…but they’re CHILDREN!

Does the total separation of paediatrics from adult services cause more harm than good?

Many years ago when I was training I was working on an adult trauma intensive care unit and we had an adult sized patient admitted with multiple injuries.  Everyone assumed she was in her late teens or early twenties, she received good care and after initial resuscitation and operation was brought to the intensive care unit. She continued to receive excellent care by nurses and doctors experienced in dealing with trauma patients and although still unstable was showing signs of improvement and the outlook was good.
Then her identity was established and it turned out she was 15 years old. Although her care didn’t change at all, suddenly the senior management became involved, the atmosphere changed, everyone became nervous, and there were rumours that she should be transferred to a paediatric intensive care unit. Many of us felt it made no sense to subject a critically ill patient to a transfer to a unit that doesn’t deal with trauma just because she was a few months away from official adulthood. She was adult sized, had an adult disease process, and was doing adult things when the accident happened.

Despite our protests she did get transferred. The transfer was thankfully uneventful and she continued to improve. No harm was done, but I have never forgotten how protocol and policies were victorious over common sense and the best interests of the patient.

Over the last twenty years paediatrics has separated in the main from adult services.  I have no problem with that in general, children mostly get an excellent service from the NHS and so much is done to make their hospital visit as pleasant as possible.  

In emergency care, however – particularly surgery and trauma – I feel that separating the care of children from adults can lead to increased risk and delays. Trauma is extremely rare in children, and most of the expertise in trauma care lies in the adult units.  That fact that they are “paediatric” is often prioritised over the fact that they have a time-critical illness that needs urgent surgical care.  Conditions that come to mind also include appendicitis, testicular torsion, head injuries and acute bleeding. 

Making the clinical decision that it is in the child’s best interest to be treated immediately rather than following policy and transferring is a difficult  but crucial one. Paediatric services are already outstanding in the UK, blurring the borders a little would make them even better.