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Out of the Valley of Death

Chuck Paidas checks in on a patient on the pediatric intensive care unit

In the state of Maryland, the one place a parent wants a severely injured child is in the Pediatric Trauma Center. Now, the trauma center could use some help from the state.

By Anne Bennett Swingle

It's dusk on a Carroll County highway when the head-on collision takes place at precisely 19 hours and 50 minutes into an early winter day. Arriving at the scene minutes later, paramedics find a critically injured boy strapped into the back seat. Of the three people in the car, this boy, whom we'll call J.T, appears to be in the most trouble. As soon as the paramedics see him, one grabs a cell phone and dials into a central communications hub, and the call is patched through to the Emergency Department at The Johns Hopkins Hospital. There, a physician arranges to have the boy flown 30 miles by helicopter to the trauma unit at the Children's Center.

Within minutes, at the Hospital pagers begin buzzing on the belts of surgeons, nurses, radiologists, respiratory technicians and social workers. A text message reads: Alpha, Adult ED, MVC, 10-year-old, 5 minutes arrival. In trauma talk, MVC means motor vehicle crash. Alpha connotes the most serious type of case-one which could involve multiple injuries or damage to the heart, major vessels, face, spine or head. Alphas usually are destined for the operating room or the pediatric intensive care unit. And so, within minutes of this page, a doctor and nurse from the trauma team are on the roof of the Children's Center awaiting the chopper's arrival on the helipad.

THE JOHNS HOPKINS CHILDREN'S CENTER is the only official pediatric trauma referral center in Maryland. As a level 1 trauma center for children, it is the ultimate destination, the place where any parent wants a child in the event of serious injury. In the 30 years since it was established, this trauma center has saved thousands of young lives. Like its counterpart Shock Trauma, Maryland's primary adult trauma center, the Hopkins service receives accident patients from Cumberland to the Eastern Shore. Last year, it admitted nearly 800 children. Forty percent were flown in; 50 percent came from Baltimore, many from neighborhoods adjacent to the Hospital.

On the Children's Center rooftop landing pad, a patient en route to the ED, where the pediatric trauma team awaits.

Hopkins has been home to the pediatric trauma center since 1973. Alex Haller was chief of pediatric surgery then, and it was he who convinced the Hospital board of the need for such a service. At the time, there was growing awareness that unexpected critical injuries were the main cause of death in American children. But in Maryland these cases were still being brought to general hospitals around the beltway, and most of those facilities had no pediatricians, let alone pediatric surgeons, on staff. (Even today, pediatric surgeons are a rare breed-in the entire country only about 750 physicians are trained in the specialty.) Hopkins, in fact, was the only place in the state with pediatric surgeons, its fellowship training program having commenced in the late 1960s. Once the board gave its approval, Haller went about launching the elaborate communications and transportation protocols required to give pediatric trauma cases immediate access to a hospital.

Today, the chief of children's trauma here is Charles (Chuck) Paidas. A pediatric surgeon who did his specialty training at Hopkins in the early '90s and then stayed on as a faculty member, Paidas has been running the service since Haller stepped down in 1997. He's come to understand its intricacies like no one else from a medical perspective and a business one. One point Paidas makes over and over is that a trauma unit is like no other hospital service because it's obligated to have physicians and dedicated resources and equipment ready round the clock. "Trauma is capricious," Paidas says. "You never know when it will strike." Or, as Allen Walker, director of pediatric emergency services, puts it, "trauma is inconvenient-for patients, for families, for physicians and for hospitals-because it always happens at the wrong time."

Statistics bear them out: trauma likes nights and weekends when every doctor's office is closed; it loves sunny summer days when kids are off school. Even during this unremarkable week in October, it already has visited a 3-year-old boy whose chest was penetrated by a rusty nail when he was hit with a board. It paid a call on one girl in Carroll County who fractured her skull while riding an ATV and another in northern Baltimore County who ruptured her spleen when she was kicked by a horse. It looked in on a baby who was stabbed in the neck by her deranged, drug-addicted mother and on a 10-year-old boy who fell from B level to A level near the customs exit inside Baltimore-Washington International Airport. And of course, it also visited J.T.

