THE INJURED CHILD

BY

C, EVERETT KOOP, MD

SURGEON GENERAL

      AND

DEPUTY ASSISTANT SECRETARY FOR HEALTH

    THE ROBERT E, GROSS LECTURE

PRESENTED TO STUDENTS & FACULTY OF THE

UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER

         HOUSTON, TEXAS

FEBRUARY 19, 1983


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(GREETINGS TO HOSTS, GUESTS>

  THIS HAS BEEN AN EXTRAORDINARY THREE DAYS. IT'S BEEN TOTAL
IMMERSION IN THE FIELD OF PEDIATRIC MEDICINE. AND I WONDER WHAT ON
EARTH I CAN POSSIBLY CONTRIBUTE NOW, AT 4 O'CLOCK ON THE THIRD AND
LAST DAY OF THIS EXCEPTIONAL COURSE ON THE INJURED CHILD,

  I UNDERSTAND THAT THIS WAS TO HAVE BEEN A CONTINUING EDUCATION

PROGRAM FOR ALL THE REGISTRANTS,  BUT I HOPE DR, BROOKS CAN INCLUDE MY

NAME ON THE ROSTER OF STUDENTS BECAUSE IT HAS BEEN A TREMENDOUS

LEARNING EXPERIENCE FOR ME AS WELL.

THIS HAS ALSO BEEN A WONDERFUL TIME FOR REMINISCING ASOUT THE

EARLY YEARS OF My PARTICULAR SPECIALTY, PEDIATRIC SURGERY, AND FOR

REMEMBERING ONCE AGAIN THE MAJOR ROLE PLAYED BY BOB GROSS IN THE

DEVELOPMENT OF THAT SPECIALTY,

  MY FRIENDSHIP WITH BOB GROSS BEGAN IN 1945, WHEN I WENT TO BOSTON

CHILDREN'S HOSPITAL WITH INSTRUCTIONS TO LEARN WHAT I COULD AND TO
RETURN TO PHILADELPHIA TO ESTABLISH THE COUNTRY'S SECOND TRAINING

PROGRAM IN PEDIATRIC SURGERY.  IT WAS AN EXCITING TIME FOR ME. BUT IT

WAS ALSO ONE OF THE MOST DIFFICULT FOR BOB GROSS. THERE WAS NO


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CERTAINTY THAT HE \JOULD GET THE WILLIAM E. LADD CHAIR OR THE
APPOINTMENT TO BE SURGEON-IN-CHIEF OF B,C,H, YET, IN SPITE OF THE
ErlOTIONAL TURMOIL HE MUST tiAVE BEEN ENDURING, HE CONTINUED TO FORGE
AHEAD ON INNOVATIVE CARDIOVASCULAR TECHNIQUES AND REAL BREAKTHROUGHS

IN SURGERY,

  SO I HAVE KNOldN BOB GROSS IN THE BEST OF TIMES AND IN THE WORST OF

TIMES,  WE'VE BEEN FRIENDS FROM THEN UNTIL NOW AND FREQUENTLY SHARED
OUR HOPES AND ASPIRATIONS FOR THE SPECIALTY OF PEDIATRIC SURGERY, FOR
T:iE DEVELOPME;4T,OF ITS QUALIFIYING BOARD AND THE JOURNAL OF PEDIATRIC
SURGERY, ArID MUCH MORE,  SO I All PROUD TO BE HERE AT THIS TIME AND IN

HIS HONOR,

w

UNTIL 1381 I HAD SPENT !'lY \ilHOLE PROFESSIONAL LIFE AS A PEDIATRIC

SURGEON,  IT's BEEN ONLY TWO YEARS THAT I TRADED ~IY 0.~~ GOWN FOR THE
UNIFOR!'! OF THE SURGEON GENERAL OF THE UNITED STATES, I DON'T REGRET

DOING THAT -- BUT IT TAKES AN EVENT SUCH AS THIS TO REMIND ME JUST tl0
QUICKLY MEDICINE CAN ABSORB NEW INFORMATION,, ,NEW PEOPLE,, ,AND NEW

PROBLEMS,  SO I HAVE LEARNED A GREAT DEAL SINCE EARLY THURSDAY

MORN I FIG I  AND I WANT TO CONGRATULATE DRS, BROOKS AND HOELZER FOR
PUTTING TOGETHER SUCH AN INFORMATIVE AND IMPORTANT PROGRAM AND FOR
BEING ABLE TO BRING TO HOUSTON SUCH AN OUTSTANDING FACULTY,


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  WHEN I WAS PREPARING THESE REMARKS, I HAD BEFORE ME YOUR PROGRAM

AND I WONDERED WHAT MY coNTRIBuTIoN ~IIGHT BE, IN THE LIGHT OF THE

PAPERS THAT WILL HAVE BEEN READ BY THE TIME OF THIS LECTURE AND ALSO IN

THE LIGHT OF MY OWN PARTICIPATION PROVIDING EXTEMPORANEOUS "SUMMATIONS"

FOR THE PANEL PRESENTATIONS EACH DAY, SO I DECIDED THAT I WOULD DO AT

THIS POI!T WHAT I HAVE NOT BEEN ALLOWED TO DO SINCE THURSDAY MORNING.

AND THAT IS, TALK ABOUT WHAT I WANT TO TALK ABOUT, REGARDING THE
PRORLEMS THAT SURROUND THE INJURED CHILD. SOm,,HERE GOES.

