The American Journal of Surgery (2015) 210, 1063-1069

Southwestern Surgical Congress

Pediatric trauma system models: do systems using adult trauma surgeons exclusively compare favorably with those using pediatric surgeons after initial resuscitation with an adult trauma surgeon? P. J. Stiles, M.D.a, Stephen D. Helmer, Ph.D.a,b, Jeanette G. Ward, M.S.C.R.c, Jared Reyes, M.Ed.a, Paul B. Harrison, M.D.d, James M. Haan, M.D.a,c,* a

Department of Surgery, The University of Kansas School of Medicine – Wichita, 929 N. Saint Francis St., Room 3082, Wichita, KS 67214, USA; bDepartment of Medical Education, Via Christi Hospital Saint Francis, 929 N. Saint Francis St., Room 3082, Wichita, KS, USA; cDepartment of Trauma Services, Via Christi Hospital Saint Francis, 929 N. Saint Francis St., Room 2514, Wichita, KS 67214, USA; d Department of Trauma Services, Wesley Medical Center, 550 N. Hillside, Wichita, KS 67214, USA KEYWORDS: Pediatric trauma surgeons; Adult trauma surgeons; Trauma systems; Outcomes

Abstract BACKGROUND: A shortage of pediatric surgeons exists. The purpose of this study was to evaluate pediatric outcomes using pediatric surgeons vs adult trauma surgeons. METHODS: A review was conducted at 2 level II pediatric trauma centers. Center I provides 24-hour in-house trauma surgeons for resuscitations, with patient hand-off to a pediatric surgery service. Center II provides 24-hour in-house senior surgical resident coverage with an on-call trauma surgeon. Data on demographics, resource utilization, and outcomes were collected. RESULTS: Center I patients were more severely injured (injury severity score 5 8.3 vs 6.2; Glasgow coma scale score 5 13.7 vs 14.3). Center I patients were more often admitted to the intensive care unit (52.2% vs 33.5%) and more often mechanically ventilated (12.9% vs 7.7%), with longer hospital length of stay (2.8 vs 2.3 days). However, mortality was not different between Center I and II (3.1% vs 2.4%). By logistic regression analyses, the only variables predictive of mortality were injury severity score and Glasgow coma scale score. CONCLUSION: As it appears that trauma surgeons’ outcomes compare favorably with those of pediatric surgeons, utilizing adult trauma surgeons may help alleviate shortages in pediatric surgeon coverage. Ó 2015 Elsevier Inc. All rights reserved.

The authors declare no conflicts of interest. Presented at the 67th Annual Meeting of the Southwestern Surgical Congress, April 26–29, 2015, Monterey, California. * Corresponding author. Tel.: 11-316-268-5538; fax: 11-316-291-7892. E-mail address: [email protected] Manuscript received April 14, 2015; revised manuscript August 20, 2015 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2015.08.005

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There is a misallocation of, and overall shortage of, pediatric surgeons in the United States.1 The vast majority of the pediatric surgery workforce practice in major metropolitan areas, leaving smaller communities underserved.1 Also, there are many more adult surgeons in practice compared with pediatric surgeons. As an example, in 2011 the state of Kansas had .74 pediatric surgeons per 100,000 residents compared with 42 surgeons of any kind per 100,000 residents.2 Thus, many communities that are short on fellowship trained pediatric surgeons use adult surgeons to care for pediatric patients.1 Recent studies have suggested that using adult general surgeons to care for pediatric patients may not result in optimal care given the lower number of pediatric cases being performed by general surgery trainees.3 However, the American College of Surgeons (ACS) Committee on Trauma, the society charged with verifying pediatric trauma centers, recognizes that in some communities pediatric resources may be scarce. In those communities, ‘‘adult trauma centers, of necessity, may serve as the primary pediatric resource for the region and therefore may need to provide care for injured children.’’4 In 2012, there were only 35 level I pediatric trauma centers in the United States, and 32 level II centers.5 To our knowledge, no study has directly compared pediatric surgeons with adult trauma surgeons in the care of pediatric trauma patients postresuscitation. Our primary

Table 1

objective was to first determine if the likelihood of mortality among the pediatric population is negatively affected by the use of adult trauma surgeons for postresuscitative care as compared with pediatric surgeons for postresuscitative care. Secondarily, we sought to determine if mortality among pediatric trauma patients could be predicted by variables available on presentation to the trauma center.

