Paediatric trauma call, 5 minutes.
How does that make you feel? What thoughts go through your head?
Most of us will not encounter serious paediatric trauma. So, do you need to read on?
The challenge is that trauma is unpredictable. However good our trauma networks and however proficient our prehospital teams are, we are always faced with the possibility of a paediatric trauma call coming to our front door in the Emergency Department. Whether they need local stabilisation before transfer, whether they’ve been brought in by a parent in their car through reception, whether they weren’t obviously a major trauma at the start but are quickly identified as such (e.g. a non-accidental injury), paediatric trauma falls under our remit.
We may not be experts but there are principles we all need to stick to if we are to provide safe and expedient care to those children who unexpectedly find themselves in our Emergency Department. Whilst these are high acuity low opportunity events (HALO), we owe it to our patients to be ready in the same way we are ready for that unexpected premature delivery in the middle of the night shift.
I myself, am a paediatrician. I came to the Royal London Hospital a year ago as a trauma fellow with the express purpose of “levelling up” my near non-existent trauma skills.
So, what did I learn?
In short, it’s easier than you think. Here is my beginner’s guide, laying out my approach to trauma calls in three phases with my ten top tips of how to make your transition to trauma pro easier.
TIP 1 – Expect the unexpected
It is easy to imagine the worst. Road traffic accidents, obvious open fractures, active bleeding or a difficult airway. Thankfully such events are rare. Instead, keep an open mind to the broad spectrum that is paediatric trauma…
These are just a few examples. Many are not high acuity. The (very paediatric) challenge of course is determining which of the many need the most. Who needs imaging? Who needs theatre? Also, who just need simple monitoring and reassessment?
Some kids manage miraculous escapes with no injuries. Others, following seemingly trivial incidents, require an urgent trip to the operating theatre and intensive care.
No two children are the same. No two incidents are the same.
I’m not suggesting every low acuity case is a high acuity case in disguise. I am saying don’t be caught out. For a multitude of reasons, treat every case the same, at least at the start. As well as picking up subtle clues and not missing an occult injury, you will also hone your skills for when the truly sick child comes knocking at your door. For more on levelling up for each and every trauma call, listen to the excellent talk given by Anna Dobbie at DFTB19.
TIP 2 – Crowd control
Many hands make light work. Having a team in trauma is of course essential. Occasionally you may put out a number of pre-alerts, for example at the Royal London we have the following menu…
Adult trauma call – 16 years and older
Paediatric trauma call – 15 years and younger
Code red – major haemorrhage
Code black – neurocritical emergency
Paediatric / neonatal crash call – paediatric / neonatal emergency
At the Royal London, as a minimum, we get an anaesthetist, an ODP (operating department practitioner), a surgeon (or two), an orthopod (or two), a paediatrician (or two), a paediatric nurse and a number of emergency medicine doctors and nurses as available. That’s without including the play therapist, research teams and the myriad specialists that are case dependent (neurosurgeons, trauma surgeons and more).
As a teaching hospital, it is not uncommon to have even more doctors, nurses and students as well.
Without doing the maths, that’s A LOT of people. Noise levels and extrinsic cognitive load can quickly escalate. So what do you do?
Establish your presence
Stand tall, know your main players by name and establish roles early. Those taking an active part stand in front of you and those not involved stand clear and stand behind. Be prepared to say, “quiet please!” Be prepared to ask people to leave. Expect this, then it won’t phase you.
Establish boundaries early
Large groups of people are gathering in a small space. Before long people start chatting. It may be nerves. It may be the first time they’ve stood still all day. Whatever the reason, you want to clearly establish that the sick child is their priority. On the one hand, it is useful team orientation to the resus bay and to each other but on the other, there is crowding. Have limits to the number of people present and further limit those who aren’t immediately needed. Again, have your words chosen ahead of time. For example, “Thank you, but if you are here to learn I need you to either be quiet or step out.”
The only thing you want to be thinking about when that child arrives is the patient.
Each leader has their own style, but if you are consistent the team will come to know you. Many of the challenges will melt away.
TIP 3 – Avoid repetition
Having a shared mental model ahead of the child arriving is useful. However, what is less useful is repeating the prehospital handover to each person as they arrive. Nerves can get the better of us, but a little silence or preferably a focus on roles and people’s names goes a long way in the few minutes it takes for everyone to arrive.
Then, clearly and concisely communicate the information you have to your team so they themselves can mentally prepare. Even then, remember words can be spoken but not heard. Your team members may have just been running down a flight of stairs to be there or mentally still be dealing with their last patient.
TIP 4 – Use eye contact
Gain eye contact with your team, communicate in a way that they hear you. That does not mean increasing volume. It does mean gaining a rapport early with your team. It can also mean having the prehospital handover written in large black letters on the whiteboard. This not only satisfies people’s curiosity as they arrive but serves as a useful reminder.
Much of this constitutes your ZERO point survey. For more, watch Ben Lawton’s video, “the first few minutes of a trauma call” in the DFTBdigital trauma course or read Professionals Prepare Properly by Shane Broderick.
TIP 5 – Hold the room
As demonstrated at the start of Anne Weaver’s DFTB19 talk on “maturing your approach to trauma,” we all carry a little anxiety when it comes to a paediatric trauma patient.
Managing your own anxieties is one thing. “Holding the room” is another. Holding the anxieties of the paramedics, the anxieties of the family, the anxiety of your team. Holding the room means not ignoring the emotions around you, not suppressing the emotional atmosphere, but instead allowing for it, containing it and maybe even using it to your advantage.
