When Seconds Count - Inside the Pediatric Trauma Center

As the first accredited pediatric Level 1 Trauma Center in Pennsylvania, Children's Hospital of Philadelphia is a premier site for the evaluation, treatment, and expert care of children who have experienced severe and life-threatening injuries. The Trauma Center's success depends on its ability to execute a multidisciplinary team approach to the care of injured children.


When Seconds Count - Inside the Pediatric Trauma Center at CHOP

Unknown Speakers: Everybody ready? One, two, three.

Dr. Etchings: Deep breaths. Good girl.

Hi, Lauren. My name is Dr. Etchings. I'm one of the residents going to help take care of you today. A lot of things are going to happen real fast here, okay? A lot of people are going to be taking care of you. Keep those big breaths in and out for me.

Lauren: It really hurts.

Kristine Biggie, RN, MSN: When a trauma comes to The Children's Hospital of Philadelphia, we are always ready to do everything that we can to take care of that child.

Dr. Etchings: Squeeze my finger as hard as you can, both sides.

Narrator: The trauma Center at The Children's Hospital of Philadelphia treats more than 1,000 trauma cases each year, many referred from emergency rooms throughout the region.

Aaron Donoghue, MD: Trauma, across the board, is a very common reason for a child to come to an emergency room.

Dr. Etchings: And as I press on your back, I need you to tell me yes or no if it hurts. That's all you've got to say.

Nurse: One, two, three

Kristine Biggie, RN, MSN: You see children from a lot of different injuries, from riding their bike to motor vehicle crashes to simple falls in the home.

Kristine Biggie, RN, MSN: It may look like chaos on the outside, but it's actually a very regimented series of steps that are performed by very well trained personnel that know exactly what their role is.

Doctor: Right AC and a 22 on her right hand.

Kristine Biggie, RN, MSN: We try to simultaneously examine, diagnose and treat a patient, and the idea is to detect the life-threatening injuries and get them treated now.

Dr. Etchings: Lauren, the worst is over, okay? We got done messing with you, all right? I'm going to go call the bone doctor who's going to take a look at your leg, okay?

Marla Vanore, RN, MHA: CHOP has been a pediatric trauma center since October of 1986. We were the first pediatric trauma center accredited in the state of Pennsylvania.

John M. Templeton, MD: In the middle of the 1980s, 54 percent of all kids who died from 1 year to 18 years died from trauma.

Michael L. Nance, MD: Trauma's the leading cause of death for all children in the United States, far surpassing any other cause. In fact, it's greater than all other causes put together.

John M. Templeton, MD: And so it's a disease problem, and yet nobody treated it as a disease.

Aaron Donoghue, MD: Because trauma is number one on the list of causes of death and long-term morbidity for kids, it stands to reason that if you do trauma care well, you're improving child health on a large scale.

Marla Vanore, RN, MHA: This is absolutely not just a glorified emergency department.

Michael L. Nance, MD: You can't just hang a shingle out in front of the hospital and declare yourself a trauma center. You have to be verified and accredited.

Marla Vanore, RN, MHA: Children's Hospital of Philadelphia is at the highest level as a Level 1 Pediatric Trauma Center.

John Flynn, MD: Level 1 trauma centers have certain capacity as designated by state and regulatory agencies, and it requires that there's a certain team on the ground and available in the hospital when an injured child arrives, and that includes in-house neurosurgery expertise, in-house orthopedic expertise, general surgery, etc.

Aaron Donoghue, MD: And it all has to be physically present and able to rapidly deploy themselves at any time.

Michael L. Nance, MD: Children's Hospital, we have about 1,300 admissions every single year to the trauma service.

Kristine Biggie, RN, MSN: About half of our trauma admissions are actually transferred from other local hospitals.

Michael L. Nance, MD: And so we, at times, know what's coming and when it's coming. Other times we don't have that luxury; they're brought in directly, and the command center here will send out a notification to everybody.

Level 1 Trauma Care at CHOP: The First Minutes

Unknown Speaker: Emergency trauma three.

Aaron Donoghue, MD: It triggers a sequence of events that's sort of pre-arranged and choreographed and involves the alerting of personnel throughout the ED and the Hospital.

