning. This preponderance of trauma admissions highlights the need for emergency nurses to possess specific paediatric trauma skills—there was no difference in the proportion of non-hostile action admissions among the paediatric patients between 2011 and 2012.

Figure 2

Paediatric mortality across R3 BSN from 1st January 2011 to 01 October 2012. ED, emergency department; ICU, intensive care unit; OT, operating theatres; R3 BSN, Role 3 in Camp Bastion.

Figure 3

Mechanism of injury of Paediatric ED admissions during 2011. ED, emergency department. IED, Improvised Explosive Device; GSW, gunshot wound; RTC, road traffic collision.

Figure 4

Mechanism of injury 2012. Mechanism of injury of Paediatric admissions to Camp Bastion ED from 1 January 2012 – 30 Sept 2012. ED, emergency department.

Discussion

The limited literature on the management of paediatric trauma in military treatment facilities identifies the need for appropriate training to equip military health professionals to care for paediatric casualties on operations.1 ,4 ,5 Medical support to military operations is tailored to the military population at risk, although it is often necessary to provide support to indigenous military forces, captured personnel and other eligible personnel, which includes the provision of emergency care to all casualties where this is urgently needed.6 Military doctrine specifies that any care given must be within existing capability and should not create a dependency among the local population.6 Health provision is often an emotive subject, as reducing or controlling access in favour of different groups may become a destabilising influence.7 A historical Surgeon General policy document supported clinicians identifying the point that civilian paediatric cases should be returned to their local health facility.8 Well-intentioned military medical activities risk undermining the military mission by creating an unsustainable dependence or compromising efforts made by the local government to rebuild its own health system.

Children have distinctly different physical needs for treatment.3 Clinicians working in emergency care should ensure that they are skilled in specific aspects of treating a child, such as obtaining intravenous/ intraosseous access, administering paediatric doses of medications and blood products.9 However, there continues to be a lack of consensus whether children should be treated as small adults. Fendya et al10 argued this is not the case as children have different physiology with varying anatomical differences, which require the clinicians looking after them to have specific knowledge and skill sets, whereas Bree et al9 suggested that ultimately the immediate priorities for life-saving treatment are the same as adults; fundamentally the <C>ABCD approach (<C> indicating catastrophic haemorrhage) should be adopted whether treating an adult or child, but to function effectively in any of the paediatric trauma team roles there are specific knowledge and skill sets for paediatric patients.3 Specific skills required, such as approaches to vascular access and the administration of blood products, may not translate from adults to paediatrics and these are likely to always remain. During a paediatric trauma resuscitation in the ED the Belmont rapid infusion system can be used to infuse warmed blood faster than traditional methods; however, care must be taken and training received to ensure the operator is conversant with the different administration methods and flow rates required for paediatric patients.11 Analysis of this evaluation revealed the preponderance of paediatric presentations were trauma-related, thus highlighting the need for emergency nurses to possess specific paediatric trauma skills. This finding along with the breakdown of individual roles nurses carry out during a trauma resuscitation leads to recommendations for the following skills to be incorporated into the pre-deployment phase and form part of the emergency nurse core competencies;

  • Paediatric massive transfusion knowledge.

  • Belmont rapid infuser use in children.

  • Recognition of the sick child/triage.

  • Paediatric drug calculations.

  • Analgesia.

  • Ability to gain intravenous/intraosseous access in a child.

A common theme highlighted throughout the literature was the magnitude of paediatric injuries presenting to Field Hospitals on operations, which were predominantly gunshot wounds and explosive injuries, which are simply not seen in peacetime.12 Thus, military personnel face significant challenges in gaining the experience of managing major paediatric trauma in peacetime environments as relevant opportunities within the UK are limited.4 This was confirmed in a study by Nordmann5 who reported that 31 paediatric patients were admitted for surgical intervention after trauma over a 3-month period in Afghanistan; in comparison, the average ED in the UK sees less than one seriously injured child each month.4 The low trauma levels in the UK make it difficult to replicate patterns of injury seen on operations and obtain appropriate competencies to prepare for deployment.

The author's personal experience reflects the evidence in the literature, which suggested that due to the uniqueness of the environment, only trauma seen on operations actually prepares an individual to deal with future trauma presentations.4 ,13 No amount of civilian experience will expose clinicians to the injuries sustained during conflicts. Personnel will only develop their skills and knowledge to manage seriously injured children while on operations and their confidence will increase to deal with similar presentations. Conversely, the experience and skills military medical and nursing personnel gain on operations have facilitated enhanced training for NHS hospitals and other organisations.14 A report by the Care Quality Commission15 confirmed the provision of trauma care provided by the DMS on operations as ‘exemplary’ and called for increased cooperation between the DMS and NHS. Evidence demonstrates that care should be led by consultants experienced in major trauma, but major trauma is most likely to occur at night-time or at weekends when consultants are less likely to be present in the ED. Having a dedicated consultant present in an ED produces quicker and better decision-making in the care of major trauma patients. As the Iraq and Afghanistan conflicts matured, case studies were published illustrating how invaluable experienced medical or nursing staff are when there is a need to make early decisions in the management of a severely injured paediatric patient.12 ,13 ,16 The deployed ED is able to boast 24 h consultant-delivered care.

Conclusion

The considerable differences in injury patterns between military and civilian paediatric trauma patients mean that military emergency nurses are unlikely to be familiar with the types of injury seen on deployment until they deploy. Polytrauma suffered by children in the UK does not replicate the patterns of injury seen in Afghanistan. Although these patterns may vary in future conflicts, it is essential that there is an awareness of the injury patterns sustained during recent military operations to aid the development of training and forward planning of the resupply chain.

The data from this study offer insight into the paediatric trauma exposure gained by ED nurses during periods of highly kinetic operations that cannot be replicated in peacetime roles. These data have led to recommendations for specific skills that emergency nurses should develop during the pre-deployment phase to allow them to feel more competent when caring for this level of paediatric trauma patient.

To obtain the appropriate competencies and prepare for deployments, the DMS uses simulation in a purpose-built hospital trainer and future research should review the effectiveness of this method of training. In addition there may be the appetite to explore the psychological consequences of deploying without obtaining the necessary skills to treat paediatric trauma patients.

References

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Footnotes

  • Twitter Follow Paula Pearce at @ppearce1980

  • Acknowledgements The author acknowledges contributions from Lt Col Paul Reavley and Lt Col Jayne Cumming for their editorial support of the service evaluation during OP HERRICK 16. Also, Wg Cdr Di Lamb and Lt Col Lizzy Bernthal for their continued editorial support in preparing this paper for publication.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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