Pediatric Annals

EDITORIAL 

When Pediatricians Cannot Hesitate

Milton I Levine, MD

Abstract

We rarely think of the tremendous responsibility of every practicing pediatrician. It is a part of our lives that we take for granted. We are responsible for the growth and development of each child, protection from contagious diseases, treatment of infections and allergies, minor cuts, bruises, sprains, and gastrointestinal upsets. Parents look to us for advice on emotional and social problems, as well as learning difficulties, perceptual problems, and hypo- or hyperactivity. Every so often, we are faced with a disfiguring or lifethreatening traumatic injury that demands quick action.

I was in my office one busy afternoon when a mother called and cried out that her 5-year-old daughter had amputated half of her left forefinger in the slamming of a door, and she was unable to find the severed portion. I asked her to look on the door, where she quickly found the lost part adhering to the edge. I had a surgeon waiting for the child when the mother reached the hospital with her daughter and the amputated portion of the finger, wrapped in wet dressings. Soon it was expertly reattached; the union became perfect and within a few months the use was as faultless as it had been before the accident.

Occasionally, when faced with a severe injury, I have acted quickly, but in retrospect have had reason to question my own judgment. A hysterical mother called one day. Her 6-year-old daughter, attempting to cross the street, had been knocked down and run over by a car. An ambulance had been called and was taking the child to the nearest hospital. Could 1 get to that hospital immediately? I reached the hospital in about 20 minutes.

The child was lying on an examining table in the admission office when 1 arrived. She was in partial shock and was receiving a glucose infusion. Examination revealed that there was a severe abdominal injury. What should I do? This was only a second-rate hospital at best, without any pediatrie surgeons or, to my knowledge, adequate facilities to care for a seriously injured child. I decided to take a chance and bring the little girl to my own institution, New York Hospital, immediately by ambulance. I called ahead and had the surgeon, operating room, and staff waiting for her when she arrived 20 minutes later. On operation, two large lacerations in her liver were found and the abdomen was filling up with blood. The liver was quickly repaired, transfusions were given and the child recovered completely. After seeing that abdomen, I wondered then and still wonder: Did I seriously endanger this child's life by transporting her and losing over 20 more precious minutes? Did I do the right thing?

The present issue of Pediatrie Annals is under the Guest Editorship of Dr. Peter K. Kottmeier, Professor and Chief of Pediatrie Surgery at the Downstate Medical Center of the State University of New York, Brooklyn. He has selected for this symposium five important subjects in the area of pediatrie injuries. Almost all of the contributions are written by authors nationally known for their expertise in their specific field.

The first article, entitled "The Crucial Hour," is written by Dr. Burton H. Harris et al. Dr. Harris is Professor and Chief of Pediatrie Surgery at Tufts University, New England Medical Center. The contribution also comes from the Kiwanis Pediatrie Trauma Institute in Boston. This is a most important paper emphasizing that airway obstruction, hypovolemia, and central nervous system injury are the "three quick killers" ending in hypoxia. Step by step, the authors direct the stabilization of the pediatrie trauma victim by restraint of the…

We rarely think of the tremendous responsibility of every practicing pediatrician. It is a part of our lives that we take for granted. We are responsible for the growth and development of each child, protection from contagious diseases, treatment of infections and allergies, minor cuts, bruises, sprains, and gastrointestinal upsets. Parents look to us for advice on emotional and social problems, as well as learning difficulties, perceptual problems, and hypo- or hyperactivity. Every so often, we are faced with a disfiguring or lifethreatening traumatic injury that demands quick action.

I was in my office one busy afternoon when a mother called and cried out that her 5-year-old daughter had amputated half of her left forefinger in the slamming of a door, and she was unable to find the severed portion. I asked her to look on the door, where she quickly found the lost part adhering to the edge. I had a surgeon waiting for the child when the mother reached the hospital with her daughter and the amputated portion of the finger, wrapped in wet dressings. Soon it was expertly reattached; the union became perfect and within a few months the use was as faultless as it had been before the accident.

Occasionally, when faced with a severe injury, I have acted quickly, but in retrospect have had reason to question my own judgment. A hysterical mother called one day. Her 6-year-old daughter, attempting to cross the street, had been knocked down and run over by a car. An ambulance had been called and was taking the child to the nearest hospital. Could 1 get to that hospital immediately? I reached the hospital in about 20 minutes.

The child was lying on an examining table in the admission office when 1 arrived. She was in partial shock and was receiving a glucose infusion. Examination revealed that there was a severe abdominal injury. What should I do? This was only a second-rate hospital at best, without any pediatrie surgeons or, to my knowledge, adequate facilities to care for a seriously injured child. I decided to take a chance and bring the little girl to my own institution, New York Hospital, immediately by ambulance. I called ahead and had the surgeon, operating room, and staff waiting for her when she arrived 20 minutes later. On operation, two large lacerations in her liver were found and the abdomen was filling up with blood. The liver was quickly repaired, transfusions were given and the child recovered completely. After seeing that abdomen, I wondered then and still wonder: Did I seriously endanger this child's life by transporting her and losing over 20 more precious minutes? Did I do the right thing?

The present issue of Pediatrie Annals is under the Guest Editorship of Dr. Peter K. Kottmeier, Professor and Chief of Pediatrie Surgery at the Downstate Medical Center of the State University of New York, Brooklyn. He has selected for this symposium five important subjects in the area of pediatrie injuries. Almost all of the contributions are written by authors nationally known for their expertise in their specific field.