Marla Vanore, RN, MHA: We're activating a whole team of people. We have a team of surgeons that come in. The Emergency Department has a core group of physicians and nurses that respond to the resuscitation.

Doctor: All right, we're going to roll you, okay, buddy? You don't need to do anything, okay?

Michael L. Nance, MD: At the head of the bed is going to be the critical care physician or ED physician helping manage and assess the airway. And at the side of the bed is going to be somebody who's called a primary assessor, and they're going to do the initial evaluation of the patient, and they're going to relay that information to the team.

Doctor: Let's recap. We have a 15-year-old male who has stab wounds to his left--

Marla Vanore, RN, MHA: Radiology is on call to read X-rays immediately.

John Flynn, MD: Trauma doesn't always follow a pattern. There can be a wide variety of associated injuries that you have to sort out piece by piece.

Kristine Biggie, RN, MSN: A child may be crossing a street and get hit by a car, and they can have injuries to basically any part of their body.

John Flynn, MD: It's often not just a simple fracture. Their head can be injured. Their chest can be injured. They can have internal abdominal injuries.

Aaron Donoghue, MD: You deal with the most imminently life-threatening problem first, and that literally happens, you know, second to second when the child arrives. That critical time period has a lot to do with survival and outcomes, and there's always an ongoing dialogue and collective decision making to figure out what has to happen first.

Marla Vanore, RN, MHA: We have something called family presence in our resuscitation room, so even the most injured children can have their families close by. Social workers and Child Life talk to the families and make sure that the families understand what is going on.

Letitia Batton, MSW: I have to be able to meet the family where they are and be supportive to talk about the injury, mentally and physically. They need to know everything that is going on, and we need them to talk to us. So they play an integral part.

Michael L. Nance, MD: And in many cases, they can actually provide us information that helps with their care, or they can comfort the child.

Treating Trauma: Specialized Surgical Care

Marla Vanore, RN, MHA: After a patient is in the Emergency Department, some of them will go straight from here directly to the operating room.

Narrator: There are many reasons a trauma patient might require surgery. One of the most common is a fracture.

John Flynn, MD: In the last decade or so, there's been a very fast movement towards operative management of something like a femur fracture, where we will take the child to the operating room on the day of their injury or the day after their injury. And that's been a dramatic positive improvement. It's not just that the bone will look fine on an X-ray in a couple months, but that this child is not in a body cast. And we were looking at the child holistically, and it took awhile for the orthopedic community to embrace that, but now I would say it's certainly standard of care throughout the United States.

Narrator: Surgery may also be necessary for some abdominal and head injuries.

Michael L. Nance, MD: The leading cause of death for kids that die from trauma is a head injury, and so we are much better able to care for the children with the most severe head injuries, to manage the pressure in their head, to control the bleeding, and to have better outcomes.

Narrator: After surgery, patients go to one of CHOP's inpatient units. Here, the expertise of the trauma nursing staff comes together with many disciplines to provide care for the child and the whole family.

Letitia Batton, MSW: How you doing, Lewis?

Lewis: Fine.

Letitia Batton, MSW: How you feeling today?

Okay. I hear you're going to surgery later on.

Our team is unique because we have nurse practitioners, because of the trauma attendings and fellows who specialize specifically in trauma.

Kristine Biggie, RN, MSN: What we do on a day-to-day basis is provide and guide a lot of the medical and nursing care that a child would need.

Nurse: Uh-oh. Don't hit those plates.

Aaron Donoghue, MD: Our Child Life Specialists and various Social Workers and Psychologists that are a part of each of the teams involved, whether it's the ED, the Trauma Program themselves, the ICU, they get involved very early and very deeply.

Letitia Batton, MSW: We have a great working relationship, and that's important, because when I go in and I say that I'm a part of the Trauma team, I reiterate that by saying, "The nurse that is assigned to you is the one that I'm working with, who's already updated me."

Road to Recovery: Support Through Rehabilitation

Cara Rakow, RN, MSN: When they're stabilized in the Pediatric Intensive Care Unit, whether that takes a day or weeks or months, they then come down to the inpatient unit, and we get to care for them on the road to recovery. So they've made it out of the Intensive Care Unit, and now they get to talk about a healing process in a different way.

