Saving Kids Worldwide

One of the leading causes of death worldwide is injury to children, especially between 1-14 years of age. Most people are unaware that injury should be considered a disease. There is so much awareness of the benefits of immunization to prevent childhood disease but injury continues unabated. Action to prevent injury and death will save the lives of children and reduce the disability that results.

Worldwide, the challenge is the “burden of injury” which creates a significant economic and social impact upon the family, community and society. The effect upon the family is significant: absence of the child from school, loss of employment by the parent, reduction in income for the family who must care for the child and isolation of the family from the community. After a child steps upon a landmine or plays with unexploded ordinance, the mobility of the child is eliminated after an amputation of an extremity. In many cultures the family is shunned by the community. The “burden” affects the entire community that is responsible to provide a safe environment for the child. Surgeons can prevent death, improve the quality of life and provide a chance for rehabilitation following disability from injury.

Nevertheless, about 10% of the injuries to children worldwide challenge the best surgeons and health care systems. We rely upon a team of people to help save children once they are injured. It takes a system that includes response at the point of injury, acute treatment and a commitment to rehabilitation, to prevent the death of the child and restore them to health. The initial response time has impact upon the outcome. It is imperative that we prepare the first responder and the Emergency Medical System to save the life of the child and to provide transfer to an appropriate level of trauma care.

Sudden events that result in injuries, such as earthquakes, riots or political conflicts, create a challenge for all levels of the system. It takes a long time before you have a response by emergency services, so the bystander and local team need to be able to initiate emergency care while providing transfer to a facility for acute treatment. In the United States, only 10% of injured children have access to a verified pediatric trauma center, so that means 90% receive acute care in general hospital facilities.

The big question is “how do we take care of these kids no matter where they are in the world?” After 10 years of war in Iraq and Afghanistan, the approach to care for the injured child changed. This knowledge and experience affects the system of care and the approach to treatment that makes a difference to children. Better prevention, acute care and rehabilitation will improve the quality of life for the community.

A community has the opportunity to learn from the global experience with injury or to share them with colleagues throughout the world. The convenience and accessibility of using web-based technology can share life-saving ideas quickly. We now can provide access to new surgical techniques and to accelerate practical application in a matter of weeks, instead of years. As an example, The Childress Institute for Pediatric Trauma creates web symposia to provide cutting-edge practice to medical professionals in 33 countries over the past two years.

The timely transfer of pediatric trauma care knowledge is saving the lives of injured children worldwide. The challenge to provide contemporary trauma care to the worldwide community is worthy of our efforts. 

- MartinR. Eichelberger, M.D., Professor of Surgery and of Pediatrics at George Washington University, Children’s National Medical Center in Washington D.C.

Blast Injury by Dr. Eichelberger

*Please note that some links may lead to graphic information not suitable for all audiences.

The Fourth of July inspires celebration - sometimes fireworks, bonfires and other fun activities can lead to serious injuries. This can be even scarier when children are involved. While thinking about "bombs bursting in air" and all of the week's news from war-torn countries, we turn our attention to an issue that is prevalent around the world, and unfortunately hit close to home last year in Boston.

Injury is the number one killer of kids in America and kills many worldwide. Unfortunately, over the last 10 years, children around the world are not just being injured by vehicles or gunfire or falls, but they are actually sustaining injury from explosion, a blast injury. This injury is rare in the United States, but the episode at the Boston Marathon bombings reveals that a new mechanism of injury can occur.  

The explosion creates a pressure wave that results in a blast injury. The most common and dangerous devices are land mines, unexploded devices or “improvised” explosive devices (IEDs), otherwise known as a roadside bomb. In a war-torn country, many of the bombs don’t explode upon impact. These devices have blue, yellow and red tags and children play with the tags, sometimes pulling the pin that detonates the device. These kids become victims of an explosion that result in a unique injury. 

In countries that are experiencing a civil war, such as Colombia, India, Chile, Iraq and Afghanistan, there are millions of “active” land mines. Even when enemies are not fighting, these devices are buried waiting to go off. Innocent children are out there walking and playing where it's easy for them to step upon a land mine.  

Historically, war creates the opportunity to learn new medical techniques and approaches to treatment of the injured patient, which is applicable to the adult patient and to children. When American and other military medical personnel are in these areas, they treat the children as well as the soldiers. Their experience and treatment techniques learned in the field are extremely valuable in saving children around the world. This process is going on right now! For example, in trauma centers we are changing the way we resuscitate pediatric patients with a new concept known as damage control resuscitation. We realize that when a child develops severe shock due to a critical injury, they do much better when we reduce the amount of crystalloid fluid typically given to these kids and instead, immediately treat hemorrhage with infusion of blood products. This approach is more focused upon the importance of coagulation of circulating blood to the survival of the child. Quickly sharing this information saves lives - Sami is an example.

Most American civilian surgeons know little about the effects of a blast from an explosion. Military surgeons who have treated a significant number of children with a blast injury are able to transfer the knowledge to their civilian colleagues to improve the capacity to care for children. A blast pattern is something that most surgeons in the U.S. will never see until there is a devastating emergency. That is one of the reasons we developed the web-based, Childress Pediatric Trauma Symposium and held three of them in the last two years. Our hope is to share knowledge and experiences with our colleagues around the world in time to save lives.