Methods Patients and setting A retrospective review was conducted at 2 geographically similar ACS-verified trauma centers. The trauma centers are both adult level I and pediatric level II centers, and are geographically only 2 miles apart. The trauma centers serve the same catchment area: northern Oklahoma and the majority of Kansas excluding the northeast corner of the state. Both hospitals are similar in size, availability of resources, and see a similar volume of pediatric patients. They also share some of the same pediatric surgical subspecialists including pediatric orthopedic surgeons and pediatric neurosurgeons. They differ, however, in type and structure of pediatric surgical coverage for their respective trauma centers. Center I

Comparison of patient demographics, admission characteristics, and injury severity Adult trauma service

Pediatric trauma service

Parameter*

N

Value

N

Value

P value

Number Age (years) Male sex Race (Caucasian) Uninsured Transfer patient Mechanism Blunt mechanism Penetrating mechanism Drowning/burn Mean systolic blood pressure (mm Hg) Systolic blood pressure ,90 mm Hg Heart rate Respiratory rate Temperature Oxygen saturation ISS ISS group %15 16 to 24 R25 GCS score GCS score %8

465 465 465 465 465 464

47.5% 8.1 6 5.7 304 (65.4%) 336 (72.3%) 77 (16.6%) 197 (42.5%)

514 514 514 514 506 514

52.5% 7.6 6 5.8 310 (60.3%) 460 (89.5%) 14 (2.8%) 229 (42.5%)



465 465 465 444 444 463 462 451 461 465

448 (96.3%) 12 (2.6%) 5 (1.1%) 120.0 6 21.7 21 (4.7%) 110.5 6 29.9 22.9 6 9.1 98.5 6 1.0 98.6 6 2.0 6.2 6 7.2

514 514 514 504 504 514 512 506 510 512

467 (90.9%) 29 (5.6%) 18 (3.5%) 117.5 6 21.2 37 (7.3%) 112.2 6 31.6 21.7 6 9.0 98.2 6 1.2 98.2 6 3.3 8.3 6 8.3

441 441 441 464 464

407 (92.3%) 15 (3.4%) 19 (4.3%) 14.3 6 2.5 26 (5.6%)

499 499 499 501 501

421 (84.4%) 41 (8.2%) 37 (7.4%) 13.7 6 3.5 51 (10.2%)

GCS 5 Glasgow coma scale; ISS 5 injury severity score. *Data are presented as mean 6 standard deviation or number (percent).

.176 .102 ,.001 ,.001 .509 .006

.078 .094 .396 .037 ,.001 .169 ,.001 ,.001

,.001 .009

P.J. Stiles et al. Table 2

A comparison of two pediatric trauma care models

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Comparison of resource utilization, hospital length of stay, and mortality Adult trauma service

Pediatric trauma service

Parameter*

N

Value

N

Value

P value

Ultrasonography Positive ultrasound Blood product used CT scan ICU admission ICU stay (days) Mechanical ventilation Ventilator days Hospital stay (days) Death

465 422 465 465 465 174 435 30 465 465

422 (90.8%) 6 (1.4%) 13 (2.8%) 189 (40.6%) 174 (37.4%) 2.4 6 3.5 30 (6.5%) 4.0 6 4.4 2.3 6 4.6 11 (2.4%)

514 319 514 514 514 243 514 56 514 514

319 (62.1%) 25 (7.8%) 16 (3.1%) 230 (44.7%) 243 (47.3%) 2.3 6 2.6 56 (10.9%) 3.7 6 4.2 2.8 6 4.4 16 (3.1%)

,.001 ,.001 .770 .195 .002 .838 .014 .728† ,.001† .476‡

CT 5 computed tomography; ICU 5 intensive care unit. *Data are presented as mean 6 standard deviation or number (percent). † Equal variances between groups not assumed. ‡ Includes patients that presented in full arrest (SBP 5 0).