Kristine Biggie, RN, MSN: We also do quite a bit of one-on-one education with the parents at the bedside about how they're going to care for their child and the best way they can help them heal quickly.

John M. Templeton, MD: We send parents home with amazing care skills. So they don't stay in the Hospital as long as they used to, because they've become part of the treatment team.

Michael L. Nance, MD: Many, if not most, kids will go home after their injury and recover and do quite well. Others, with more significant injuries, will move from the inpatient setting to a rehab setting.

Nurse: Two, three

Marla Vanore, RN, MHA: It's called Children's Seashore House, and we have the facilities to take care of the patients, even long-term. Sometimes the child will stay in the rehabilitation facility, or they might be at home and visiting as an outpatient.

Nurse: Can you bring that right foot back over? Good.

Cara Rakow, RN, MSN: That's just another light that we get to help that family see is bringing them to a whole new unit to say, "You're closer. You're closer to getting better and healthier, because we've worked through all of your acute problems at this time."

Nurse: Good

Before the Injury: Preventing Trauma

Michael L. Nance, MD: Some of the best work we do here at Children's Hospital is not happening in the trauma bay or not happening in the operating room. It's actually happening on the injury prevention front, and that's preventing the injuries from happening so that they never need our services.

Gina Duchossois, MS: All of these injuries are preventable, and many of them are predictable, as well.

Cara Rakow, RN, MSN: So we'll educate the family about the specific injury that they have, how it could have been prevented, how they're going to prevent it in the future, how they can tell their friends and family to prevent it in the future.

Aaron Donoghue, MD: Sometimes it's very tangible things, like giving out equipment for safety as far as injury prevention in cars, on bikes, and so on. And other times it's just being able to spend time and explore a family's situation.

Cara Rakow, RN, MSN: We have a Safety Center located on the first floor of our Main Hospital, and the store is set up purely to help families prevent accidents and teach trauma education.

Safety Educator: Stephanie and I are going to show you how to install the car seat. Now, there's two ways to install a car seat into your car, using the seatbelt or the latch system.

Kristine Biggie, RN, MSN: We can provide parents, at a low cost, with a lot of safety and injury prevention products, such as car seats, bicycle helmets, safety gates, etc., with a safety educator to show parents how to use it properly.

Gina Duchossois, MS: A lot of people, when they think of our injury prevention program, they think of our Safety Center here at the Hospital. But we have so many aspects, including our car seat inspection stations. We have 10 sites out in the community, where we meet with families and teach them how to use their car seats. We also do larger community events, so we do have a lot of different locations where we go. And our Kohl's Safety Van travels in the community, and it really takes what we provide here in our Safety Center out into the community and on the road.

Michael L. Nance, MD: A lot of the work that we've done in the injury prevention world is because of support from the Kohl's Foundation.

Safety Advisor: And then you can see on the side that this will eventually turn into a belt-positioning booster seat for him, so this would be the last seat you would need for him.

Gina Duchossois, MS: We're able to take these safety devices with us and teach families how to use the devices, and then we sell those devices at cost.

Safety Advisor: Fits really well. We're going to tighten it up in the back a little bit. Great, great. You've got yourself a new helmet.

Nurse: So I'm one of the nurses here on--

Narrator: Other prevention efforts take place right in the Hospital, where there's plenty of time for teaching.

Nurse: Did you ever cross the street wherever you live?

Cara Rakow, RN, MSN: We received a grant to start what we call a traveling trauma education cart. The cart goes through all the units in the Hospital about once a month to provide education about specific topics pertinent to that season or time.

Nurse: How about if a ball rolls across the street? Do you run out and get it?

Child: No.

Nurse: No. What do you do?

Child: Tell my mommy.

Nurse: Very good.

Cara Rakow, RN, MSN: We also talk about pedestrian safety. What does a stop sign mean? What does the red, green and yellow light mean? We have them play games so that when they go home, they can still play safe and bring the information back to their community.

Nurse: Do you feel better?

Child: Uh-huh.

Nurse: Good. You were excellent. Thanks, mom and dad.

Aaron Donoghue, MD: Communication with other hospitals also goes on on an ongoing basis with our trauma patient review program. When we see things that are either problematic or particularly good, we try to be in direct contact with the physicians there to let them know that things went well or could have gone better or help them to identify opportunities for improvement in their systems.