  FIRST, LET ME SAY THAT I TRULY VALUE THIS OPPORTUNITY TO SPEAK TO

THIS COMMUNITY OF SURGEONS AND OTHER MEMBERS OF THE HEALTH TEAM ON THE

SUBJECT OF "THE INJURED CHILD,"  YOU ARE AMONG THE MOST CONCERNED INDI-

VIDUALS REGARDING THIS PROBLEM, AND YOU ARE ALSO AMONG THE FEW GROUPS

OF PEOPLE WHO CAN BRING ABOUT CHANGE -- WHO CAN STIMULATE AND CAUSE

IMPROVEMENT TO TAKE PLACE -- FOR THE ULTIMATE BENEFIT OF CHILDREM WHO

ARE VICTIMS OF TRAUMA,

  FRANKLY, THAT IS LESS OF AN OBSERVATION AND MORE OF A CHALLENGE,

THE EXTENT OF INJURY TO CHILDREN IS TRULY AWESOME IM THIS, THE MOST

TECHNOLOGICALLY ADVANCED SOCIETY IN HISTORY, THE IROrjY, OF COURSE, IS

THAT THE ROOT CAUSES OF TRAUMA TO CHILDREf4 HAVEN'T CHANGED MUCH OVER

THE YEARS,  FOR EXAMPLE, or4 THE 3AsIs OF FIGURES FROM CALENDAR


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YEAR 1981, THE LATEST COMPLETE ONES WE HAVE, WE CAN SEE THAT THE MOTOR

VEHICLE IS STILL ONE OF THE LEADING CAUSES OF INJURY TO CHILDREN. IN

1981, OVER A QUARTER OF A MILLION CHILDREN WERE ADMITTED TO EMERGENCY

ROOMS FOR TREATMENT OF INJURIES INCURRED FROM SOME KIND OF ACCIDENT

WITH A CAR OR TRUCK, TWO THIRDS OF THOSE CHILDREN WERE BETWEEN THE

AGES OF 5 AND 14 AND A THIRD -- CLOSE TO 90,000 -- WERE UNDER THE AGE

OF 4.

  BUT, ACCORDING TO THE GOVERNMENT'S NATIONAL ELECTRONIC INJURY

SURVEILLANCE SYSTEM, THE LEADING CAUSE OF INJURY TO AMERICANS IN 1981

WAS NOT THE MOTOR VEHICLE AT ALL.  IT IS SOMETHING MUCH HUMBLER. THE

LEADING CAUSE WAS STAIRS -- THOSE LITTLE ARCHITECTURAL AIDS THAT ARE

SUPPOSED TO HELP US GET SAFELY FROM ONE LEVEL IN SPACE TO ANOTHER.

  GENERALLY THEY DO,  BUT IN 1981 THERE WERE 784,000 EMERGENCY ROOM

ADMISSIONS FOR INJURIES INCURRED BY PEOPLE PRIMARILY GOING -- OR BEING

CARRIED -- UP OR DOWN STEPS,  OF THE THREE QUARTERS OF A MILLIoN

INJURIES ASSOCIATED WITH STAIRS, ONE FOURTH OF THEM -- OR ABOUT 200,000

-- INVOLVED CHILDREN UNDER THE AGE OF 140


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  THE NEXT LARGEST CATEGORY OF INJURIES INVOLVED THE USE OF BICYCLES.
THERE WERE AN ESTIMATED HALF MILLION SUCH INJURIES IN 1981, OF WHICH

ABOUT THE GREAT MAJORITY -- 178,000 -- INVOLVED CHILDREN UNDER THE AGE

OF 141

  I WON'T GO ANY FURTHER WITH SUCH A LITANY, MANY OF YOU ARE ALREADY
QUITE FAMILIAR WITH THESE KINDS OF STATISTICS, BUT I THINK THEY BEAR

REPEATING.  IT HAPPENS TO BE MY OPINION THAT OUR CONFERENCE THIS WEEK
MAY WELL BE ONE OF THE FEW CONFERENCES THIS YEAR IN ANY AREA OF MEDI-
CINE THAT WILL .BE FOCUSING ON SO LARGE POPULATION OF VULNERABLE, VIR-
TUALLY DEFENSELESS PEOPLE WHO SUFFER SUCH A VARIETY OF LIFE-THREATEN-

ING INSULTS.

  AND THAT IS WHY I BELIEVE THIS CONFERENCE ON "THE INJURED CHILD"
CANNOT BE ONLY OUR OPPORTUNITY TO ASSEMBLE THE BEST OBSERVATIONS ON

THIS SUBJECT,  AND IT CANNOT 3E REMEYIBERED PRIMARILY AS A "SUPIMATION

OF SUMMATIONS,"  RATHER, THIS CONFERENCE, AS I MENTIONED A MOMENT AGO,
SHOULD BE A GREAT PERSONAL AND PROFESSIONAL CHALLENGE TO EACH OF US.

  AND THE FIRST CHALLENGE, BY THE WAY, IS RIGHT THERE IN THE TITLE.
I WANT TO SPEND JUST A MOMENT TO TAKE A CLOSER LOOK AT THAT WORD

"INJURED."  IT USUALLY MEANS THAT THERE HAS BEEN SOME BLOW TO THE


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HEAD, THE CHEST, OR TO THE EXTREMITIES,..OR THERE ARE BURNS, CUTS, OR

OTHER FORMS OF DISFIGUREMENT, ,, OR THE CHILD HAS SUFFERED POISONING,

STARVATION, OR SOME OTHER ACCIDENTAL OR DELIBERATE ASSAULT, THAT'S

THE USUAL CLUSTER OF EXPLANATIONS FOR THE WORD "INJURED,"

  BUT CHILDREN SUSTAIN MANY KINDS OF INJURIES FOR WHICH MEDICINE CAN

FUMBLE FOR AN ADEQUATE RESPONSE,  AND SOMETIMES WE SIMPLY HAVE NO

RESPONSE AT ALL,  FOR EXAMPLE, THERE ARE THOUSANDS OF CHILDREN ON OUR

STREETS TODAY FOR WHOM THE WORD "FAMILY" HAS LITTLE OR NO PERSONAL
@AN I NG ,  THEY'VE BEEN DENIED THE KIND OF FAMILY LOVE AND CARE THAT
THE REST OF us FAKE FOR GRANTED,  THE ABSENCE OF A CARING FAMILY IS A

CRUEL AND PROFOUND INJURY.  AND I DON'T BELIEVE THERE IS ANYTHING --

EVEN rr~ SUCH A FINE HEALTH SCIENCE CENTER AS THIS -- THAT CAN REPAIR

THAT PARTICULAR KIND OF HURT. NOTHING AT ALL,

  OTHER CHILDREN HAVE BEEN PHYSICALLY AidD SEXUALLY ABUSED IN THEIR

OWN HOMES.,. THEY'VE BEEN PREYED UPON IN THEIR OWN NEIGHBORHOODS,,.BEEN

EXPLOITED BY EVIL PEOPLE FOR EVIL ENDS,  AND OUR SCHOOLS AND COMMuNITY

ORGANIZATIONS MAY HAVE FAILED THEM JUST WHEN HELP WAS NEEDED THE

MOST.  THESE ARE NOT "INJURIES" AS THEY ARE UNDERSTOOD IN TRADITIONAL


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PHYSICAL I'IEDICINE, BUT THEY ARE TRAUMATIC NEVERTHELESS, AND THEY ARE

IMPORTANT, BECAUSE THEY DETERMINE WHETHER OR NOT A CHILD HAS THE WILL

TO FIGHT THE PAIN OF PHYSICAL INJURY -- OR SIMPLY TO SURRENDER.