(pediatric center) provides pediatric trauma coverage through the use of 24-hour, in-house trauma surgeons with mid-level support to resuscitate pediatric patients and then handoff patients to a pediatric surgery service for all operative and nonoperative management. Center II (adult center) provides 24-hour, in-house senior surgical resident coverage with an on-call trauma surgeon no more than 15 minutes away. The training level of the trauma surgeons at both centers is comparable with approximately 50% of the surgeons at each center having board certification in critical care or were grandfathered in. None of the pediatric surgeons from Center I were specifically trained in trauma or critical care. All operative and nonoperative management in Center II is provided by adult trauma surgeons with resident support, with a pediatric surgeon available for specific consultation.

Data collection All pediatric trauma activations resulting from any injury mechanism in patients 17 years of age or younger between May 1, 2011 and June 30, 2013 were identified. Patient data were retrieved from the 2 hospital’s trauma registries, as well as from patient medical records. Data collected included patient demographics: age, sex, race, insurance status, and transferred from outside hospital or not. Injury data were also collected and included: mechanism of injury, injury severity (injury severity score [ISS] and Glasgow coma scale [GCS] score), and initial vitals. Treatment and outcome data recorded included the following: imaging utilization (ultrasonography and computed tomography scan), blood product utilization, intensive care unit (ICU) and ventilator utilization, hospital length of stay (LOS), and mortality. This study was approved for implementation by the Institutional Review Boards of Via Christi Hospitals Wichita, Inc and Wesley Medical Center.

Analysis Comparisons of continuous and categorical data were conducted using one-way analysis of variance and chisquare analysis, respectively. Univariate analyses were first conducted using all available observations, then secondary analyses were conducted after excluding patients that arrived in full arrest (pediatric center 5 3, adult center 5 3). All statistical tests were 2 sided and analyses were considered significant when the resultant P value was less than .05. All analyses, except where noted, were conducted using SPSS release 19.0 (IBM Corp., Somers, NY). Multivariable analysis was conducted using a complete case analysis. To account for limitations imposed by using a complete case analysis, we followed methods suggested by Van Ness et al.6 These methods allow investigators to screen for violations of collinearity, multicollinearity, and missingness, while choosing the most reliable covariates for use in regression models. A forward selection method for logistic regression, using the Wald c2 statistic as the criterion, was conducted sequentially until all variables that reliably contribute to predicting mortality were included in the final model. The resulting logistic regression model was internally validated using bootstrapping procedures on 1,000 random resamples from our own sample. Bootstrapping procedures were conducted using SPSS release 22.0 (IBM Corp.). Confidence intervals (CIs) for variables in the model were adjusted to reflect a more robust estimate of parameter values. The logistic regression model was evaluated for accuracy using a receiver operating characteristics curve. The accuracy of the model for predicting mortality from trauma in a pediatric population was determined by the area under the curve (AUC); models that are more accurate will have greater AUC values. It is accepted that models having AUC values greater than .85 are considered good prediction models for the response variable in question.

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Table 3

Logistic regression analysis of mortality in pediatric patients as a function of 3 trauma variables 95% CI (bootstrapped)

Variable

B

Wald chi-square

Odds ratio

Lower

Upper

P value

GCS , 9 ISS Pediatric surgical service Constant

2.35 2.56 2.60 27.03

10.65 21.46 .94 46.10

10.50 12.92 .55

1.02 1.44 22.19

18.01 16.93 .90

.001 ,.001 .332 ,.001

CI 5 confidence interval; GCS 5 Glasgow coma scale score; ISS 5 injury severity score grouped as mild (,16), moderate (16 to 24), and severe (R25).

Results Univariate analyses A between-center comparison of patient demographics and variables available on presentation to the hospital for all available patients (n 5 979) is displayed in Table 1. Patients presenting to the pediatric trauma service were more severely injured as evidenced by higher ISS and lower GCS, and with more patients presenting with penetrating injury. Comparisons of resource use, LOS, and mortality are shown in Table 2. Patients from the pediatric trauma center underwent ultrasonography less often, but with a higher proportion with positive ultrasound findings. They also were more often admitted to the ICU and were more often mechanically ventilated. Hospital LOS was increased in the pediatric center patients, while ICU LOS and

Figure 1

ventilator days were not different between centers. In the overall population of patients, mortality was not different between centers (3.1% vs 2.4%, P 5 .476). Three patients from the adult trauma center and 3 from the pediatric center arrived at the hospital in full arrest. After excluding these patients from analyses, mortality between trauma centers was not significantly different (2.6% vs 1.8%, P 5 .418; data not shown).