Kristine Biggie, RN, MSN: Our ultimate dream in all of trauma is to be out of business. If we could prevent injuries, that would be ideal.

The Next Generation: Training Trauma Providers

Marla Vanore, RN, MHA: Another part of being a Level 1 Pediatric Trauma Center is the fact that we're a teaching Hospital.

John M. Templeton, MD: CHOP trains people, that's probably its greatest contribution. Those young residents who then go out into family practice, or they go out in various specialties, including the fellows that get trained in emergency departments.

Michael L. Nance, MD: Trainees will come here and view the latest advances in the fields, whether it's trauma or other aspects of surgery or other aspects of medicine, and can take that information and apply it in their communities.

John Flynn, MD: It's our responsibility and also our great joy to be able to supervise these young doctors in training. They bring so much enthusiasm and so much skill. Not only is it good for the patient, but it also challenges us to be the best we can be.

Trainee: Pulse ox is going on now.

Trainee: I want to hear whether we have breath sounds or not.

Narrator: Simulation training helps the Trauma team keep skills sharp so they're ready for anything that comes through the door.

Gina Duchossois, MS: We have very high-fidelity mannequins that allow us to do a high level of precision in reality with patients without having to put an actual human being in harm's way.

Trainee: Our blood pressure is now 51 over 34.

Gina Duchossois, MS: We have all the participants, from the nurses to the doctors to the respiratory therapists, all participate and act as if this is a real patient who they really have to save.

Resident: I'd like to just go around the circle and have everybody tell me what you're really--

Aaron Donoghue, MD: This training program has done a remarkably good job of identifying and correcting problems or shortcomings.

Gina Duchossois, MS: So that the next time we see a patient like that, we're just even that much better.

Advancing the Field: Trauma Research

Michael L. Nance, MD: Children's Hospital has long held our research mission, and trauma research has been a priority, both in the institution and in the Trauma Department.

Kristine Biggie, RN, MSN: Research into what is the best treatment for these specific types of injuries.

Safety Educator: After that, I will give you the instructions for the different brain exercises.

Michael L. Nance, MD: In many of these areas, we lead the field or write the literature that's put in use every single day at most trauma centers across the country.

Gina Duchossois, MS: Most of our program is evidence-based, which means we take our research, much of it being done here at Children's Hospital, and then we weave that into our programming.

Michael L. Nance, MD: The best thing is when bedside observations lead to real world changes. One of the sentinel events was the first report of a child that died from exposure to an air bag. That led to additional work at the positioning of car seats in the best location in the cars, and that led to policy changes in states. So that was real world observations leading to real world change.

John Flynn, MD: So questions that come up during the care drive the research, the answers to the research drives the care, and it's a virtuous cycle for the kids over time.

John M. Templeton, MD: You can make enormous improvements if you are of a mindset of how to empower people.

John Flynn, MD: There is a lot of hope for reducing some of the worst injuries that we see and some of the ones that are truly preventable.

Michael L. Nance, MD: Most of our work is kids getting better, but not always. And the kids will occasionally have long-term injuries or unrecoverable injuries. And the most devastating times are those when you know that the injury could have been prevented.

Gina Duchossois, MS: An injury can happen in a split second. That's why CHOP is so committed in making sure that our children in this neighborhood receive the education they need in addition to the safety devices to keep them safe.

Safety Educator: Do you see anything here that might be--

Kristine Biggie, RN, MSN: Typically, when I tell a non-medical person about my job, they think it's a very sad, depressing job. And I admit, some days it absolutely is. But most days I walk out of here going, "Yes, that's why I do my job," because the kids really do get better.

John Flynn, MD: Why we sign up for it has a lot to do with the joy we get from watching kids go from devastating injury to full return.

Marla Vanore, RN, MHA: It's really something that we can do something about, either through prevention or through giving the best possible care.

Michael L. Nance, MD: If we can lessen an injury, that's progress. If we can prevent a death, that's progress. We learn every single day from the children we treat. And whether it's helping make that child better or learning from one injury we see so that the next time we see something like it we can manage it better, that's progress.

Unknown: Say cheese.

Related Centers and Programs: Trauma Center, Orthopaedic Trauma Program, Division of Orthopaedics