Injury Prevention 21205

Chuck Paidas has always been a big believer in finding ways to curtail injuries among inner-city Baltimore kids. Now as director of the Children's Center's pediatric trauma service, he is establishing an injury prevention program in ZIP code 21205, an area with one of the highest injury rates in the city and, ironically, the medical campus's own.

In 21205, the top three injuries are falls from heights, motor vehicle accidents and pedestrian "strucks," as they are called. Many are entirely preventable, but in this neighborhood, all too few kids bother with crosswalks, lights or bike helmets. As part of the new Injury Free Coalition for Kids of Baltimore, groups of parents will learn about first aid and CPR and how to help their neighborhood become safer. Each group ultimately will mentor another group of parents.

Several groups are collaborating with the pediatric trauma service to make the program work: the Children's Safety Center at the Children's Center, the Center for Injury Research and Policy at the Bloomberg School of Public Health and four East Baltimore groups. The undertaking, funded by the Robert Wood Johnson Foundation, links Hopkins to a network of trauma centers around the country that have received similar RWJ grants.

For Paidas, meeting with members of the coalition has been eye-opening. "It's taught us a tremendous amount about why we're seeing the injuries we're seeing. The grant empowers parents to prevent injuries."

DESPITE ALL THE REFINEMENTS in two-way communication between doctors at the Hospital and paramedics in the field, the pediatric trauma team never knows exactly what to expect when a patient arrives. It's trained to assume the worst. J.T., it turns out, is not the worst. He's awake, alert and oriented. For now.

Because J.T. is an Alpha, the entire trauma team has assembled in the trauma bay, Room 3 in the adult ED, the entry point for most pediatric trauma patients. On hand from pediatric surgery are the attending physician, the fellow, the senior resident and the intern. Trauma coordinator Susan Ziegfeld, a nurse practitioner, also is there, along with several ER nurses. They're surrounded by doctors from the pediatric intensive care unit (PICU), a couple of radiology specialists and a social worker.

J. T. arrives on a backboard. He is wearing a neck collar and is hooked up to an IV and oxygen. What the team notices as soon as they start examining him is that he has what's known as seat-belt sign on his abdomen, a bruise that looks exactly like a seat belt. His belly is tender and distended, but doctors first check his ABCs-airway, breathing and circulation. So far, so good. Then they take initial X-rays. A CT scan pinpoints a problem: a grade-4 liver laceration. It's a serious injury, but one that doesn't always require an operation. Interestingly, most trauma is non-operative-liver, spleen and closed head cases, for example. Even so, on a trauma service, surgeons run the show because they're the ones who understand best when to operate and when not to. In J.T.'s case, they'll be operating. He's bleeding more and more and now has become unstable. He's rushed to the OR.

Trauma surgeons at Hopkins have the luxury of calling on a host of specialists: orthopedic surgeons, urologists, ophthalmologists, plastic surgeons and neurosurgeons. But the trauma surgeons themselves do all the belly cases, vascular repairs, lung and chest procedures and even most surgeries involving the extremities and the back. J.T. is all theirs.

Just after 10 p.m., the attending, pediatric surgeon Jeff Hoehner, and Brett Englebrecht, a resident in the second year of his two-year pediatric surgery fellowship, make the first cut. They repair the liver laceration and drain the blood from the pelvis and around the liver. Blood also has accumulated in the lung cavity, a condition known as a hemothorax. As they open the thoracic cavity for the thoracotomy, the surgeons find and repair a torn pulmonary ligament. Just before midnight, J.T. is taken to the PICU. He'll be watched round the clock.

TRAUMA IS EXPENSIVE. A level 1 pediatric service must provide not only 24/7 medical care for accident victims, it must also be prepared to offer immediate consultations to physicians anywhere in Maryland who need help with a seriously injured child; it must engage in research (at Hopkins, a meticulous registry of cases soon will supply new information about treating cervical spine, horse and ATV

injuries), and it must train first responders at fire departments, EMS facilities, troopers and paramedics in emergency techniques. Under Paidas' leadership, community injury-prevention programs also are becoming an important focus, in collaboration with the Bloomberg School of Public Health.

