Wow such nasty rumors. Im not sure there is a real problem here. Please allow me (Christ EM program director, Bob Harwood, MD, MPH, FACEP, FAAEM) to shed a little light.
There seems to be 2 concerns:
1. RRC-EM accreditation
2. Experiencing & being proficient with pediatric trauma resuscitations.
1. RRC-EM accreditation
Quite frankly, I continue to be very optimistic about our last RRC-EM site (8/23/05) and upcoming review (Feb, 2006). Our department and residency program has gotten stronger in the 6.5 years since 1999 site visit. From the RRC-EMs point of view, pediatrics & peds trauma has just never been a past problem, and I dont see this all of a sudden becoming a problem.
A. Christ has received the highest accreditation possible 5 years continued full accreditation in 1984, 1989, 1994, & 2000. (From 1977-82, we were accredited by the Pre-RRC-EM accrediting organization, LREC.)
B. Christ has been a level 1 trauma center (State of Illinois designation) for both the city of Chicago and a large portion of suburban, exurban, and rural Chicagoland since the state/city got serious about regionalizing trauma sometime in the mid-1980s (Im not sure of the exact year). We also accept adult (but not pediatric) trauma transfers from NW Indiana. Christ hasnt been a designated level 1 pediatric trauma center for 8-9 years. This is nothing new, and it certainly pre-dates our 1999 site visit & 2000 RRC-EM accreditation.
C. What does interest the RRC-EM is the number of resuscitations EM residents get to perform. Our residents more than meet the resuscitation requirements for peds, peds trauma, adult & adult trauma. Therefore, I cant see this is a problem. If it becomes a problem, well rotate our residents someplace else to assure they get what they need. (In the 1970s & early 1980s, our residents did trauma rotations at the Shock Trauma Unit in Baltimore, at Denver General, at Martin Luther King in LA, and at Cook County.)
2. Experiencing & being proficient with pediatric trauma resuscitations
In 2006, most peds trauma (defined at Christ as age 13 & under) is actually a non-surgical disease. Deceleration aortic tears are unheard of (or case reports) under age 10. According to NEXUS, there were only 11 peds patients (age 8 & under) with C-spine injuries (out of 34,069 total patients, age less than 1 to 101). Although there were SCIWORA patients in NEXUS, one of the surprise findings was that SCIWORA wasnt a pediatric problem in NEXUS. Pediatric spleen & liver injures are routinely treated non-operatively. Some of these pediatric trauma principles are now being applied to adults. (Without getting off the subject too much, Christ trauma surgeons have successfully treated, non-operatively, adult GSWs to the liver. This never, ever happened in the 1970s, 80s, or 90s.)
Heres what currently happens when a Level 1 peds trauma comes in:
A. An EM resident & EM attending evaluate, resuscitate, and stabilize the patient.
B. If the pediatric patient is in need of an immediate life saving operation, either a pediatric surgeon (if available) or a trauma surgeon (always available) will take the child to the OR.
C. If the patient has been over triaged and isnt really seriously injured, the child will be patched up & sent home (or admitted if abuse is suspected). The trauma service wont be activated or notified.
D. If the pediatric patient has an isolated head trauma (baseball bat, GSW, etc.), the ED will call peds neurosurg & usually this child will go to PICU (we have a peds ICU fellowship) or the OR (if indicated). Again, the trauma service isnt directly involved.
E. If the pediatric patient is indeed a level 1 trauma, but can be stabilized in our ED, he/she will be packaged for transfer. [We usually transfer to Loyola University Medical Center (Maywood, IL), Comer Childrens Hospital (Chicago), or Childrens Memorial (Chicago)]. For sake of full disclosure, we also transfer serious burn victims (adult & pediatric) after they are stabilized in our ED.
F. If the trauma patient is age 14 or older, they are considered & treated as adult patients.
Lets take a real example of E from last week. I was working in the main ED with an EM-2 resident (it would have been the same if I had been with an EM-1 or EM-3). We got an EMS call that a City of Chicago ambulance was bringing in a young boy (later his mom told me he was 8) Pedestrian hit by a truck. He arrived immobilized, no IVs. The rest of the team consisted of ED RNs, ED Peds resp techs, & ED techs. The RNs started IV & the EM resident did the A-B-C-D-Es (under my direct supervision). She determined that the patient had stable ABCs, VSs, a benign abd, no signs of a spine injury, but the GCS was waxing & waning from 3 to 7, and the child needed intubation (there was a scalp lac & forehead contusion). RSI was initiated & in-line intubation was performed by the EM resident (I assisted & supervised). Patient transfer was arranged, and a few x-rays were taken (ET tube was pulled back 1 cm; no chest tubes were needed, but had it been needed, the same resident would have put them in). The patient was packaged (OG tube, foley, immobilization, sedation, etc.) and the transport team arrived & transported him. The only thing we wanted to do & didnt, was to see his CTs, but this isnt in the best interest of the child. (Might delay transfer; and since receiving institutions always repeat them, the double radiation exposure is a real issue.)
So, from the RRC-EMs point of view, the EM-2 got to direct a major peds trauma resuscitation & perform a peds intubation. (By he way, I believe the RRC-EM defines peds as 18 & under).
From an EM resident point of view, she got to direct a major peds trauma resuscitation & perform a peds intubation (under my direct supervision). She did a fine job; she felt good about her performance & herself.
So as long as we continue to get enough peds trauma, (and we have over the last 20+ years), and as long as our residents get to manage these patients (the peds residents dont manage them), I just dont see a problem.
I final note: Christ Medical Center has a new CEO, who started in late 2005. I know he is committed to expanding pediatric services at the Medical Center. My expectations are more peds beds, peds surgeons & peds surgical sub-specialists. I see my role is to make sure the EM residents training in peds emergencies (including trauma), does not become diminished, but become enhanced with future expansion.
Further questions on this topic or other topics should be directed to me 708.684.5375 or
[email protected].
Future rumors should be directed to President Bush, Bears coach Lovie Smith, or Howard Stern.