  IT HAS ALWAYS BEEN MY FEELING THAT, ALTHOUGH WE CALL OURSELVES

PROFESSIONALS, WE NEVERTHELESS PRACTICE AN INCOMPLETE FORM OF PEDIATRIC

MEDICINE, IF WE CONFINE OURSELVES TO THAT DISCIPLINE. I BELIEVE MOST

COLLEAGUES AGREE WITH THAT,  BUT I DON'T THINK IT CAN BE RE-STATED TOO

OFTEN,  WE HAVE TO HEAR IT OFTEN -- AND BELIEVE IT ALWAYS,

  1/E NEED TO BE MINDFUL OF WHAT IS HAPPENING TO THE CHILDREN IN OUR

COMMUNITY IN ALL ASPECTS OF THEIR LIVES, AND WHERE WE CAN, WE MUST BE

COUNTED AMONG THEIR MOST ARDENT ADVOCATES FOR BETTER EDUCATION, BETTER

FAMILY CARE, BETTER SOCIAL SERVICE, BETTER RECREATIONAL OPPORTUNITIES,

AND BETTER PROTECTION AGAINST THE OCCASIONAL II6ULTS OF A SOPHISTI-

CATED BUT SOMETIMES INSENSITIVE SOCIETY m

  WE HAVE NO POWER IN OUR KIND OF MEDICINE TO REPAIR THE HURT DONE

TO A CHILD BY A FAMILY OR A COMMUNITY GONE WRONG, BUT WE MIGHT HAVE

THE KNOWLEDGE AND THE ABILITY TO PREVENT THAT WRONG FROM EVER TAKING


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PLACE,  THIS IS PROBABLY ONE OF THE MOST IMPORTANT KINDS OF "PREVENTIVE
MEDICINE" ANY COMMUNITY CAN PRACTICE FOR THE HEALTH OF ITS CHILDREN.

  AT THIS POINT I WANT TO FOCUS IN ON TWO ASPECTS OF EMERGENCY

SERVICE,,, ASPECTS THAT HAVE BEEN MENTIONED THIS WEEK IS SEVERAL PAPERS,
BUT WHICH NEED OUR CONTINUED ATTENTION, THE FIRST ASPECT COVERS THE
TIME AND THE CIRCUMSTANCES IN WHICH THE TRAUMA PATIENT IS FIRST EN-
COUNTERED BY THE EMERGENCY MEDICAL TEAM. THE SECOND ASPECT COVERS THE
PATIENT AFTER RELEASE FROM THE INSITITUTION, WHETHER FROM A HOSPITAL
OR TRAUMA CENTER,

  FIRST, I WANT TO ACKNOWLEDGE SOMETHING THAT HAS BEEN IMPLIED OVER
AND OVER AGAIN IN THIS CONFERENCE BUT OUGHT TO SAID OUTRIGHT AND WITH
GREAT CLARITY:  WE'VE MADE GREAT PROGRESS IN THIS COUNTRY IN DEVELOP-
ING NOT ONLY THE CONCEPT OF EMERGENCY MEDICAL SERVICE SYSTEMS, BUT
ALSO IN HAVING A LARGE NUMBER OF SUCH SYSTEMS IN PLACE AND WORKING,

  IN OUR ZEAL CONSTANTLY TO IMPROVE THE JOB WE DO, WE TEND TO OVER-
LOOK THE KIND OF STRONG BASE UPON WHICH WE WORK, THE AMERICAN PEOPLE
SUPPORT EMERGENCY MEDICAL CARE WITH THEIR DOLLARS, THEIR VOTES, AND


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THEIR TIME.  THEY CONTRIBUTE TO THE PURCHASE OF NEW EQUIPMENT, SUCH AS

AMBULANCES AND HELICOPTERS, NEW RESCUE SQUAD COMMUNICATIONS, AND THE

RISING COSTS OF HIRING GOOD PEOPLE. THERE ARE VERY FEW FAMILIES IN
THE UNITED STATES TODAY WHO HAVE NOT HAD A MEMBER'S LIFE SAVED -- OR

WHO DON'T KNOW OF SUCH AN EVENT.

  E.M.S. WORKS,  AND THE COUNTRY KNOWS IT WORKS, SO WHEN WE LOOK
CRITICALLY AT SOME ASPECTS OF EMERGENCY CARE -- SUCH AS THE CARE FOR

CHILDREN, FOR EXAMPLE -- I THINK WE DO SO 111. RESPONSE TO THE PUBLIC'S
DESIRE TO IMPROVE WHAT THEY ALREADY CONSIDER TO BE A BLESSING. AND IT

rs IN THAT SPIRIT THAT I WANT ~0 COI,~MENT 0N THAT VERY IMPORTANT

"PRE-HOSPITAL PHASE" OF EMERGENCY CARE.

  I MENTIONED A MOMENT AGO THE LARGE NUMBERS OF CHILDREN WHO ARE

INJURED AND ADMITTED TO EMERGENCY ROOMS FOR SOME KIND OF TREATMENT,

THE MOST RECENT FIGURES I HAVE INDICATE THAT, OF THE 11 MILLION
PERSONS TRANSPORTED BY EMERGENCY VEHICLES LAST YEAR, ABOUT 1 MILLroN

WERE CHILDREN UNDER THE AGE OF 14.  THESE CHILDREN NEED So% SPECIAL

UNDERSTANDING -- THEY CAN'T BE TREATED AS "LITTLE ADULTS," AS THIS

AUDIENCE KNOWS BETTER THAN MOST,  YET, THE SPECIAL NEEDS OF INJURED

CHILDREN ARE NOWHERE TO BE FOUND IN THE TRAINING GIVEN TO EMERGENCY

MEDICAL PERSONNEL.


