The Pattern of Paediatric Trauma on Operations

Global Burden of Violence

This article documents the increasing numbers of children impacted annually by 1 or more types of violence against children and describes the range of types of injuries and their immediate and long-term impacts on child outcomes. The article describes the growing number of international collaborations to decrease the numbers of children impacted by violence and to mitigate the consequences thereof, with a particular emphasis on children living in war zones.

Global surgery for paediatric casualties in armed conflict

Background

Understanding injury patterns specific for paediatric casualties of armed conflict is essential to facilitate preparations by organizations that provide medical care in conflict areas. The aim of this retrospective cohort study is to identify injury patterns and treatment requirements that are specific for paediatric patients in conflict zones.

Methods

Characteristics of children (age < 15 years) treated in medical facilities supported by the International Committee of the Red Cross (ICRC) between 1988 and 2014 in Kabul, Kao-i-Dang, Lokichogio, Kandahar, Peshawar, Quetta and Goma were analysed; patient characteristics were compared between treatment facilities and with those of adult patients (age ≥ 15 years).

Results

Of the patients listed in the database, 15% (5843/38,088) were aged < 15 years. The median age was 10 years (IQR 6–12); 75% (4406/5843) were male. Eighty-six percent (5012/5,843) of the admitted children underwent surgery, with a median of 2 surgeries per patient (IQR 1–3). When compared with adult patients, children were more frequently seen with fragment injuries, burns and mine injuries; they had injuries to multiple body regions more often and had higher in-hospital mortality rates.

Conclusions

Children more often sustained injuries to multiple body regions and had higher in-hospital mortality than adults. These findings could have implications for how the ICRC and other organizations prepare personnel and structure logistics to meet the treatment needs of paediatric victims of armed conflicts.

Blast injuries in children: a mixed-methods narrative review

BACKGROUND AND SIGNIFICANCE

Blast injuries arising from high explosive weaponry is common in conflict areas. While blast injury characteristics are well recognised in the adults, there is a lack of consensus as to whether these characteristics translate to the paediatric population. Understanding blast injury patterns in this cohort is essential for providing appropriate provision of services and care for this vulnerable cohort.

METHODS

In this mixed-methods review, original papers were screened for data pertaining to paediatric injuries following blasts. Information on demographics, morbidity and mortality, and service requirements were evaluated. The papers were written and published in English from a range of international specialists in the field.

RESULTS

Children affected by blast injuries are predominantly male and their injuries arise from explosive remnants of war, particularly unexploded ordinance. Blasts show increased morbidity and mortality in younger children, while older children have injury patterns similar to adults. Head and burn injuries represent a significant cause of mortality in young children, while lower limb morbidity is reduced compared with adults. Children have a disproportionate requirement for both operative and non-operative service resources, and provisions for this burden are essential.

CONCLUSIONS

Certain characteristics of paediatric injuries arising from blasts are distinct from that of the adult cohort, while the intensive demands on services highlight the importance of understanding the diverse injury patterns in order to optimise future service provisions in caring for this child blast survivor.

Effects of armed conflict on child health and development: A systematic review

BACKGROUND

Armed conflicts affect more than one in 10 children globally. While there is a large literature on mental health, the effects of armed conflict on children's physical health and development are not well understood. This systematic review summarizes the current and past knowledge on the effects of armed conflict on child health and development.

METHODS

A systematic review was performed with searches in major and regional databases for papers published 1 January 1945 to 25 April 2017. Included studies provided data on physical and/or developmental outcomes associated with armed conflict in children under 18 years. Data were extracted on health outcomes, displacement, social isolation, experience of violence, orphan status, and access to basic needs. The review is registered with PROSPERO: CRD42017036425.

FINDINGS

Among 17,679 publications screened, 155 were eligible for inclusion. Nearly half of the 131 quantitative studies were case reports, chart or registry reviews, and one-third were cross-sectional studies. Additionally, 18 qualitative and 6 mixed-methods studies were included. The papers describe mortality, injuries, illnesses, environmental exposures, limitations in access to health care and education, and the experience of violence, including torture and sexual violence. Studies also described conflict-related social changes affecting child health. The geographical coverage of the literature is limited. Data on the effects of conflict on child development are scarce.

INTERPRETATION

The available data document the pervasive effect of conflict as a form of violence against children and a negative social determinant of child health. There is an urgent need for research on the mechanisms by which conflict affects child health and development and the relationship between physical health, mental health, and social conditions. Particular priority should be given to studies on child development, the long term effects of exposure to conflict, and protective and mitigating factors against the harmful effects of armed conflict on children.

Lessons from the organisation of the UK medical services deployed in support of Operation TELIC (Iraq) and Operation HERRICK (Afghanistan)

This paper provides the definitive record of the UK Defence Medical Services (DMS) lessons from the organisation of medical services in support of Operation (Op) TELIC (Iraq) and Op HERRICK (Afghanistan). The analysis involved a detailed review of the published academic literature, internal post-operational tour reports and post-tour interviews. The list of lessons was reviewed through three Military Judgement Panel cycles producing the single synthesis 'the golden thread' and eight 'silver bullets' as themes to institutionalise the learning to deliver the golden thread. One additional theme, mentoring indigenous healthcare systems and providers, emerged as a completely new capability requirement. The DMS has established a programme of work to implement these lessons.

