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TRAUMA: LEADING CAUSE OF DEATH AMONG CHILDREN
Trauma is the number one cause of death in children under fifteen years of age. In fact, in this country alone, 10,000 children die every year due to injury, while more than 100,000 children are permanently disabled. Children who sustain minor injuries may have prolonged disability in either cerebral function or psychological adjustment.
Recent evidence suggests that as many as 60% of children who sustain severe multisystem trauma have residual personality changes at one year following hospital discharge, and 50% show cognitive and physical handicaps. Severely disabled children may require many years of custodial or institutional care, while others suffer the misery of a lifelong functional impairment.
The annual cost of caring for injured children exceeds 15 billion dollars; the human cost is much greater. A major consideration in dealing with injured children is the effect that injury may have on subsequent growth and development. Social, affective, and learning disabilities are present in one half of seriously injured children. Childhood injuries have a significant impact on the family structure as well, with personality and emotional disturbances in two thirds of uninjured siblings.
A child's injuries can also strain a family's marital relationship, forcing financial and sometimes employment hardships. Thus, how the family responds may affect the quality of the child's life for years to come. Considering the devastating impact that childhood injuries may have on the child and his or her family, the physicians and nurses involved in the care of injured children have an obligation to be engaged in efforts directed toward injury prevention.
Blunt trauma is the most common mechanism of childhood injury and death. It includes nonaccidental trauma, motor vehicle crashes, children struck by motor vehicles, and falls. Children who live in urban settings are particularly susceptible to these types of injury due to a variety of reasons including, lower economic status (lack of car seats and protective gear, e.g. helmets, pads, etc.), proximity to automobile traffic, tall apartment buildings (lack of window guards, excessively hot water), parental absence or poor supervision, and neighborhood violence. Penetrating trauma, while slowing in progression, remains the fifth leading cause of traumatic death in children, particularly among adolescents and teenagers. It is an urban problem entwined with drugs and personal violence. Conflict conducive to violent action is often difficult to identify prospectively, however, community sponsored drug awareness programs, gun control, and programs designed to teach appropriate measures for dealing with anger and conflict resolution are probably beneficial.
The Trauma Center at Boston Medical Center
The Trauma Center at Boston Medical Center, formerly Boston City Hospital, has long been recognized as a regional resource center for the comprehensive care of severely injured adults and children. It is supported by experienced ground and aeromedical transport systems and composed of a dedicated team of individuals practiced in the management of acute life threatening injuries using state-of-the-art diagnostic imaging, monitoring, and operative techniques.
The Division of Surgery is chaired by Dr. James Becker and the Trauma Service is headed by Dr. Erwin Hirsch; both have demonstrated a long and sustained commitment to care of the injured. In July of 1995, Dr. Steve Moulton was recruited as a full-time, board-certified pediatric surgeon-with extensive expertise in pediatric trauma--to enhance the clinical and academic activities of the Pediatric Trauma Program. More recently, Dr. Borger has been recruited to further enhance the trauma program, especially in the areas of trauma prevention.
The Trauma Center plays an important role in the training of residents, nurses, emergency medical personnel, medical students, and technicians, and is a resource for ongoing clinical and basic science research. In recognition of the expert trauma care delivered at Boston Medical Center, the Trauma Center is verified by the American College of Surgeons as a Level 1 Adult and Pediatric Trauma Center. As such, BMC provides care for the majority of seriously injured children in Boston and the surrounding area.
PHYSICAL FACILITY
Boston Medical Center (Harrison Campus) was completed in 1994 as a state-of-the-art medical center in design and construction. Patients arrive via helicopter or ground transport. The heliport is used by Boston MedFlight and New England Life Flight and is located adjacent to the Emergency Department (ED). The ambulance bay can accommodate eight ambulances simultaneously, ensuring efficient entry of patients into the ED. Severely injured patients are brought into any one of three fully equipped and self-contained trauma resuscitation rooms. One room is uniquely dedicated to pediatric patients in that it contains equipment and supplies used specifically for children. Children with less severe injuries are transported to the acute or non-acute treatment areas of the pediatric ED, which is geographically separate from the adult ED. A spiral CT scan capable of reconstructing 3-dimensional images is available in the emergency radiology area, adjacent to the trauma resuscitation rooms.
The advantage of timely access to this technology is of tremendous benefit to the pediatric trauma patient. Should the patient require emergency surgery, eight operating rooms are located on the second floor directly above the emergency department. A central bank of four elevators can take a trauma patient with a trauma team to an operating room in less than a minute.
Adjacent to the operating rooms and post-anesthesia recovery rooms are the blood bank and all of the clinical laboratories, which are equipped with micro-sampling analyzers for pediatric blood samples. A separate family/visitor lounge and cafeteria are also on the second floor.
PEDIATRIC EMERGENCY DEPARTMENT
The Pediatric Emergency Department is a 16-bed specialty area staffed by attending pediatricians 24 hours/day. The department cares for approximately 24,000 pediatric patients each year. All of the pediatric ER attending physicians are board-certified in pediatrics and pediatric emergency medicine. The pediatric ED nursing staff consists of over 20 RN's, half of which have greater than 10 years of pediatric emergency and trauma experience.