The first article, entitled "The Crucial Hour," is written by Dr. Burton H. Harris et al. Dr. Harris is Professor and Chief of Pediatrie Surgery at Tufts University, New England Medical Center. The contribution also comes from the Kiwanis Pediatrie Trauma Institute in Boston. This is a most important paper emphasizing that airway obstruction, hypovolemia, and central nervous system injury are the "three quick killers" ending in hypoxia. Step by step, the authors direct the stabilization of the pediatrie trauma victim by restraint of the neck, airway control, hyperventilation, and reconstitution of the circulatory volume.

Those of us who have been practicing pediatrics for more than a few years have probably had serious trauma cases among our patients. For these children, optimal care becomes of vital importance. This is an article worth preserving for quick reference, especially when called to treat a child with multiple injuries.

The second paper discusses "Trauma of the Airway and Thorax" and is authored by Dr. Martin R. Eichelberger, Associate Professor of Surgery and Child Health at George Washington University, and Director of Emergency Trauma Services at the Children's Hospital National Medical Center, Washington, DC. This is the first of a series of excellent papers expanding on "The Crucial Hour" discussed in the previous article. Dr. Eichelberger, a national authority on traumatic injury in children, confines his discussion to injuries which compromise ventilation. He emphasizes that without effective airway management the child will succumb to tissue anoxia. Diagnosis and treatment must occur simultaneously.

The most frequent causes of hypoxia are presented in detail, and other rarer causes are mentioned as well. It is noted that the small size of the pediatrie airway makes special instrumentation necessary. The pediatrician is reminded that before treating or even examining an injured child, one must first protect the cervical spine lest manipulation result in spinal cord injury. Step-by-step careful directions are given for rapid recognition of serious chest injuries and their treatment. Dr. Eichelbeigei warns that the successful treatment of a life-threatening chest injury depends on early recognition. There is a wealth of valuable information in this article. It, too, should be carefully read and held for possible future reference.

The next contribution is on "Pediatrie Abdominal Trauma," one of the most difficult problems following an injury. It has been written by Dr. Max L. Ramenofsky, Professor and Chief of Pediatrie Surgery at the University of South Alabama College of Medicine, Mobile. This article deals with evaluating and resuscitating a child who has suffered blunt abdominal injury. Two main problems must be faced immediately - blood loss and organ dysfunction.

The blood loss can be quickly corrected to prevent or treat hypovolemic shock. But whether open surgery is indicated depends on an accurate diagnosis. Dr. Ramenofsky carefully directs the examination of the abdomen and then points out that, when necessary, two valuable diagnostic means are available: the CT scan for identifying an organ injury, and the use of intravenous contrast substance to provide information on the status of the kidneys, ureters, and bladder.

Most of us remember when a ruptured spleen, seen not infrequently in pediatrie sledding accidents, was an indication for splenectomy. Today, with our knowledge of the long-range danger of such operations, repair of splenic tears has been highly successful. This is again a valuable and informative article.

The fourth article covers a subject commonly seen among our patients - burn injuries. It has been written by Dr. Charles V. Coren, Assistant Professor of Surgery, State University of New York, Downstate Medical Center; and Director of the Pediatrie Burn Unit, Kings County Hospital Center, Brooklyn. Dr. Coren starts his discussion with some startling figures; burns are the second leading cause of accidental death in children. He also notes the high incidence of burns due to child abuse.

There follows a description of the various types of bums based on the degree of dermal injury and the specific treatment for each type. The possible need for hospitalization is discussed, which includes burns that are self-inflicted or the result of child abuse. Directions for the treatment of minor and major bums are carefully set forth. The need for intravenous resuscitation in all serious burns is discussed with the urgent advice that it be given as soon after the injury as possible. Operative treatment and long-term management are also well presented.

The final paper deals with "The Battered Child" and is authored by Dr. Peter K. Kottmeier, the Guest Editor for this issue of the journal. Here is a superb summation of this whole condition by a pediatrie surgeon with a wealth of experience in handling such children.

I have mentioned before that I was there in the early 1940s when Dr. John Caffey presented us with a group of x-rays of children with subdural hematomas. Some were said to have (alien off chairs, or out of their beds, or had fallen from arms while being carried. Dr. Caffey, the Pediatrie Roentgenologist at the College of Physicians and Surgeons, was the most careful and curious individual I have ever known. He x-rayed the whole body of each child and found to his amazement numerous evidences of healing fractures of their bones. Was this some form of bone pathology or was it due to repeated traumatic experiences? It is interesting that a leading pediatrie textbook (Halt and Howland) in 1936 noted that while subdural hematomas were frequent in foundlings, illegitimate children, and those institutionalized, breastfed infants were notoriously free of the condition.

In 1957 Dr. Caffey concluded that many of the lesions he found on children with subdural hematomas were inflicted by parents. These conditions were later carefully studied and confirmed by Dr. Henry Kempe who termed it the Battered Child Syndrome.

In this present article, Dr. Kottmeier has brought together our present knowledge of this syndrome. He first advises on a study of the supposed abuser, his or her personality, basic family relationships, and whether there has been a crisis which triggered the child abuse incident. The physical examination of the child is detailed. "It must be at least as thorough as the examination of an accidentally injured child," Dr. Kottmeier states.

The various areas of the body are covered one by one with detailed instructions on what to observe, such as the appearance of individual lesions, the color of bruises, the condition of the mouth as well as other orifices. The type of fractures are studied as are the location and type of burns. The determination of sexual abuse is covered with the knowledge that 75% of sexually abused children are molested by a family member or friend of the family. This is an important article which should be of value and interest to all practicing pediatricians. We must be skilled at diagnosing the "battered child" and detecting the child abuser.

10.3928/0090-4481-19870401-04

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