Komal Bajaj, in describing how to be a good leader identifies two key traits: strength and warmth. Be strong, know your medicine, know your team and lead with calmness. Lead also with compassion, be warm. The anxiety level will drop, the team will rally, you will enter that zone. Slow down. Breathe.
TIP 6 – Nail the first two minutes
If you “nail the first two minutes” everything that follows will be calmer and the entire patient journey starts to resemble a formula one pit stop with order out of the chaos. Remember “the sickest patients need the calmest leadership.”
My thanks again to Anna Dobbie for these words of wisdom. I can’t stress enough how important it is to find your own style, but for example’s sake, these are her words during the first two minutes…
Hello, my name is Anna. I’m the trauma team leader
f we can get the patient across
Then we can hear what’s going on
(thank the team that brought the patient in)
Can we take hold of the head at the top end?
Can we split the scoop top and bottom?
So we’re going to take the right side of the scoop out first
So three people down the patient’s left-hand side.
And we’re going to have all hands over ‘cause we’re bracing
And we’re going to take the right-hand side of the scoop out first
The command from the top when you’re ready is going to be ready brace remove
If we can now have those three people down the right-hand side, we’re taking the left side out
And again the command from the top is going to be ready brace remove
If we can resecure the head
If we can have some observations, please
If we can have a nice loud and clear primary survey
TIP 7 – The scoop
So you know the difference between a thoracotomy and a thoracostomy, you know how to insert a chest drain, you’re practised at IV access and you’re even happy with bag-mask ventilation. But do you know how to break the scoop and remove it? Don’t be a trauma chump, begin as you mean to go on. Getting the patient off the scoop slickly sets the tone and puts you on a sure footing.
TIP 8 – Have some flexibility, but know your priorities
In medicine, many of us are perfectionists. Applying high standards across your practice, even during lower acuity cases will serve you well. However, you still need to be flexible. Children are not small adults. They don’t all come in strapped to a stretcher, able to follow instructions and lying nicely in the anatomical position.
A toddler with scalds probably won’t want to leave their parent’s arms.
A child with c-spine injuries may not lie still on command and instead needs the consistency of one friendly face or the additional magic of a play therapist.
A teenager who is stabbed may not cooperate and lie down to be examined, panicking with impatience thinking they’re going to die.
In all the above examples I have forgone the standard rigid ATLS structure and prioritised regaining calm control. Be prepared to do away with the formality and take a practical approach.
Clearly assert acceptable compromises
“Let’s get the toddler on parent’s lap, let’s get analgesia, then let’s examine and get photographs.”
Determine priorities and set your boundaries
“One person stay at the head, everyone step back, bring in the play therapist, the priority is c-spine control, monitoring and primary survey will follow.”
Assert your goals
“Sir,” (I say sir to male teenagers, it’s my authentic style), “I need your help. If you focus on my friend here,” (e.g. the anaesthetist), “I can focus on making sure you are ok. We need to perform a thorough stab check before we move on.”
TIP 9 – Set time directed goals
With so much potential for chaos, it is easy to lose situational awareness and lose track of time.
This may seem very basic but keep one eye on the clock.
Knowing the time of arrival, the time of handover, the time taken for the primary survey does wonders to provide you and your team a sense of progress. In my experience, setting time directed goals (for example, I want this child in the CT-scanner in 10 minutes) has the amazing ability to focus and give the illusion of time slowed down. Rather than feeling rushed, the sense of purpose and direction aids care and ensures a shared awareness that you are dealing with a time-critical emergency such as a traumatic brain injury.
Use the clock, don’t fight it.
Additional tips when the patient arrives include: actively listening to the handover with a focus on the mechanism, thanking the paramedics, keeping momentum and don’t delay, aiming to complete the primary survey within five minutes, beginning thinking about what happened (mechanism and timing), your findings (the primary survey) and what’s going to happen next…
Once the primary survey is complete, it is time to take some decisions…
This requires knowledge, understanding and experience. Trauma is a team sport, so don’t forget your team and share the conundrum with the collective expertise in front of you (and behind you, assuming additional personnel are in the wings).
My advice for practising such decision making is to first acquire practical knowledge through study and courses such as DFTB Trauma (no conflicts of interest, I promise). Then, test group dynamics around decision making, through simulation, for imaging, theatre and beyond. There are many much more qualified to discuss decision making in trauma, so instead let me finish by revisiting Ben Lawton and his advice, to keep things simple…
TIP 10 – Keep it simple
Trauma is fundamentally simple
Air must go in and out
Blood must go round and round
The brain must not be squashed
With all that is going on it is easy to lose sight of your goals. It is easy to become overwhelmed by complexity. By keeping it simple, care can be streamlined and time-critical goals set. You do not need all the answers at the start. Reassessment, keeping an eye on vital signs, gathering further imaging as indicated from x-rays or CT imaging, gathering further collaborative insight from your team is all dynamic processes. What cannot wait are these three priorities.
Is the patient oxygenating and ventilating? Is this a risk?
Do they need a tracheal tube? Do they need a chest drain?
Is the patient perfusing? Are they in shock? Are they exsanguinating?
Do you need to stop the blood loss? Do you need to replace it?
(Remember, avoid the salty stuff in trauma).
Is the brain protected? Has there been a primary insult? Can we prevent a secondary insult?
Is the pressure in the head rising? Do they need neurosurgery? Can it wait for a scan?
It is my hope you now have a mental model of how to approach paediatric trauma. These tips are not intended to make you a trauma pro overnight. They are intended to be a series of practical tips to make your trauma journey a little gentler, to help your learning curve become a little steeper and maybe, just maybe, make the care you provide your next trauma patient just a little bit easier.