Discussion

The limited literature on the management of paediatric trauma in military treatment facilities identifies the need for appropriate training to equip military health professionals to care for paediatric casualties on operations.1 ,4 ,5 Medical support to military operations is tailored to the military population at risk, although it is often necessary to provide support to indigenous military forces, captured personnel and other eligible personnel, which includes the provision of emergency care to all casualties where this is urgently needed.6 Military doctrine specifies that any care given must be within existing capability and should not create a dependency among the local population.6 Health provision is often an emotive subject, as reducing or controlling access in favour of different groups may become a destabilising influence.7 A historical Surgeon General policy document supported clinicians identifying the point that civilian paediatric cases should be returned to their local health facility.8 Well-intentioned military medical activities risk undermining the military mission by creating an unsustainable dependence or compromising efforts made by the local government to rebuild its own health system.

Children have distinctly different physical needs for treatment.3 Clinicians working in emergency care should ensure that they are skilled in specific aspects of treating a child, such as obtaining intravenous/ intraosseous access, administering paediatric doses of medications and blood products.9 However, there continues to be a lack of consensus whether children should be treated as small adults. Fendya et al10 argued this is not the case as children have different physiology with varying anatomical differences, which require the clinicians looking after them to have specific knowledge and skill sets, whereas Bree et al9 suggested that ultimately the immediate priorities for life-saving treatment are the same as adults; fundamentally the <C>ABCD approach (<C> indicating catastrophic haemorrhage) should be adopted whether treating an adult or child, but to function effectively in any of the paediatric trauma team roles there are specific knowledge and skill sets for paediatric patients.3 Specific skills required, such as approaches to vascular access and the administration of blood products, may not translate from adults to paediatrics and these are likely to always remain. During a paediatric trauma resuscitation in the ED the Belmont rapid infusion system can be used to infuse warmed blood faster than traditional methods; however, care must be taken and training received to ensure the operator is conversant with the different administration methods and flow rates required for paediatric patients.11 Analysis of this evaluation revealed the preponderance of paediatric presentations were trauma-related, thus highlighting the need for emergency nurses to possess specific paediatric trauma skills. This finding along with the breakdown of individual roles nurses carry out during a trauma resuscitation leads to recommendations for the following skills to be incorporated into the pre-deployment phase and form part of the emergency nurse core competencies;

• Paediatric massive transfusion knowledge.

• Belmont rapid infuser use in children.

• Recognition of the sick child/triage.

• Paediatric drug calculations.

• Analgesia.

• Ability to gain intravenous/intraosseous access in a child.

A common theme highlighted throughout the literature was the magnitude of paediatric injuries presenting to Field Hospitals on operations, which were predominantly gunshot wounds and explosive injuries, which are simply not seen in peacetime.12 Thus, military personnel face significant challenges in gaining the experience of managing major paediatric trauma in peacetime environments as relevant opportunities within the UK are limited.4 This was confirmed in a study by Nordmann5 who reported that 31 paediatric patients were admitted for surgical intervention after trauma over a 3-month period in Afghanistan; in comparison, the average ED in the UK sees less than one seriously injured child each month.4 The low trauma levels in the UK make it difficult to replicate patterns of injury seen on operations and obtain appropriate competencies to prepare for deployment.

The author's personal experience reflects the evidence in the literature, which suggested that due to the uniqueness of the environment, only trauma seen on operations actually prepares an individual to deal with future trauma presentations.4 ,13 No amount of civilian experience will expose clinicians to the injuries sustained during conflicts. Personnel will only develop their skills and knowledge to manage seriously injured children while on operations and their confidence will increase to deal with similar presentations. Conversely, the experience and skills military medical and nursing personnel gain on operations have facilitated enhanced training for NHS hospitals and other organisations.14 A report by the Care Quality Commission15 confirmed the provision of trauma care provided by the DMS on operations as ‘exemplary’ and called for increased cooperation between the DMS and NHS. Evidence demonstrates that care should be led by consultants experienced in major trauma, but major trauma is most likely to occur at night-time or at weekends when consultants are less likely to be present in the ED. Having a dedicated consultant present in an ED produces quicker and better decision-making in the care of major trauma patients. As the Iraq and Afghanistan conflicts matured, case studies were published illustrating how invaluable experienced medical or nursing staff are when there is a need to make early decisions in the management of a severely injured paediatric patient.12 ,13 ,16 The deployed ED is able to boast 24 h consultant-delivered care.