Logistic regression We conducted sequential logistic regression with 12 covariates likely to be available when a patient enters trauma activation. These covariates were age, presence of shock (systolic blood pressure , 90 mm Hg), sex, type of insurance, race (coded as white or nonwhite for analysis), heart rate, respiratory rate, temperature, GCS score

Response operating characteristic curve for model accuracy in predicting mortality from calculated probabilities.

P.J. Stiles et al.

A comparison of two pediatric trauma care models

(grouped as ,9 or R9), ISS (grouped as ,16, 16 to 24, and R25), and mechanism of injury (drowning, burn, penetrating, or blunt trauma). Heart rate, respiratory rate, and drowning were eliminated from the model because of collinearity. Insurance, race, penetrating injury, and burn injuries were removed from consideration because they did not reliably predict mortality (P . .2) in a bivariate model before further consideration in a multivariable model. During the sequential selection process, the covariates temperature, shock, blunt trauma, age, and sex did not enter the model because of an associated Wald c2 less than 2.00, and P ..05, or both. The final model included 930 observations with 909 survivors and 21 nonsurvivors. The final model with pediatric surgical service as the predictor and GCS less than 9 and ISS as covariates of mortality was statistically significant (c2 5 118.3, P , .001, n 5 930), indicating that the variables as a set significantly distinguished between pediatric trauma survivors and nonsurvivors. However, the presence of a pediatric trauma service was not statistically significant when considered with covariates. Table 3 shows regression coefficients, Wald statistics, odds ratios, and the bootstrapped 95% CIs for odds ratios for each of the covariates and the predictor variable. A response operating characteristic curve (Fig. 1) was plotted using the predicted probabilities of mortality derived from our logistic regression model. The AUC was statistically significant (AUC 5 .981, 95% CI .970 to .993, P , .001), indicating a good fit between predicted group membership and actual group membership.

Comments Our study demonstrates that a system using adult trauma surgeons for postresuscitative care results in equivalent outcomes and care when compared with a system using fellowship-trained pediatric surgeons to care for pediatric trauma patients in the postresuscitative setting. To the best of our knowledge, this is the first study directly comparing the outcomes of trauma systems using adult vs pediatric surgeons in this setting. Previous studies have compared pediatric trauma centers, housed within a pediatric hospital, vs adult trauma centers with regard to both outcomes and the care delivered. The results of those studies are variable, with some studies showing improved outcomes when pediatric patients are treated at pediatric centers,7–9 others show no difference in outcomes between centers,10,11 and in one study outcomes were improved in the adult center.12 Other studies have shown a difference in care delivered, with adult centers having higher operative rates for liver and splenic injuries.10,13 Moreover, in the majority of these studies adult trauma centers are receiving older, more severely injured patients, with a higher rate of penetrating injury.10,13 In general, where pediatric surgeons care for patients at a pediatric center and adult trauma surgeons care for patients at an adult center, there is likely to be a large

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discrepancy in the pediatric resources available with regard to pediatric specialists between the 2 centers. Our study accounts for some of these differences because these 2 ACS Committee on Trauma–verified level II pediatric centers are similar with regards to many of the available resources. Our centers differ with regard to the make-up of the trauma services, with 24-hour in-house coverage at the pediatric center and on-call coverage at the adult center, although initial resuscitation and care at both centers are under the direction of adult trauma surgeons. At the pediatric center, postresuscitation and operative care are provided by a pediatric surgeon. Specialty care, as well as imaging services, are comparable between the 2 centers. In our study, there was no difference in mortality or number of computed tomography scans utilized between the 2 centers. The adult center did have a higher utilization of ultrasound, primarily because it is a resident training service and nearly all patients presenting receive a FAST examination during the trauma assessment for training purposes. Unfortunately, we could not evaluate the operative rates of the centers because of differences in recording between the 2 trauma centers. The pediatric surgeons placed a higher percentage of patients both in the ICU and on the ventilator, although this is likely attributable to the fact that pediatric hospitals’ patients had significantly higher ISS. They also had a higher hospital LOS, but these numbers, although statistically significant, do not demonstrate clinical significance. There were several limitations to our study. First, the rural Kansas population may not be generalizable to other populations. Second, missing data were noted, which could have affected our results; however, this is unlikely because missing data account for less than 2% of cases in the multivariable analysis. Our population in general was minimally injured, with the majority having low ISS, high GCS, and with a minority of patients presenting with penetrating injury or in shock. Outcomes may be different in a more severely injured population. Furthermore, patients cared for at the pediatric center were in general younger and more severely injured, although our use of regression analyses should have adequately accounted for these population differences. The event in question (mortality) was rare, and the small number of events limits the statistical power of our analysis. It is possible that the protective effect of a pediatric service, although not statistically significant in our study, was not detected because of the rarity of mortality in our sample. Furthermore, in both systems, adult trauma surgeons were used for initial resuscitation, and pediatric surgeons only accepted care after the initial resuscitation period. In a system where pediatric surgeons were responsible for care from initial resuscitation through discharge, we may have seen different results. Finally, this study is retrospective in nature and compares data extracted from 2 separate databases. Because of differences in recording between sites, we were unable to evaluate certain care processes such as operative interventions. However, in conducting