The pediatric emergency department is one of only three departments in New England with a fellowship training program in pediatric emergency medicine. The pediatric emergency division provides medical control for all pediatric medical and surgical cases throughout the city of Boston. This direct contact with paramedics in the field provides early consultation and promotes pre-notification of incoming ill children. In addition, Boston Medical Center is a participant in the non-designated roster of Boston MedFlight.
The pediatric emergency division medical staff work closely with the Boston paramedics and providers of basic life support by providing EMT orientation in the pediatric ED, ongoing lectures on pediatric emergency topics, and the teaching of PALS (Pediatric Advanced Life Support) courses. The nursing staff frequently represents the division and medical center at neighborhood health fairs in the Boston community, to distribute information related to preventive medicine and injury prevention. Pediatric trauma victims receive care from the pediatric trauma team, which consists of a pediatric surgeon, a pediatric ER attending physician, a chief surgical resident, two senior ER residents, and a myriad of support personnel. The composition of this team has been approved by the standards document of the American College of Surgeons.
The patient population served in the pediatric ED is multicultural and multilingual. Most live in the surrounding neighborhoods and are socially and medically under-served. As a result, the ED staff work closely with area neighborhood health centers to promote primary care and ensure adequate follow-up; there is a clinical follow-up nurse who works full-time in this capacity. A pediatric social worker is employed full-time in the ED to provide counseling and coordinate follow-up to victims of violence and sexual assault. The pediatric ED also employs a Child Life Specialist to prepare children and families for procedures as well as providing coping techniques for the family. Emotional support for trauma victims, as well as family grief assistance, is provided by pastoral care professionals and psychiatric nursing.
All of the pediatric ED nurses are trained in evidence collection procedures as well as procedures for care and follow-up of victims of domestic assault, child abuse/neglect, adolescent victims of violence and abuse of the disabled. Established follow-up programs for victims of violence include the Child Protection Team; the Adolescent Victim Care program (which provides evening and weekend interventions and follow-up), and the Child Witness to Violence Program (see below).
PEDIATRIC INTENSIVE CARE UNIT
The Pediatric Intensive Care Unit (PICU) is centrally located in the pediatric wing of the inpatient facility. This four-bed specialized unit cares for critically ill children ranging from newborns to young adults. Nearly half of all the children admitted to the PICU are pediatric trauma patients. Each PICU room is equipped with state-of-the-art bedside monitoring, as well as a centralized monitoring system located at the nursing station. All monitors have non invasive as well as invasive modules, including pulse oximetry, end-tidal CO2, intracranial and pulmonary pressure monitoring.
The PICU is staffed entirely with RNs. All PICU RNs are Pediatric Advanced Life Support (PALS) certified. The nurse-to-patient ratio is 1:1 for all trauma patients. Dr. Moulton is the surgical director of the PICU.
PEDIATRIC WARD AND REHABILITATION
The pediatric wards are separated into two distinct areas: one for infants and toddlers and the other for school-aged children and adolescents. With the help of Child Life interns and volunteers, a Child Life Specialist coordinates developmentally appropriate activities for the children in the infant/toddler playroom and adolescent lounge, which doubles as a library. A rooftop playground is open during the warmer months. Support for this project came from the Celtics' Wives, a group of prominent philanthropic women in the community. Inpatient pediatric occupational and physical therapy are initiated upon transfer out of the intensive care unit. Inpatient pediatric rehabilitation is provided by Dr. Carl Wilson, who is the Director of Rehabilitation Medicine at The Franciscan Children's Hospital
PEDIATRIC TRAUMA PROGRAM
The Pediatric Trauma Service is headed by the director of Pediatric Surgery with assistance provided by four (of nine total) adult trauma surgeons credentialled in the care of injured children. Inclusion of these four adult trauma surgeons in the care of severely injured children greatly enhances our ability to deliver first-line trauma care, for it allows us the ability to blend the expertise and experience of managing a variety of unusual or life threatening injures with a pediatric perspective. Recruitment for a second pediatric surgeon to join Dr. Moulton in July 1999 is in progress.
- Tom Hamilton, MD Chief, Pediatric Surgery and Director of Pediatric Trauma
- James Borger, MD Co-director of Pediatric Trauma
- Erwin Hirsch, MD Chief, General Surgery and Director of Trauma Services
- Fred Millham, MD Director, Trauma Registry and Chairman, MA Committee on Trauma of the American College of Surgeons
- Ingrid Erikson, PNP Pediatric Nurse Practitioner, Pediatric Trauma Coordinator
- , Secretary, Division of Pediatric Surgery
- R4 General Surgery Resident
- R1 General Surgery Resident
CLINICAL ACTIVITY
Pediatric Trauma Service
The Pediatric Trauma Service covers all types of pediatric injuries, including burn, thoracic, abdominal, genitourinary, oromaxillofacial, otolaryngologic, orthopedic, plastic, ophthalmologic and neurosurgical. Between 7/1/97 and 6/30/98 over 3,000 injured children were evaluated in the pediatric emergency room and trauma resuscitation suite. Of these patients, only 289 children (birth-18 years) were admitted to the hospital. Children 14 and under accounted for approximately 13% of all trauma center admissions.
To schedule an appointment, please call (617) 414-4841
Pediatric Specialty Group
Surgery
Dowling 2 South, Room 2419
1 Boston Medical Center Place
Boston, Massachusetts 02118
(617) 414-5131
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