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  WE DON'T KNOW TO WHAT AN EXTENT THIS LACK OF KNOWLEDGE HAS

CONTRIBUTED TO THE LOSS OF SOME CHILDREN SO FAR, MY INSTINCTS TELL ME

THAT IT HAS,  AND I DOUBT THAT WE NEED TO CARRY OUT ANY EXHAUSTIVE,

COSTLY, AND TIME-CONSUMING RESEARCH TO VERIFY SUCH AN OBVIOUS RESPONSE,

INSTEAD, I WOULD HOPE THAT THE SURGEONS OF THIS COUNTRY -- WORKING

ALONG WITH THE MANY OTHER PROFESSIONS AND DISCIPLINES CONCERNED WITH

THE QUALITY OF BOTH EMERGENCY MEDICINE AND PEDIATRIC MEDICINE -- WOULD

COME TOGETHER AND FOCUS ON THIS SPECIFIC AREA.  I THINK THE TRAINING

COULD BE ACCOMPLISHED QUITE HANDILY AND WOULD NOT POSE AN UNFAIR

BURDEN UPON OUR EMERGENCY MEDICAL PERSONNEL. ON THE CONTRARY, I THINK

SUCH PERSONNEL WOULD WELCOME THIS KIND OF ASSISTANCE,

  OF COURSE, ONE MIGHT WELL ASK, "WHO ARE WE -- THE SURGEONS OF

AMERICA -- THAT WE SHOULD CAST THE FIRST STONE?" YOU MAY RECALL THAT

THE 1976 EDIT1014 OF EARLY CARE OF THE INJURED PATIENT, PUBLISHED BY

OUR OWN AMERICAN COLLEGE OF SURGEONS, HAD ONE CHAPTER OUT OF 24

DEVOTED ~3 THE comor~ rrmRrEs 0F CHILDREN, BUT THE NEW i9z32 EDITION,

PRESUMABLY ENRICHED BY NEW INFORMATION AND UNDERSTANDING, HAS 25

CHAPTERS -- BUT NOTIE ON THE PROBLEMS OF INJURED CHILDREN, THE EARLIER

45-PAGE CHAPTER HAS BEEN REDUCED TO ABOUT THREE-QUARTERS OF A PAGE ON

HO'A TO HANDLE PEDIATRIC FRACTURES.


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  I THINK MORE OUGHT TO BE PUBLISHED ABOUT THE PROPER HANDLING OF

INJURED CHILDREN -- AND I THINK IT ALL SHOULD START RIGHT HERE WITH US,
WITH THE PEDIATRIC SURGEONS AND MEDICAL SPECIALISTS FOR WHOM THE
INJURED CHILD IS OUR REASON FOR BEING IN PRACTICE IN THE FIRST PLACE.

  ANOTHER AREA IN WHICH WE NEED MORE UNDERSTANDING AND TRAINING IS
IN THE PROBLEMS POSED BY THE INJURED CHILD'S FAMILY, WHEN WE SPEAK OF
THE "MANAGEMENT OF THE INJURED CHILD," WE SHOULD BE INCLUDING THE
SPECIAL KINDS OF CARE THAT NEED TO BE OFFERED TO THE CHILD'S FAMILY AS

WELL,

  THE EMERGENCY TECHNICIANS SEE THE CHILD IN MEDICAL TERMS.m'ITS
INJURIES ARE PHYSIOLOGICAL AND CAN BE ANATOMICALLY MAPPED AND ASSESSED
, . BAND THE COMMUNICATIONS QUICKLY TURN INTO A HIGHLY COMPRESSED MEDICAL

SHORTHAND.  ALL THAT IS GOOD,  PLEASE DON'T MISUNDERSTAND ME, BUT ALL

THATdS NOT ENOUGH.

  THERE HAS TO BE SOME BETTER WAY TO HANDLE THE HORROR AND THE SHOCK,
THE FEAR OF IMPENDING LOSS, THE POSSIBLE FEELINGS OF GUILT, AND THE
TERRIBLE CONFUSION FELT BY THE FAMILIES OF CHILDREN SUFFERING SERIOUS

PHYSICAL INJURY'


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  GRANTED, THERE IS VERY LITTLE TIME FOR CONVERSATION ON THE SITE OF

A SERIOUS ACCIDENT,

  GRANTED, WE DON'T ALWAYS KNOW THE FULL EXTENT OF THE CHILD'S

INJURIES AT THE FIRST ENCOUNTER,

  AND GRANTED, THE PRIMARY NEEDS TO BE ANSWERED ARE THOSE OF THE

CHILD, NOT OF PARENTS OR SIBLINGS, HOWEVER DISTRAUGHT THEY MAY BE.

BUT SRANTING ALL THAT, I STILL MAINTAIN THAT WE DO BOTH THE CHILD AND

ITS FAMILY A GREAT DISSERVICE, THE LONGER WE PUSH ASIDE THIS ASPECT OF

EMERGENCY PEDIATRIC SERVICE,  I WOULD CALL UPON OUR COLLEAGUES I/ THE

SOCIAL SERVICES, IN PSYCHOLOGY, AND IN PASTORAL COUNSELING TO HELP US

BETTER UNDERSTAND l/HAT WE MIGHT BE ABLE TO DO -- AND ENCOURAGE US TO

DO IT.

  THERE IS A THIRD AND -- IF YOU CAN IFIAGINE IT -- AN EVEN TOUCHIER

ASPECT OF THIS "PRE-ADMISSION PHASE" OF EMERGENCY AND I WANT TO TACKLE

IT HEAD-ON \IITH YOU THIS AFTERNOON,


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  FOR MANY YEARS IT HAS BEEN ALMOST A RULE OF THUMB THAT YOU WANT TO

WHISK THE INJURED PERSON TO THE MEDICAL FACILITY THAT IS CLOSEST TO

THE SCENE OF THE ACCIDENT, KEEPING TRANSPORT TIME TO A MINIMUM. AT
ONE TIME, NEARLY 10 YEARS AGO, THAT PROBABLY MADE GOOD SENSE, SINCE

MOST FACILITIES HAD ABOUT THE SAME UNDERSTANDING OF EMERGENCY MEDICINE
AND MOST, ALSO, HAD MADE ABOUT THE SAME MINIMUM COMMITMENT OF MONEY,

STAFF, AND EQUIPMENT,

  BUT TIMES HAVE CHANGED ..,WE KNOW A LOT MORE TODAY THAN WE DID 10

YEARS AGOwAND TODAY IT IS POSSIBLE TO IDENTIFY THOSE INSTITUTIONS

THAT ARE COMMITTED TO QUALITY EMERGENCY MEDICINE AND THOSE THAT ARE

NOT,  THE DIFFERENCE IS CRITICAL -- 1 MIGHT EVEN ADD, THE DIFFERENCE

CAN BE LIFE-SAVING.

