• The Needle Tip

    Dr. Christopher Newton

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    Pediatric Trauma and Critical Care in Adult Facilities

     Over the past two years, our healthcare system has endured multiple waves of COVID-19, placing repeated stress on our capability to provide the care we are accustomed to.  This was evident in so many different ways, impacting communities at different times and in different ways depending on the depth and breadth of local resources.   Amid the overwhelming needs of COVID-19 patients, each community has also been challenged to maintain the essential emergency capability for trauma and critical care for non-COVID-19 related patients.   At some moments, and in some communities, this challenge reached the state of a crisis that necessitated adjusting systems, changing standards, and embracing the unconventional all to meet the demands to the very best of our capability.  I must say, I am deeply proud of the trauma community in America that has repeatedly demonstrated the amazing skill of our specialty: to be an expert in the room that gets the very best possible accomplished amid exhaustion, chaos, and confusion.

    The guidelines for these moments are referred to as crisis standards of care (CSC).  These guidelines have been broadly outlined in reports from the National Academy of Medicine, providing a framework for how to approach impossible scenarios.[1] [2] CSC is defined as substantial changes to usual health care operations due to a pervasive or catastrophic disaster that necessitates rational utilization of scarce resources to provide the best possible delivery of health care to the greatest number of patients.   CSC may be declared in an emergency proclamation from local jurisdiction, or maybe enacted out of necessity by a local hospital or EMS system.  CSC should be considered only in circumstances when healthcare demands exceed capabilities after all “contingency level” efforts have been implemented.  Practically, this means doing everything possible to remain in a “contingency state,” where systems may be stressed and care may be unconventional, but all are still meeting the needs of patients.

    During the COVID-19 waves, many, if not most, communities have been in this contingency state multiple times enacting practices and tools that may be considered unconventional.  One of the most common tools is system load balancing.   However, for a trauma hospital or EMS system, this tool can have a very dramatic impact.  Simply put, this is the practice of shifting where care is taking place to offload facilities in crisis.   One example that has been observed repeatedly is the shifting of age ranges for trauma and EMS, allowing young adults to be cared for in pediatric facilities, or children to be cared for in adult facilities (depending on the local need).   While this has understandably made many uncomfortable, necessity has also brought out the best in our people and taught many of us a flexibility we did not know we possessed. 

    Caring for a child when your facility is not accustomed to children can be frightening.  Several resources are available to provide help when it is needed the most. 

    • Some education is extensive, such as the Society for Critical Care Medicine pediatric fundamentals course, but if you have the time to invest in this, it is truly tremendous.

    https://www.sccm.org/Education-Center/Educational-Programming/Fundamentals/Pediatric-Fundamental-Critical-Care-Support   

    • Another excellent resource comes from a task force established by the American College of Chest Physicians that recently published guidance from pediatric intensivists on some of the more critical aspects of pediatric critical care in an adult unit.[3]

    https://www.sciencedirect.com/science/article/pii/S0012369222000058?via%3Dihub   

    • OPENPediatrics maintains some excellent reference and education material.

    https://www.openpediatrics.org/

    • The Pediatric Trauma Society also maintains clinical resource guides specific to trauma and critical care for kids. https://pediatrictraumasociety.org/resources/clinical-resources.cgi
    • A just-in-time pediatric emergency care manual was developed recently with a target to specifically support adult practitioners caring for children in disaster settings (i.e., shelters).  While the focus is quite specific, the manual attempts to provide “pearls” and tips that are practical and address aspects of care that would make one anxious.[4]

    https://wrap-em.org/media/attachments/2021/11/04/wrap-em-peds-disaster-handbook.pdf

     

    From these many resources, there are some wonderful lessons. My overarching summary of some of the best “pearls” are:

    • The underlying concepts of management are not as different as you may believe. Your skills, knowledge, and training in caring for adults are still useful when your patient is a child. 
    • Of course, adjust everything you do to the appropriate size in kg.
    • Remember your Advanced Trauma Life Support training. The pediatric lessons in that are pretty solid.
    • Involve the parents and caregivers in the child’s care! They are more helpful and resilient than you may think.
    • Know what your facility is good or not good at doing, and then play to your strengths:
      • For example, you may be well equipped for pediatric orthopedics, but not prepared for pediatric ECMO.
      • Load balancing does not mean you take every condition.
      • Certain conditions do need a PICU! Move pediatric congenital cardiac conditions, pediatric malignancies, chronic or rare syndromes, etc. to tertiary centers, and embrace the kids you can care for.
      • Connect with local pediatric specialists for phone/telemedicine help.

    [1] Institute of Medicine. (2012). Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response: Volume 1: Introduction and CSC Framework (D. Hanfling, B. M. Altevogt, K. Viswanathan, & L. O. Gostin, Eds.). The National Academies Press. https://doi.org/10.17226/13351

     

    [2] National Academies of Sciences, Engineering, and Medicine. (2020). Rapid Expert Consultation on Crisis Standards of Care for the COVID-19 Pandemic (March 28, 2020). The National Academies Press. https://doi.org/10.17226/25765

     

    [3] King, M. A., Matos, R. I., Hamele, M. T., Borgman, M. A., Zabrocki, L. A., Gadepalli, S. K., & Maves, R. C. (2022). PICU in the MICU: How Adult ICUs Can Support Pediatric Care in Public Health Emergencies. Chest. https://doi.org/10.1016/j.chest.2021.12.648

     

    [4] Western Regional Alliance for Pediatric Emergency Management. (2021). Just in Time Handbook: A Quick Pediatric Reference Guide for Adult Healthcare Providers. Retrieved February 14, 2022, from https://wrap-em.org/media/attachments/2021/11/04/wrap-em-peds-disaster-handbook.pdf

     

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