Trauma doc: Kids are not little adults

New research published in June by the Journal of the American Medical Association highlights the importance of pediatric trauma centers for the care of injured teens and adolescents. The study, conducted by Randall Burd, M.D., Ph.D., of Children’s National Medical Center in Washington, D.C., found significantly lower mortality rates for patients between the ages of 15 and 19 who were treated at dedicated pediatric trauma centers as opposed to adult or mixed trauma centers. 

Previous research has compared these types of trauma centers and found improved outcomes for younger children, but until recently, few studies had examined outcomes for older pediatric patients. 

As the only pediatric trauma center in South Carolina, MUSC Children's Hospital treats some of the most severe cases in the state. In his role as director of the Division of Pediatric Emergency Medicine, Keith Borg, M.D., Ph.D., has seen many of them firsthand. He offers his insight into what sets his hospital apart. 

Q: What is a trauma center, and how is it different from a typical emergency room?

Trauma centers are designated facilities to provide trauma care. Any emergency department is required to take care of any patient that comes in, but trauma centers provide higher quality, team-based care. At a trauma center, the health care team is fully integrated – from the nurses to the trauma surgeons and all the subspecialists in between. We train together as a team, and we act as a team – from the second a patient hits the door until their discharge and rehabilitation. 

Q: How is a pediatric trauma center different from an adult or mixed trauma center?

Different patient populations require different resources to take care of them. Children aren’t just little adults. They require specialists and specialized training for their unique medical problems. Pediatric trauma is different from adult trauma and children respond differently to treatment.

Children are more susceptible to radiation, for example. We do a lot of computed tomography (CT) scans in adults, but we want to minimize that in children. Children also need different forms of resuscitation; they experience different types of injuries. Pediatric trauma centers have specialists trained to recognize those differences and take care of those patients. 

Q: How do those differences add up to better outcomes for patients?

The experience is different right from the start. We’re talking about patients who, at a young age, can’t even talk. So we have to pay attention to parents and families in addition to the patient and make sure we’re explaining everything as we go. Those things make a big difference in outcomes.

What’s surprising is, we’ve known for a long time that there is a survival benefit for much younger patients, but recent research says there is a benefit for adolescents as well. That’s kind of interesting, because their injuries and physiologies are closer to adults. You wouldn’t think there would necessarily be that much of a difference. But, sure enough, there is. 

The research accounts for severity of injury and other factors, but they don’t really have an answer for why the outcomes are so much better for even older patients. I think it’s the team-based approach– that’s my theory. 

It’s not just the ED docs or the trauma surgeons who make a difference. It’s the nurses. It’s the techs. It’s Child Life. It’s the environmental services teams that clean our rooms and take care of our facility. We all work really well together as a team, and we’re really proud of that. 

Q: What is the pediatric cutoff age?

A: Here at MUSC, pediatric is defined as under 18. It’s a little different at every center. 

Q: What are some of the most common injuries you see among children and adolescents?

Head injuries are relatively common. We see a lot of injuries to extremities, such as abrasions and broken bones. It depends on what the mechanism is. With motor vehicle crashes, for example, fortunately, kids who are properly restrained in car seats have a relatively low injury rate. We see cases frequently where adults have severe or even life-threatening injuries, but children and infants restrained in car seats are in much better shape. 

We know that anecdotally, right? If you watch NASCAR on Sunday, you see guys hit a wall at 200 miles per hour, then get up and walk away and thank their sponsors. If you have a properly-designed four-point restraint system, it really makes a difference. But, an unrestrained child could have absolutely devastating injuries. 

Q: If outcomes are so much better, why don’t all hospitals have pediatric trauma centers?

Putting the teams together and giving them the resources they need takes time and effort. Every hospital should have the basic capacity to take care of children, but it’s expensive to have a place that’s staffed 24/7/365 with all the specialists required to take care of the most serious injuries. 

Serious injuries in children are fortunately relatively rare. That said, trauma is the leading cause of death in children. So, building those resources and having them at the ready is important. 

Q: How does MUSC’s role as an academic medical center affect patient outcomes?

A: MUSC isn’t just a hospital. Education is a huge part of our mission. Our residents and students are integral to the team, and they go out to work throughout South Carolina, which contributes to our strength, and it strengthens the state. And frankly, that’s why I’m here doing the job that I do. It’s the chance to be part of that. 

Q: How can patients and families ensure they receive the best medical care available? 

If they’re self-transporting, they should certainly come to MUSC. If they’re coming via EMS, they should request to come here. If they’re severely injured, EMS usually knows to bring them here. They typically bring us the most severe patients anyway. With less severely injured patients, they may or may not give families options, but patients and families can certainly make that request as well.