  I HAD A RATHER NEGATIVE COMMENT ABOUT THE AMERICAN COLLEGE OF

SURGEONS BEFORE, REGARDING THE SHORT SHRIFT THEY GIVE TO CHILDREN IN

THEIR LATEST TEXT ON THE CARE OF IFIJURED PATIENT, HOWEVER, I WANT TO

CONGRATULATE THE COLLEGE AND ESPECIALLY ITS NATIONAL COMMITTEE 0N

TRAUMA FOR GOING AHEAD WITH THE "MAJOR TRAUMA OUTCOME STUDY," THERE

ARE MANY FASCINATING SIDES TO THIS STUDY AND I HOPE TO MENTION SOME OF

THEM,  BUT ONE PIECE OF INFORMATION ALREADY HIGHLIGHTED BY THE STUDY

OUGHT NOT TO BE IGNORED ANY LONGER,


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  DR. CHARLES FREY, VICE PRESIDENT FOR THE DEPARTMENT OF SURGERY AT

THE UNIVERSITY OF CALIFORNIA, DAVIS CAMPUS, SCHOOL OF MEDICINE, IS

CARRYING OUT THIS STUDY FOR THE NATIONAL COMMITTEE, HE'S WORKING HARD

IT AT FOR A NUMBER OF REASONS, NOT THE LEAST OF WHICH IS THIS

APPALLING STATISTIC: OF THE TOTAL NUMBER OF PATIENTS WITH MULTIPLE

INJURIES WHO DIED LAST YEAR IN THE COURSE OF RECEIVING EMERGENCY CARE,

FULLY 25 PERCENT OUGHT NOT TO HAVE DIED,  IN OTHER WORDS, 1 OUT OF 4

PATIENTS WITH MULTIPLE INJURIES RECEIVE INADEQUATE TREATMENT: GIVEN

THE NATURE OF THEIR INJURIES, THEY PROBABLY WOULD HAVE SURVIVED, HAD

THEY BEEN TAKEN TO A FACILITY EQUIPPPED -- AND COMMITTED -- TO

HANDLING THEM.'

  AT THE TI!lE OF THE PICKUP, THE EMERGENCY MEDICAL TEAM MAKES A

DECISION AS ~0 THE FACILITY ~0 HEAD FOR WITH THEIR INJURED PATIENT.  rr~

MANY CASES, THAT DEcIsroN 1s STILL BASED ore WHAT FACILITY IS CLOSEST.

IN SUBURBAN AND URBAN AREAS, HOWEVER, WE ARE BEGINNING TO SEE AN

INCREASE IN THE COMPETITION FOR EMERGENCY PATIENTS, HOSPITALS THAT

ARE EXPERIENCING A DROPPING BED CENSUS, ARE LOOKING TO THEIR EMERGENCY

ROOMS AS HELPING CORRECT THE DOWNWARD CURVE OF ADMISSIONS, BUT THOSE

SAME HOSPITALS, COMING LATE ~0 AN INTEREST IN TRAUMA CARE AND comG


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FOR THE WRONG REASONS, ARE NOT MAKING THE NECESSARY COMMITMENT TO

PROVIDE QUALITY EMERGENCY CARE.  I WOULD SUSPECT WE WOULD FIND THAT IT

rs rr~ THOSE HOSPITALS THAT THE UNNECESSARY DEATHS 0ccuR. THE

SUSPICION IS SO STRONG THAT #E WOULD BE TERRIBLY REMISS, IF WE DID NOT

GIVE THE SITUATION A THOROUGH REVIEW.

  THIS COMPETITION PHENOMENON IS NOW FURTHER COMPLICATING AND

ENDANGERING THE LIVES OF INJURED CHILDREN. FOR SOME TIME, ALL OF US

IN PEDIATRIC SURGERY HAVE PLEADED WITH HOSPITALS AND TRAUMA CENTERS TO

PAY MORE ATTENTION TO THE SPECIAL NEEDS OF INJURED CHILDREN, A GREAT

DEAL OF EFFORT HAS BEEN EXPENDED ON CERTAIN REGIONAL CHILDREN'S

HOSPITALS SO THAT THEY ARE THE DESTINATIONS OF CHOICE FOR MOST

EMERGENCY PEDIATRIC CASES,  BUT THIS NEW ELEMENT OF COMPETITION

FRANKLY GIVES ME AN UNEASY SENSE OF FOREBODING. THAT KIND OF

ADMINISTRATIVE ACTION CAN QUICKLY UNDO SO MUCH EXCELLENT WORK ON THE

MEDICAL SIDE -- THE KIND OF WORK SO CAREFULLY AND ELOQUENTLY DESCRIBE

IN THE PAPERS GIVEN AT THIS CONFERENCE,

:D

  THE "MAJOR TRAUMA OUTCOME STUDY" HAS SOME 77 HOSPITALS AROUND THE

COUNTRY SIGNED UP.  SEVENTEEN ARE PEDIATRIC MEDICAL CENTERS, MANY OF


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THEM ARE BEGINNING TO DELIVER PATIENT CARE DATA TO THE STUDY'S
COMPUTER TEAM HEADQUARTERED IN WASHINGTON, D,C, EVENTUALLY THE STUDY
SHOULD HAVE A DATA BASE THAT WILL CONTAIN THE NATURE OF THE TRAUMA, AN

ANALYSIS OF ITS MANAGEMENT, AND THE OUTCOME FOR EACH OF 20,000

PATIENTS.  THAT IS LARGER THAN A "STATISTICALLY VALID SAMPLE" HAS TO

BE,  I THINK THE INFORMATION COULD BE VERY SIGNIFICANT IN HELPING US
SHAPE THE FUTURE COURSE OF TRAUMA CARE IN THIS COUNTRY,