The Boston Marathon bombing is a critical example of why we need to know how to treat a child following a blast injury. If we can share techniques developed to treat children, we can save the lives of children worldwide.

Martin R.Eichelberger, M.D., Professor of Surgery and of Pediatrics, George Washington University, Children’s NationalMedical Center, Washington D.C.

Sami's Story - an International Success

I am a surgeon in the Department of Paediatric Surgery at University Children‘s Hospital (UKBB) in Basel, Switzerland.  Only one week after the first Global Cast/Childress Institute for Pediatric Trauma international webinar on pediatric trauma management in 2012, we were able to save the life of a five-year-old boy, Sami, using techniques learned during the webinar. 

Sami was injured on a Swiss mountain farm - his abdomen was crushed between the tire of a tractor and a gate post. He immediately complained of severe abdominal pain and became very pale. At the regional trauma hospital, a CT scan revealed massive amounts of free fluid in his abdomen and thorax, which was due to bleeding of the liver, pancreas and spleen.

When he arrived by helicopter transport at our pediatric trauma center, his body was suffering from severe hemorrhagic shock. As recommended in the pediatric trauma webinar, my team utilized the new concept of damage control resuscitation and surgery to treat Sami's condition.

Sami underwent an emergency laparotomy to stop the ongoing abdominal hemorrhage.  The bleeding sites of the liver, spleen, and pancreas were controlled in the two-hour procedure and two parts of the spleen were preserved. Immediately after his surgery, Sami was transferred to the pediatric intensive care unit for further care.

Four weeks after his injury, Sami returned to his mountain farm home and has been well ever since. The pediatric-trauma-specific education provided by the webinar and the Childress Institute helped us to save the life of this five-year-old boy. The suggestions and opinions of the panelists that participated in the webinar were very helpful in the postoperative management of Sami.

Knowledge gained from these webinars is of considerable value, especially since it is not freely available elsewhere. It is even more valuable to the families that benefit directly. Everyone counts on the fact that a child’s doctor or surgeon knows the best procedure in an emergency, and these webinars connect us across the world in ways we usually cannot on our own. Having access to innovative techniques saves lives. Sami is one of them.

- Dr. Johannes Mayr

International Perspective from Dr. Meredith

In the United States, trauma is the number one killer of kids. In the world, especially the third world, but depending on the country, it is second or third to infectious diseases and birth-related problems.

As those issues improve and sanitation improves and vaccinations improve, trauma is rapidly becoming a greater percentage of the deaths of children than ever before. Fortunately it's because the other diseases are becoming less frequent and less fatal. It's good that they're becoming less frequent and less fatal, but it's bad that trauma is not becoming less frequent and less fatal. Trauma is, in fact, globally becoming more frequent. It is more fatal in many parts of the world, injury per injury, than it is here.

There are several reasons for that. The first reason that it’s globally becoming more common is as you industrialize countries and the economies of countries improve, there's a lot more traffic. There's a lot more development needed in the supporting infrastructure: in the safety, in the emergency response, the treatment knowledge, and all the pieces that we've taken for granted in this country for years. The infrastructure is not there in a lot of countries, especially third world countries.

There are a lot of transportation injuries that are fatal to children. There are a lot more fires that are fatal to children, and sadly, war. There's a lot of war. I participated in a global web symposium last week that connected surgeons, emergency physicians and nurses to share knowledge about techniques and experiences that can help everyone. In these webinars, we have talked a lot about blast injury effects, and some other things that you would not otherwise know about. Part of the reason is that citizens and physicians of this country need to be made aware of it.

It's rare here, but we have our Boston Marathon bombings, and when these catastrophes occur, people need to be able to step up and know. You need to train and drill on things that are not common. Also, you need to learn from the experiences of people in our military and other places, experts that can inform the physicians in the world where these injuries are not uncommon. Without the international and convenient capability of the webinar medium, we wouldn’t be able to gather this knowledge or connect with such a broad audience.

Reducing the number of children dying from critical injuries is easier to attempt with the current technology for these webinars that can transmit knowledge worldwide. There is a huge appetite for this kind of knowledge, especially because it’s available and of interest to our colleagues around the world. These medical professionals need educational opportunities about pediatric trauma.

Additionally, there are some types of injuries that are relatively rare for us that other people around the world see that we need to know about. There are brilliant, creative people who are treating and taking care of patients in very austere conditions with very few resources who have come up with ideas that will be helpful to the other members of the world community. They will be helpful to us even though we have more resources in the highly-industrialized world.

The pediatric trauma web seminar I participated in is the busiest one that the provider, GlobalCast MD, hosts. We had approximately 1,400 attendees from 26 countries around the world. Of all the pediatric health seminars that they host, this is the most well-attended, most highly subscribed, by quite a margin. It just goes to show how ubiquitous the problem is and how thirsty people are in the world for these solutions.

Good smart ideas are still good smart ideas. Creating this network, this community of individuals committed to improving the fate of injured children is in-and-of-itself a good thing. It is a good thing at an intellectual level. It's a good thing at a humanitarian level. It's just the right thing to do.