Accidents and their associated traumas have now become the number-one cause of death in children. No longer are infectious diseases the leading child killers. Pediatric cancers account for the second most commonly fatal entity.
Only in the past few years has the attention of the pediatric surgeon focused sharply on trauma. Perhaps the earlier lack of attention was due to concern for and interest in congenital defects - which, by and large, have become less challenging and more compartmentalized in regard to treatment. Certainly, the child with a massive trauma presents the concept of "totality of care" that for so long has been the concern of the pediatric surgeon.
Several states are establishing programs through which funds have become available for institutions seeking to better the areas of infant and child emergency care. Special state laws on child abuse have been enacted that make it a crime to inflict trauma on a child; also, in failing to report such injuries or suspicion of their cause, one may become as guilty as the actual misdoer.
There has been a rush to alter emergency-room facilities and programs designed to care for the child with a severe trauma. Many conferences and consultations between experts have shown a variety of approaches.
We are even changing our attitudes, some of which have become cemented in deep, concrete tradition. For example, splenectomy for the traumatically injured spleen has been almost synonymous with good, correct surgical judgment. Yet experience has shown that the incidence of postsplenectomy fatality from overwhelming sepsis, particularly of pneumococcic origin, is on the increase and may occur years after the operation and the cessation of prophylactic antibiotic therapy. Newer techniques, such as splenic and hepatic scans and celiac angiography, have given us tools by which we can more competently judge the extent and severity of splenic injury. So important is this area of concern that I have asked Dr. Hugh B. Lynn to write a special editorial (which follows this Introduction) reviewing the situation, which is in a critical stage of re-evaluation.
The medicolegal aspects of trauma speak for themselves. The "Good Samaritan Laws" pertain to emergency care but not to the care given in an emergency room by trained personnel. Therefore, as trauma increases in the childhood spectrum, the pediatrician, the emergency-room staff, the general surgeon, and the pediatric surgeon will be expected to become more competent in this area. It will be a legal necessity. It must be a moral and ethical medical one, too.
One other item deserves mention. That is the identification of all children with special problems - such as drug sensitivities, diabetes, epilepsy, or hemophilia - through the use of a bracelet or pendant containing the information. In this way such information can be quickly evident at times of emergency. These identification tags can be obtained through the Medic Alert Foundation.*
The contributors to this issue of Pediatric Annals have completed what we trust will be a series of articles to act not only as guidelines but also as a stimulus for all pediatricians to learn how to act, when to act, and why to act when an injured child is brought to an emergency room. To paraphrase Franklin D. Roosevelt, "The only thing we have to fear is fear itself" - plus ignorance: the ignorance of the changing and newer concepts concerning the care of the child suffering from a major trauma. Perhaps nowhere is the totality of childhood care more taxing for the pediatrician than in trauma. Perhaps no greater demands can be made on one's knowledge of basic physiology, anatomy, first aid, and common sense. The child is on the stretcher - injured. The surgeon is on his way. You are the pediatrician, and this is your patient. You must act. The child is waiting.