  THIS "MAJOR TRAUMA OUTCOME STUDY," BY THE WAY, IS NOT FEDERALLY

FUNDED,  IN FACT, THE PARTICIPATING HOSPITALS RECEIVE NO MONEY AT
ALL. QUITE THE REVERSE, IT IS COSTING THEM MONEY TO TAKE PART AND I
CONGRATULATE EVERY ONE OF THE 77 THAT HAS SIGNED ON. AND RIGHT HERE I
WOULD LIKE TO GIVE RECOGNITION TO THE CO-HOST OF THIS LECTURESHIP,
HERMANN HOSPITAL, FOR BEING AMONG THOSE 77, ALONG WITH HOUSTON'S BEN

TAUB GENERAL HOSPITAL,

  THIS KIND OF NATIONAL EFFORT IS NEEDED IN MANY AREAS OF TRAUMA

CARE,  WE STILL HAVE A LOT TO LEARN,  WE MAY HAVE TO INVEST MORE THAN
WE ANTICIPATE IN ORDER TO GAIN THAT NElJ, LIFE-SAVING KNOWLEDGE, BUT I
AM CERTAIN THAT SUCH AN INVESTMENT WILL REPAY ENORMOUS DIVIDENDS TO


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OUR SOCIETY,  IN ORDER TO HAVE THAT HAPPEN, WE u NEED TO BE AWARE OF
\/HAT OUR NATION'S RESEARCH AND SERVICE PRIORITIES ARE AND WE &f= NEED
TO TAKE PART IN THE PROCESSES THAT WEIGHT THEM, JUDGE THEM, AND CHANGE

THEM.,, IF THAT'S WHAT IS NEEDED,

  I SUSPECT WE WILL EVENTUALLY RECEIVE SEVERAL IMPORTANT AIDS FROM
THE COLLEGE OF SURGEONS' STUDY, AT THE VERY LEAST, WE MIGHT FINALLY
GET A HANDLE ON SOME FAIRLY SIMPLE,,,STANDARD,,,YET RELIABLE WAY TO
QUICKLY EVALUATE THE GRAVITY OF A PATIENT'S CONDITION AT THE TIME OF

PICKUP,

  DR. FREY AND THE COMMITTEE ON TRAUMA HAVE BEEN WORKING ON JUST
SUCH AN `WIJURY SEVERITY SCORE" WHICH SEEMS TO HOLD SOME PROMISE. THE

GLASGOW COMA SCALE HAS BEEN USEFUL.  THERE ARE ONE OR TWO OTHERS THAT
HAVE BEEN USED OVER TIFIE, ALSO, SUCH AS THE "FINGERNAIL TEST" THAT

DEMONSTRATES CAPILLARY REFILL.  WE MUST BE CAREFUL, HOWEVER, THAT WE

NOT 2IN ALL OUR HOPES ON SUCH THINGS. THE BASIC INSTINCTS OF
EMERGENCY PERSONNEL ARE ALL GEARED TO ACTIOPI,. .TO DO SOMETHING,, ,TO
GET THE PATIENT QUICKLY TO A TREATMENT FACILITY,. ,AfjD, TO BE QUITE
CAi'jDID, IF ANY OF US HAS THE POOR LUCK TO BECOME A PATIENT, I WOULD


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3ET THAT WE WOULD WANT THE SAME THING: WE'D WANT SOME ACTION, SOME

MOVEMENT, SOME INDICATION AS SIMPLE AS A CHANGE OF SCENERY

THAT WE'RE "BEING TAKEN CARE OF JUST AS QUICKLY AS POSSIBLE,"

  BUT HAVING NOTED THAT CAVEAT, I STILL BELIEVE THE DEVELOPMENT OF

SOMETHING LIKE AN "INJURY SEVERITY SCORE" WOULD BE A VERY GOOD THING,

  WE ALSO NEED A GREAT DEAL MORE ATTENTION PAID TO HOW WE ORGANIZE

THE DIAGNOSTIC AND TREATMENT PERSONNEL WHO TAKE OVER FROM THE
EflERGENCY MEDICAL TECHNICIANS,  A GOOD MODEL SEEMS TO BE THE MULTI-

DISCIPLINARY ORGAtU.ZATIOl'~ OF BURN CENTER TEAflS, I CJOULD CONSIDER IT A

MAJOR STEP FORWARD, IF EVERY TRAUMA CENTER \/AS INDEED ORGANIZED ON A

f.luLTr-DISCIPLINARY TEAM BASIS, WITH A GENERAL SURGEON rr~ CHARGE -- r10T

A SURGEON GENERAL BUT A GENERAL SURGEON -- SOFIEONE WHO HAS THE HEALTH

OF THE WHOLE CHILD AS HIS OR HER MAJOR RESPONSIBILITY AND CAN ASSESS

WHAT OUGHT TO BE DONE -- AND HOW WELL THINGS ARE DONE -- BASED ON THE

CHILD'S OVERALL WELL-BEING.

  I HAVE NO INTEFiTION OF DISPARAGING THE SURGICAL SPECIALTIES, FAR

FROM IT,  NEVERTHELESS, CHILDREN DON'T LIVE ACCORDING TO VERTICAL

MEDICAL SPECIALTIES ,,.THEY ARE GENERALLY NOT INJURED 0NLy BY SPECIALTY


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AREA,..AND WE KNOW THEY DO NOT RECOVER ON A SPECIALTY-BY-SPECIALTY

BASIS,  HENCE, I WOULD ENCOURAGE THE DEVELOPMENT OF THE TEAM APPROACH,

WITH PRIMARY RESPONSIBILITY RESTING IN THE HANDS OF A GENERALIST.

  BUT I DON'T WANT TO DWELL ON THESE MATTERS, SINCE THEY A@ PART OF
THE IN-HOSPITAL PHASE,  INSTEAD, I WANT TO MOVE ON AND FOCUS 'SOME

ATTENTION ON THE PROBLEMS OF THE POST-HOSPITAL PHASE OF CARE FOR THE

INJURED CHILD.

  FIRST, LET ME SAY THAT WE HAVE THE PROBLEM OF HOSPITAL COMPETITION
IN THIS PROBLEM, ALSO. THERE IS THE TEMPTATION FOR A HOSPITAL WITH LOW

BED CENSUS -- PARTICULARLY A HOSPITAL IN AN OVER-BEDDED SUBURBAN OR

URBAN SETTING -- TO HANG ON TO INJURY PATIENTS FOR A LITTLE MORE TIME

THAN MIGHT BE EXPECTED IN THE NORMAL ROUTINE OF CARE. THAT TEMPTATION

MUST BE ERASED.  I DON'T WANT TO SAY ANYTHING ELSE ON THIS MATTER, BUT

I DO FEEL IT NECESSARY TO AT LEAST ACKNOWLEDGE THAT THIS KIND OF THING

CAN OCCUR AND THAT WE MUST EXERCISE OUR PROFESSIONAL RESPONSIBILITY TO

SEE THAT IT DOESN'T.