Thirty years ago when Alex Haller set up the pediatric trauma service, one thing he did not do was request state support. Although Shock Trauma, based at the University of Maryland Medical Center, always has received a state subsidy, Hopkins' pediatric unit never has. "I wasn't smart enough to realize we needed to have state support," Haller says today. "I thought trauma would be treated like any other pediatric disease and insurance would pay for it, so we set it up as a part of the emergency system for children. In retrospect, I think that was an error, particularly since it turns out that many of the children we treat don't have insurance."

In fact, many of the center's young patients are on Medicaid, which reimburses physicians and nurses at only around 11 cents on the dollar. Paidas estimates that Hopkins' pediatric trauma service costs the institution $12 million a year. "We've made do for many years with philanthropic and foundation support," he says. "Now, we need help from the state of Maryland to ensure that our children continue to get the highest level of emergency care."

Over the past year, a special ad hoc committee of Maryland legislators has been looking at the whole trauma-care system. It's the first time, according to Paidas, the state has shown that it recognizes the financial burden of this business. Paidas is hoping the result will be state support, including funds for a portion of a new children's hospital here, where the trauma center will be housed in a few years.

The trauma team follows a patient from admission to discharge. For kids like J.T., the PICU is the stop that follows the emergency room and the operating room. The pride of the Children's Center, the PICU is a place that never rests. Its patients range from tiny infants, just days old, to hulking 18-year-old college students. Most have one thing in common: they're fighting for their lives. They have cancer, or serious infections, or congenital problems. They've had heart surgery, or transplants, or accidents. Of the 1,000 children admitted to the 22-bed PICU each year, 10 percent are trauma patients. Some, like J.T., come directly from the operating room. Some have been transferred here from other hospitals.

Last summer, Katie Cochrane was such a patient. A 15-year-old from southern Maryland, Katie ruptured her spleen and tore her pancreas in a dirt-bike accident. Doctors at Prince George's Medical Center, a level 2 trauma center, removed Katie's spleen and the distal portion of the pancreas. Two weeks later, her lungs collapsed. Like J.T., she had a hemothorax and needed a thoracotomy. After that, she was put on a ventilator. When it became clear that she needed highly specialized care, Katie was flown to Hopkins and admitted to the PICU under the care of Paidas and the trauma service.

The Hopkins doctors discovered the true seriousness of Katie's condition: the accident had opened a fistula in her pancreas. As she lay on the vent, three tubes were placed in her abdomen to drain it and four more drained her chest. For months, her nutrition was handled exclusively by IV. In the PICU, the average length of stay for patients is five and a half days. Katie stayed there for three weeks. After that, she was in and out of the Children's Center for weeks. Today, Marie, her mother, has no doubt what saved her. "It took experts to detect her problems," she says.

Most hospitals, even many major academic medical centers, don't have a pediatric trauma service. They get by-some of them very successfully-with a cadre of adult trauma surgeons, ER staff and general pediatricians. But Chuck Paidas isn't impressed. "Kids are different," he insists, "while they're in the hospital, when they go home. Their wants and needs are completely different from those of adults."

Allen Walker feels certain that doctors who devote their lives to the discipline of pediatric trauma have a sixth sense about such matters and quickly know how to make a positive difference in the life of a child. "Everyone's heard about children who've died in hospitals of trauma problems that were unrecognized," he says, "a kid, say, who bleeds into the belly from a liver laceration. Those children most often died at a community hospital, because the people taking care of them didn't appreciate the subtleties of what was going on."

There's no doubt that Katie or J.T. both could have been one of those children if they hadn't gotten to the right place at the right time. J.T. spent eight days in the PICU, then was transferred to the floor and finally was discharged to go home. Today, he's back in school, with no restrictions other than avoiding contact activities for six months. Katie's recovery has been slow, but it has been steady.

And that, says Chuck Paidas, is what makes all the worries worth it: the fact that happy endings like these are the rule and not the exception on the pediatric trauma service.