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this study we were able to tease out 4 variables that were predictive for mortality in pediatric trauma patients using bootstrapping. In summary, the type of service model was not associated with mortality. Given the shortage of pediatric surgeons and the limited number of level I pediatric trauma centers in the United States, our data suggest that adult surgeons can help alleviate the burden on pediatric surgeons by assisting in the care of pediatric trauma patients.

References 1. Nakayama DK, Burd RS, Newman KD. Pediatric surgery workforce: supply and demand. J Pediatr Surg 2009;44:1677–82. 2. Other ASCH PRI Maps. American College of Surgeons Health Policy Research Institute (ACSH PRI). Available at: http://www.acshpri.org/ atlas/loadflash.php?s50. Accessed April 7, 2015. 3. Gow KW, Drake FT, Aarabi S, et al. The ACGME case log: general surgery resident experience in pediatric surgery. J Pediatr Surg 2013; 48:1643–9. 4. Pediatric trauma care. In: Rotondo MF, Cribari C, Smith RS, eds. Resources for the Care of the Injured Patient 2014. Chicago, Illinois: American College of Surgeons Committee on Trauma. p. 71. Available at: https://www.facs.org/w/media/files/quality%20programs/trauma/ vrc%20resources/resources%20for%20optimal%20care%202014% 20v11.ashx; 2014. Accessed April 8, 2015. 5. Wesson DE. Pediatric trauma centers: coming of age. Tex Heart Inst J 2012;39:871–3. 6. Van Ness PH, Murphy TE, Araujo KL, et al. The use of missingness screens in clinical epidemiologic research has implications for regression modeling. J Clin Epidemiol 2007;60:1239–45. 7. Pracht EE, Tepas 3rd JJ, Langland-Orban B, et al. Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers? J Pediatr Surg 2008;43:212–21. 8. Petrosyan M, Guner YS, Emami CN, et al. Disparities in the delivery of pediatric trauma care. J Trauma 2009;67(2 Suppl):S114–9. 9. Potoka DA, Schall LC, Ford HR. Improved functional outcome for severely injured children treated at pediatric trauma centers. J Trauma 2001;51:824–34. 10. Matsushima K, Schaefer EW, Won EJ, et al. Injured adolescents, not just large children: difference in care and outcome between adult and pediatric trauma centers. Am Surg 2013;79:267–73. 11. Osler TM, Vane DW, Tepas JJ, et al. Do pediatric trauma centers have better survival rates than adult trauma centers? An examination of the National Pediatric Trauma Registry. J Trauma 2001;50:96–101. 12. Sherman HF, Landry VL, Jones LM. Should level I trauma centers be rated NC-17? J Trauma 2001;50:784–91. 13. Potoka DA, Schall LC, Gardner MJ, et al. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma 2000;49:237–45.