  BUT WE ALSO NEED TO MAKE SURE THAT PATIENTS ARE DISCHARGED INTO A

HOME-CARE SITUATION THAT WORKS, AND THAT TAKES SOME THOUGHT AND

ORGANIZATION, ALSO'


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  LET ME SAY THAT I HAVE HAD TO WORK THROUGH MY OWN THINKING ON THIS
MATTER TWICE BEFORE, IN THE SPACE OF LESS THAN THREE MONTHS; IN

MID-DECEMBER I BROUGHT TOGETHER A NUMBER OF NATIONALLY RECOGNIZED
EXPERTS -IN A "SURGEON GENERAL'S CONFERENCE ON CHILDREN WITH HANDICAPS

AND THEIR FAMILIES."  IT WAS A VERY EXCITING AND REWARDING EXPERIENCE.
                                                                           ..I

I'VE BROUGHT ALONG A STACK OF COPIES OF THE REPORT OF THAT CONFERENCE

BECAUSE I BELIEVE MANY OF THE SUBJECTS WE DISCUSSED BACK IN DECEMBER

BEAR DIRECTLY ON THE KINDS OF SUBJECTS WE'RE TALKING ABOUT TODAY,

ESPECIALLY IN THIS MATTER OF HOME CARE,

  AGAIN, JUST THREE WEEKS AGO, I ADDRESSED THE SEVENTH CLINICAL

CONGRESS OF THE AMERICAN SOCIETY OF PARENTERAL AND ENTERAL NUTRITION

AND THERE, AGAIN, THE ISSUE OF HOME CARE CONSUMED A GREAT DEAL OF TIME

AND INTEREST, THE ISSUE IS COMPLICATED BY SEVERAL FACTORS THAT NEED

TO BE SORTED OUT FOR EXAMINATION, LET ME TAKE SEVERAL OF THEM IN

ORDER.

  FIRST, WE NEED TO ACCEPT THAT FACT THAT PEOPLE HAVE A GENERALLY

LOW LEVEL OF FAMILIARITY WITH THE KINDS OF SUPPORT SERVICES THAT ARE

-- OR ARE NOT -- AVAILABLE OUT IN THEIR COMMUNITY, PEOPLE LIKE US --

SURGEONS, PHYSICIANS, NURSES, AND TECHNICIANS WHO WORK IN HOSPITALS OR


                      -2O-

TRAUMA CENTERS -- ARE USUALLY FAMILIAR WITH MOST OF THE COMMUNITY
SERVICES NETWORK AND VERY OFTEN WE ASSUME THAT EVERYONE ELSE HAS THE
SAME INFORMATION, BUT MOST PEOPLE DO NOT.

  THEY MAY, ON OCCASION, HAVE USED ONE OR ANOTHER SOCIAL SERVICE OR
HEALTH AGENCY OR THEY MAY EVEN HAVE REGULARLY CONTRIBUTED TO'CERTAIN

ORGANIZATIONS CONCERNED WITH A PARTICULAR DISEASE OR DISABILITY, BUT

WHEN FACED WITH THE IMMEDIATE NEED TO GET INFORMATION, APPLY FOR HELP,
REQUEST CERTAIN RESOURCES, MAKE CONNECTIONSf MAKE DECISIONS -- MUCH OF
THEIR PAST EXPERIENCE AND KNOWLEDGE BECOMES SOMEHOW DISJUNCTIVE, THEY

CAN EASILY BECOME OVERWHELMED BY THE OFTEN BYZANTINE COMPLEXITY OF OUR

SOCIAL SERVICE DELIVERY SYSTEM,  TIRED AND CONFUSED, THEY GIVE UP

TRYING TO GET HELP.

  IN MY PREVIOUS ROLE AS A PEDIATRIC SURGEON, I FREQUENTLY WORKED
SIDE-BY-SIDE WITH PARENTS, NEGOTIATING HELP FROM A WIDE NETWORK OF
PRIVATE, PUBLIC, FREE, AND FEE-FOR-SERVICE PROVIDERS. BUT IT IS NOT A

SURGEON'S ROLE.  FRANKLY, SURGEONS ARE REALLY NOT VERY GOOD AT IT NOR

ARE MOST PHYSICIANS, I AM SORRY TO SAY.   AT BEST THEY MAY ONLY HAVE A
SENSE THAT THERE Is SOME HELP OUT THERE, THE TRUTH OF THE MATTER IF


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THAT MOST COMMUNITIES ARE VERY RICH IN GRASS-ROOTS SERVICE AGENCIES OF

EVERY KIND. THERE MAY BE SOME OVERLAP AND THERE MAY BE SOME GAPS,

AND SOMETIMES IT CAN BE QUITE DIFFICULT TO LAY OUT ALL THE SERVICES

AMD THEIR RELATIONSHIPS ON A NEAT CHART, BUT HELP OF SOME KIND IS

USUALLY AVAILABLE"' IT IS USUALLY CAPABLE HELPmAND IT IS ALJIOST
ALWAYS DISPENSED WITH A GENEROSITY OF SPIRIT AND COMPASSION.-'

  OUR FIRST TASK, THEN, IN THIS POST-HOSPITAL PHASE OF EMERGENCY

CARE, IS TO MAKE SURE THAT OUR PATIENTS AND THEIR FAMILIES ARE

TOGETHER AGAIN AT HOME AS SOON AS POSSIBLE AND THAT THEY HAVE HELP

AVAILABLE TO THEM TO MAKE THIS HOME-CARE PHASE WORK,

  A SECOND TASK IS IN REALITY A CAREFUL QUALIFICATION OF THE FIRST.