'A band of brothers'-an exploration of the range of medical ethical issues faced by British senior military clinicians on deployment to Afghanistan: a qualitative study

AIMS

To identify and explore features of ethical issues that senior clinicians faced as deployed medical directors (DMDs) to the British Field Hospital in Afghanistan as well as to determine the ethical training requirements for future deployments.

METHOD

A qualitative study in two phases conducted from November 2014 to June 2015. Phase 1 analysed 60 vignettes of cases that had generated ethical dilemmas for DMDs. Phase 2 included focus groups and an interview with 13 DMDs.

FINDINGS

Phase 1 identified working with limited resources, dual conflict of meeting both clinical and military obligations and consent of children as the most prevalent ethical challenges. Themes found in Phase 2 included sharing clinical responsibilities with clinicians from other countries and not knowing team members' ways of working, in addition to the themes from Phase 1.

DISCUSSION

This study has drawn together examples of scenarios to form a repository that will aid future training. Recommendations included undertaking ethics training together as a team before, during and after deployment which must include all nationalities who are assigned to the same operational tour, so that different ethical views can be explored beforehand.

Preparing British Military nurses to deliver nursing care on deployment. An Afghanistan study

BACKGROUND

This paper forms part of the first British Armed forces qualitative nursing research study undertaken on deployment.

AIM

To provide an analysis of the impact and effectiveness of the pre-deployment educational preparation and clinical placements provided for military nurses.

THEORY & METHODS

A Constructivist Grounded Theory was utilised with data collected through semi-structured interviews with 18 nurses based in Camp Bastion Hospital, Afghanistan during 2013.

RESULTS

Initial coding indicated 21 educational preparation and clinical placement categories that influenced the delivery of nursing care. Analysis of these elements led to the identification of four major clusters: Military Nursing Care; Military Nurse Education; Unique Hospital Environment and Clinical Placements.

DISCUSSION

Educational preparation consists of completing deployable operational nursing competencies, specialist training and individual tailored courses. This strategy was viewed as proving the appropriate academic requirement. However, training would be enhanced by introducing a formalised military preceptorship programme focussing on fundamental nursing skills. Caring for children was a particular concern, and it was emphasised that educational courses must be combined with a standardised clinical placement policy. Adequate clinical exposure can be challenging as nurses are not routinely exposed to War Zone levels of trauma in the UK. Clinical placements need to be standardised and harmonised, and located in areas where nurses cared for patients with similar injury patterns to those witnessed on deployment. Current NHS Trust placements can reduce the opportunities for employment in suitable clinical environments and diminishing the openings for collective military training. Better use should be made of clinical rotation programmes, including high dependency units, elective surgery, medical assessment units, paediatrics, and outreach teams such as burns and plastic surgery and pain management. Practice Educators should be utilised to provide education, mentorship, supervision and continuing personal development in the operational arena. The paper considers post-Afghanistan future options.

Management of children in the deployed intensive care unit at Camp Bastion, Afghanistan

BACKGROUND

The deployed Intensive Therapy Unit (ITU) in the British military field hospital in Camp Bastion, Afghanistan, admits both adults and children. The purpose of this paper is to review the paediatric workload in the deployed ITU and to describe how the unit copes with the challenge of looking after critically injured and ill children.

METHODS

Retrospective review of patients <16 years of age admitted to the ITU in the British military field hospital in Camp Bastion, Afghanistan, over a 1-year period from April 2011 to April 2012.

RESULTS

112/811 (14%) admissions to the ITU were paediatric (median age 8 years, IQR 6-12, range 1-16). 80/112 were trauma admissions, 13 were burns, four were non-trauma admissions and 15 were readmissions. Mechanism of injury in trauma was blunt in 12, blast (improvised explosive device) in 45, blast (indirect fire) in seven and gunshot wound in 16. Median length of stay was 0.92 days (IQR 0.45-2.65). 82/112 admissions (73%) were mechanically ventilated, 16/112 (14%) required inotropic support. 12/112 (11%) died before unit discharge. Trauma scoring was available in 65 of the 80 trauma admissions. Eight had Injury Severity Score or New Injury Severity Score >60, none of whom survived. However, of the 16 patients with predicted mortality >50% by Trauma Injury Severity Score, seven survived. Seven cases required specialist advice and were discussed with the Birmingham Children's Hospital paediatric intensive care retrieval service. The mechanisms by which the Defence Medical Services support children admitted to the deployed adult ITU are described, including staff training in clinical, ethical and child protection issues, equipment, guidelines and clinical governance and rapid access to specialist advice in the UK.

CONCLUSIONS

With appropriate support, it is possible to provide intensive care to children in a deployed military ITU.