clinical practice
Consider why children may be involved in trauma ; 3-5-year-olds are surrounded by superhero cartoon characters that perform incredible feats of strength , speed , power , durability and extraordinary ability . Their vulnerability is increased as they cannot adequately assess the risks involved ( eg toddlers falling from balconies ). As children get older , they enjoy computer games and action movies often filled with death defying behaviours that may entice 5-12-year-olds to emulate these characters .
It is well known that adolescents while exploring their own limits and abilities may be involved in risk taking activities . When risk taking behaviours are combined with illicit drugs or alcohol , the outcome can be disastrous , and the result may be that the adolescent becomes a statistic – one of the 85-90 per cent of injured patients .
THE INJURED PATIENT COHORT Physical injuries include catastrophic head and spinal injuries , severe burns , or occasionally injuries associated with domestic and family violence ( shaken babies ). Other significant injuries may include degloving injuries or amputations , open globe eye injuries , asphyxia or hanging , or the more unusual injuries from electrocution .
There are minor injuries such as contusions and lacerations , soft tissue injuries , minor fractures and animal bites . There are injuries that may be minor or major depending on the outcome such as caustic ingestions or non-fatal drownings .
These well recognised trauma patients usually fit into a surgical sub-speciality , for example the lacerated liver or spleen patients will be admitted to the general surgical ward , a head injury patient will be admitted to a neuro-surgical ward and a patient with an extremity fracture will be admitted to an orthopaedic ward .
However , there is a cohort of trauma patients that may not be ‘ pretty enough ’ to fit neatly into a sub-specialty category , where the lines may blur at times . A multitrauma patient , ( eg following a high speed MVA that catches fire or an explosion in a confined place ) may suffer from head and facial injuries , solid organ injuries , plus fractures and some burn injuries and will be admitted to a trauma HDU ( high dependency unit ) or trauma ward .
However , not all hospitals have a dedicated trauma ward or HDU and ironically the multi-trauma patient may not
‘ fit in ’ to one of the defined sub-specialty wards .
Some patients may struggle with anxiety or depression , and they may harm themselves while trying to deal with their pain , but occasionally they may not be considered acute enough for the subspeciality child youth mental health team – not ‘ acute enough ’.
The numerous severe head injuries and spinal cord injuries ensure the rehabilitation team is working at their capacity . The patient with a mild to moderate head injury may not fulfil rehabilitation criteria for their subspecialty service , and these children could potentially be left to flounder – ‘ not severe ’ enough .
Some patients may not be admitted to hospital for a sufficient period of time , and that may preclude the full gamut of medical and allied health services being offered to them – not admitted for ‘ long enough ’. They may not be fluent enough in English to advocate well enough for their child – not ‘ Anglo-Saxon ’ enough .
Some adolescents display adult like behaviours such as involvement with crime , drug taking , violence , pregnancy etc . A paediatric facility may be reluctant to admit such adolescents and adult hospital may not have the specialist teams to deal with such adolescents – not ‘ paediatric enough ’. Or indeed , they may not be wealthy enough to choose a private consultation and perhaps transfer to a private facility – not ‘ wealthy enough ’.
These patients may be collectively called outliers , patients whose injuries don ’ t ‘ fit in ’ to one particular body region or into a defined diagnostic related group or sub-specialty .
THE TRAUMA SERVICE TEAM Trauma service teams are often small multidisciplinary teams , usually comprising of a mix of medical , nursing , allied health , social work or psychology that ensure safe coordinated care and expertly manage all domains of trauma .
Predominately hospitals and major trauma centres cater for physical trauma when children have sustained either minor or major injury . Trauma resuscitation is based on highly skilled personnel , preparation and training , guided by EMST principles and governed by well-honed processes as well as key performance indicators .
Severely injured children require trauma teams that respond with lifesaving pre-hospital care , rapid evacuation , ED management and surgical intervention , stabilisation and early rehabilitation . Expert clinical skills are vital in addition to the qualities of human dignity , respect and empathy , integrity , autonomy and effective communication skills .
In addition , trauma service teams need to be able to handle the emotional strain that is involved with caring for these injured patients , as sometimes there are poor outcomes . The impact of caring for multi-trauma patients on an ongoing basis can be subtle , insidious and emotionally draining and it requires a certain personality type to ‘ fit in ’ to the team and ensure longevity in this chosen profession .
THE INJURED PATIENT How an injury affects the individual patient depends on many factors , including the characteristics and personality of the child , the type and severity of the injury , the mechanism of injury , the child ’ s developmental processes and their sociocultural heritage . Coping styles vary from patient to patient from reflection and introspection to emotionally expressive reactions .
There are tools that may assist in the assessment of post-traumatic stress symptoms such as ‘ age-related ’ trauma symptom checklists for children or paediatric quality of life inventories . The results from these checklists may assist the trauma service team to direct additional support services in the highlighted areas . In addition , there are therapeutic models of trauma informed care to guide the trauma service team to understand and work effectively with these children and their families .
The injured child needs time to process the injury and the events surrounding the injury , in addition to assistance with the physical , emotional , financial , and in some cases the legal impact that the injury has on their lives . It is important that they ‘ fit in ’ once again and contribute in a meaningful way to society . The overall aim is to maximise the quality of life and functional outcome of the child after their injury , to ensure they not only survive but also thrive , with the least morbidity possible .
They need to believe they are ‘ pretty enough ’ and can reintegrate and ‘ fit into ’ society with a sense of purpose and fulfilment . ■
For references go to www . nursingreview . com . au . Tona Gillen is nurse manager , trauma , at Queensland Children ’ s Hospital .
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