I AM NOT "WAFFLING"., ,I AM QUALIFYING.  IN THE PROCESS OF DISCHARGING

OUR INJURED CHILDREN TO THE CARE OF THEIR FAMILIES, WE MUST NOT

UNWITTINGLY "ORPHAN" THEM FROM THE MEDICAL CARE SYSTEM, WE NEED TO

INSURE SOME METHOD OF STAYING IN TOUCH, SO THAT WE HAVE SOME BASIS OF

KNOWING HOW WELL WE'RE DOING.  UNFORTUNATELY, THE AVAILABLE MORTALITY

DATA WILL TELL US HOW POORLY WE'RE DOING. AND AN AUTOPSY REPORT --

MATCHED AGAINST THE RECORD OF THE MANAGEMENT OF THE DECEASED PATIENT --

WILL TELL US GREAT DEAL ABOUT THE EFFECTIVENESS OF OUR IN-PATIENT CARE.


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  BUT A SIMPLE, ROUTINE, BUT CONSISTENT METHOD OF FOLLOW-UP OF

PATIENTS WHO GO HOME WILL PROVIDE US WITH THE OTHER KIND OF RECORD --
THE ONE THAT REVEALS HOW WELL WE'RE DOING AND THE KINDS OF THINGS WE

OUGHT TO KEEP ON DOING. AS OUR DISCHARGE SYSTEM NOW STANDS, WE TEND

TO LOSE A GREAT DEAL OF VALUABLE MEDICAL INFORMATION FROM OUR

"ORPHANS," THE CHILDREN WHO'VE DONE WELL AND HAVE BEEN SENT HOME.

  THE THIRD AND LAST TASK IN THIS POST-HOSPITAL PHASE INVOLVES THE
USE OF THE NEW TECHNOLOGIES THAT MAKE HOME CARE POSSIBLE, THE
TECHNOLOGY FOR HOME CARE MUST REPRESENT A CONSIDERABLE COST SAVING

OVER IN-PATIENT CARE, WITH NO LOSS OF EFFECTIVENESS, IN OTHER WORDS,

WE MUST NOT COMPROMISE THE EFFECTIVENESS OF OUR MEDICAL CARE IN THE

NAME OF ECONOMY, THAT IS A TRAP THAT CAN BE FATAL BOTH TO OUR

PATIENTS AND TO THE PRACTICE OF GOOD MEDICINE.

  BUT SUCH AN ARGUMENT CANNOT BE USED AS A SHIELD BEHIND WHICH WE

OVER-DESIGN AND INFLATE THE TECHNOLOGY OF HOME CARE, I MAKE THIS

POINT BECAUSE A NUMBER OF PHYSICIANS FOR WHOM I HAVE GREAT RESPECT

HAVE ALREADY RAISED THIS ISSUE WITH ME, HOME HEALTH CARE IS A NEW AND

POTENTIALLY LUCRATIVE FIELD FOR THE IMAGINATIVE AND AGGRESSIVE

ENTREPRENEUR, THE GOVERNMENT AND OTHER THIRD-PARTY PAYORS ARE ALL


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INTERESTED IN HOME HEALTH CARE AS HAVING THE POTENTIAL OF BEING A
LOW-COST, MEDICALLY EFFECTIVE WAY TO DELIVER MEDICAL SERVICE TO A

PATIENT.  BUT THAT POTENTIAL CAN QUICKLY DISAPPEAR, UNDER THE PRESSURE

OF CERTAIN FORCES IN THE PRIVATE SECTOR THAT WOULD REPLACE THE HIGH

INCOMES ONCE FREELY AVAILABLE FROM TRADITIONAL HOSPITALIZATION WITH A
NEW SCHEDULE OF INFLATED FEES AND REIMBURSEMENTS FROM HOME-CARE

TECHNOLOGY.

  I'VE TOUCHED ON A NUMBER OF ISSUES THIS.AFTERNOON THAT I FEEL NEED

OUR CONSTANT ATTENTION, WE NEED TO DO A BETTER JOB PREPARING OUR

EMERGENCY MEDICAL PERSONNEL TO HANDLE INJURED CHILDREN AND TO MAKE THE

BEST POSSIBLE ASSESSMENTS AND JUDGMENTS AT THE MOMENT OF PICKUP, AND

WE NEED TO FOCUS MORE OF OUR ATTENTION AT THE PROBLEMS TO BE FACED BY

THE CHILDREN AND THEIR FAMILIES FOLLOWING DISCHARGE FROM OUR HOSPITALS

AND TRAUMA CENTERS,

  AND THESE ARE JUST A FEW OF THE ISSUES THAT MAKE THIS ENTIRE FIELD

SUCH A RICH FIELD FOR RESEARCH AND SERVICE,  IT HAS LONG BEEN MY

CONTENTION THAT WE OUGHT TO MOBILIZE OUR PROFESSIONS AND THE PUBLIC TO

ATTACK THE PROBLEMS OF TRAUMA -- PARTICULAR TRAUMA TO CHILDREN -- IN

THE SAME WAY WE ATTACKED THE INFECTIOUS DISEASES OF CHILDHOOD. THANKS


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TO AN EXTRAORDINARY, RECENT HISTORY OF VACCINE DEVELOPMENT AND MASS

CHILD IMMUNIZATIONS, WE ARE SEEING RECORD LOW NUMBERS OF MANY OF THE

MOST COMMON CHILDHOOD DISEASES,  POLIO HAS VIRTUALLY DISAPPEARED AND WE

ARE ON THE BRINK OF ANNOUNCING THE END OF INDIGENOUS MEASLES IN THE

UNITED STATES,

  THESE GREAT ACCOMPLISHMENTS IN CHILD HEALTH ARE THE RESULT OF THE

COLLECTIVE PROFESSIONAL AND PUBLIC WILL, AND WE MAY WELL NEED THE

SAME KIND OF TOTAL NATIONAL COMMITMENT TO TRAUMA, IF WE HOPE TO SEE

ANY REAL DECLINE IN THE MORTALITY AND MORBIDITY FIGURES ASSOCIATED

WITH THE INJURIES OF CHILDREN,

  CERTAINLY THE EXAMPLE OF DR, ROBERT E. GROSS AND THE ATTENTION
BEING SHOWN BY EVERYONE AT,THIS CONFERENCE CAN ONLY HELP TO CAPTURE
THE NATION'S INTEREST.  I, FOR ONE, AM HONORED TO HAVE BEEN ASKED TO

TAKE PART AND I THANK YOU AGAIN FOR YOUR INVITATION.

THANK YOU,

#I####