Discussion Dr. David Allen Partrick (Aurora, CO): The authors compare the outcomes of pediatric trauma patients from two separate but geographically very close adult Level 1 trauma centers which are both designated as pediatric Level 2 centers as well. The call system works differently, as was outlined on the discussion, one was a primary pediatric surgery-managed trauma service for the children, and then one that’s

managed by primarily adult surgeons with a pediatric surgeon available for consultation. Although similar in age and gender distribution, pediatric patients admitted to the pediatric center were more severely injured, more likely to be admitted to the ICU and require mechanical ventilation, and had a longer hospital stay. Mortality, however, was no different. The authors have concluded from these data that a system utilizing adult surgeons results in equivalent outcomes when compared to a system using fellowship-trained pediatric surgeons. I might suggest a different interpretation. The pediatric center took care of more severely injured patients with no increase in mortality compared to the adult center taking care of less severely injured patients. Both systems utilize the same pediatric surgical subspecialists, thus there must be some inherent value in having fellowship-trained pediatric surgeons helping in the management of these more severely injured children. In addition, as the authors point out, the end point of mortality is a relatively rare event in this population of mildly to moderately injured children, so the power of their statistical analysis is limited. I do have three questions. 1. How often was the pediatric surgeon who was available for consultation at the adult center utilized? In other words, how active was his or her involvement there? 2. Although it sounds like both institutions share pediatric subspecialists, such as orthopedics and neurosurgery, what other services differ between the hospitals? Since the management of pediatric trauma patients is often nonoperative, are there pediatric intensivists who help with the acute care of the more severely injured patients at each institution? Finally, other investigators have reported different rates of operative intervention between adult surgeons and pediatric surgeons taking care of injured children specifically when it comes to solid-organ injury. Do you have any data comparing the differences in operative rates between the two institutions? Dr. P.J. Stiles: As far as pediatric consultation at the adult center, it was almost 0% of the time did that happen, but it was available if we needed it, but we almost never called them. As far as the other subspecialists that differ between the two centers, each center has board-certified critical care doctors that take care of the ICU; however, they are not the same doctors. They each have their own separate critical care doctors. At the adult center, though, the trauma team takes care of those patients. The pediatrics intensivist does not take care of those patients. At the pediatric center, however, the pediatrics intensivists do take care of the ventilators of the sicker kids in the ICU, the trauma patients. Dr. Ronald M. Stewart (San Antonio, TX): Just a follow-up question with respect to splenic salvage,

P.J. Stiles et al.

A comparison of two pediatric trauma care models

operative intervention, because that’s really a key question with respect to this issue. To me, the results are not really surprising if you have pediatric intensivists and you’re equipped to take care of children. I will say, as someone who has taken care of a lot of injured children primarily as an adult surgeon and works with training a bunch of people, trying to get some adult surgeons onboard with, really, splenic salvage is, quite frankly, a great challenge. It doesn’t make me very happy, I will just say personally, but it’s a big challenge. I think it’s a really important question that needs to be answered. Dr. P.J. Stiles: You are right. It is well documented in the literature that pediatric surgeons are less likely to operate on solid-organ injury. Unfortunately, this is the real limitation of our study. We are comparing two databases. The operative interventions between the two databases were not recorded the same, so, unfortunately, we were not able to look at that. That would be very good to look at in the future. I totally agree. Dr. Lillian Liao (San Antonio, TX): I think, just in reading your manuscript, one of the things that would add much more volume and oomph to the paper in presenting to the trauma community, and specifically in convincing pediatric surgeons that adult trauma

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surgeons who take an interest in pediatric patients can do just as good of a job, if not better, than the specific cohort of pediatric surgeons taking care of trauma patients. It’s really important for you to include the nonoperative management of solid-organ rates between the two centers. I think that will add a lot more to the paper in publication. Dr. Priscilla Thomas (Grand Forks, ND): Did you have any pediatric patients who needed to then be transferred for a higher level care, such as burns or whatnot, when you were doing the retrospective review? If so, did you look at their mortality as well and also calculate or exclude those from your calculations? Dr. P.J. Stiles: Looking at the databases, that information was not available either. Anecdotally, it’s very, very rare that either center transfers a patient. We don’t have any vascular surgeons that take on pediatric patients. Those specific vascular injuries, I could see getting sent out if they were stable. Otherwise, the pediatric surgeon and adult surgeon would take them if they are unstable. The other thing that we don’t have is ECMO. If a baby were to need ECMO, that would be something that would get sent out. In my experience, I have never seen that happen at our center.

Pediatric trauma system models: do systems using adult trauma surgeons exclusively compare favorably with those using pediatric surgeons after initial resuscitation with an adult trauma surgeon?

A shortage of pediatric surgeons exists. The purpose of this study was to evaluate pediatric outcomes using pediatric surgeons vs adult trauma surgeon...
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