While Kasey Chambers was inspired to write the song entitled ‘Not Pretty Enough’ about her feeling that she did not fit in to the music industry, many injured children can relate to the sentiment of not being pretty enough: feeling that they no longer fit into society as they once did, particularly those who have cosmetic changes or scaring or those that have physical limitations as a result of their injury.
Kasey describes her feelings of vulnerability with an array of introspective questions, such as ‘Do I cry too much?’ 'Should I try harder?’ Trauma patients often gain perspective and maturity following their injury and they may struggle with society’s superficial value of physical appearance, which may impact peer status or popularity.
Broadly speaking, trauma patients are children who have sustained physical injury, ranging from minor trauma that has resolved within a short period of time to major trauma that can leave children with lifelong disabilities that require ongoing care. Minor injury tends to have self-limiting consequences and heal and repair quickly. Major injury is often described as having life-altering effect, with approximately 10% of all patients sustaining an enduring physical disability or significant scarring.
Physical trauma is usually treated with a well-established systematic clinical approach to the injured individual, and high rates of survival are in part due to the benefits of high-cost equipment and technology.
However, this is just one trauma domain. There are at least two other realms of ‘trauma’ which are best managed with a tailor-made approach after individual assessments are conducted.
The second type of trauma is psychological trauma. This is the emotional impact of an event that may ultimately affect the amygdala in the brain of these children, and in severe cases this may impair their neurophysiological and cognitive function.
The third type of trauma is referred to as medical trauma. This is a set of psychological and physiological responses related to medical procedures. It is usually associated with pain, injury, serious illness and frightening medical treatments. While these are distinct domains, they may overlap in all three areas for children that have sustained a significant injury, depending on the event itself, the experience of the event, and the effect of the event on the person.
In Australia, approximately 85-90% of all trauma (adults and children) is blunt trauma, predominately secondary to falls, sports injuries, bicycle injury, burns and motor vehicles incidents. Penetrating injures are rare at approximately 10%, these may include wounds from firearms, or secondary to stabbing or impaling objects.
Children are vulnerable to certain types of injuries depending on their age, reflecting their stage of development. In 2015–17, the leading causes of death in children aged 1–14 were injuries, followed by cancer and diseases of the nervous system (AIHW). It has been estimated that for every child that is fatally injured, 10 children will survive major trauma, but endure long-term disability requiring hospitalisation and medical care (AIHW - Pointer 2014 / WHO 2008).
Consider why children may be involved in trauma; 3-5-year-olds are surrounded by superhero cartoon characters that perform incredible feats of strength, speed, power, durability and extraordinary ability. Their vulnerability is increased as they cannot adequately assess the risks involved (eg toddlers falling from balconies). As children get older, they enjoy computer games and action movies often filled with death defying behaviours that may entice 5-12-year-olds to emulate these characters.
It is well known that adolescents while exploring their own limits and abilities may be involved in risk taking activities. When risk taking behaviours are combined with illicit drugs or alcohol, the outcome can be disastrous, and the result may be that the adolescent becomes a statistic – one of the 85-90% injured patients.
The injured patient cohort
Physical injuries include catastrophic head and spinal injuries, severe burns, or occasionally injuries associated with domestic and family violence (shaken babies). Other significant injuries may include degloving injuries or amputations, open globe eye injuries, asphyxia or hanging, or the more unusual injuries from electrocution.
There are minor injuries such as contusions and lacerations, soft tissue injuries, minor fractures and animal bites. There are injuries that may be minor or major depending on the outcome such as caustic ingestions or non-fatal drownings.
These well recognised trauma patients usually fit into a surgical subspeciality, for example the lacerated liver or spleen patients will be admitted to the general surgical ward, a head injury patient will be admitted to a neuro-surgical ward and a patient with an extremity fracture will be admitted to an orthopaedic ward.
However, there is a cohort of trauma patients that may not be ‘pretty enough’ to fit neatly into a sub-specialty category, where the lines may blur at times. A multi-trauma patient, (eg following a high speed MVA that catches fire or an explosion in a confined place) may suffer from head and facial injuries, solid organ injuries, plus fractures and some burn injuries and will be admitted to a trauma HDU (high dependency unit) or trauma ward.
However, not all hospitals have a dedicated trauma ward or HDU and ironically the multi-trauma patient may not ‘fit in’ to one of the defined sub-specialty wards.
Some patients may struggle with anxiety or depression, and they may harm themselves while trying to deal with their pain, but occasionally they may not be considered acute enough for the subspeciality child youth mental health team – not ‘acute enough’.
The numerous severe head injuries and spinal cord injuries ensure the rehabilitation team is working at their capacity. The patient with a mild to moderate head injury may not fulfill rehabilitation criteria for their subspecialty service, and these children could potentially be left to flounder – ‘not severe’ enough.
Some patients may not be admitted to hospital for a sufficient period of time, and that may preclude the full gamut of medical and allied health services being offered to them – not admitted for ‘long enough’. They may not be fluent enough in English to advocate well enough for their child – not ‘Anglo-Saxon’ enough.
Some adolescents display adult like behaviors such as involvement with crime, drug taking, violence, pregnancy etc. A paediatric facility may be reluctant to admit such adolescents and adult hospital may not have the specialist teams to deal with such adolescents – not ‘paediatric enough’. Or indeed, they may not be wealthy enough to choose a private consultation and perhaps transfer to a private facility – not ‘wealthy enough’.
These patients may be collectively called outliers, patients whose injuries don’t ‘fit in’ to one particular body region or into a defined diagnostic related group or sub-specialty.
The trauma service team
Trauma service teams are often small multidisciplinary teams, usually comprising of a mix of medical, nursing, allied health, social work or psychology, that ensure safe coordinated care and expertly manage all domains of trauma.
Predominately hospitals and major trauma centres cater for physical trauma when children have sustained either minor or major injury. Trauma resuscitation is based on highly skilled personnel, preparation and training, guided by EMST principles and governed by well-honed processes as well as key performance indicators.
Severely injured children require trauma teams that respond with lifesaving pre-hospital care, rapid evacuation, ED management and surgical intervention, stabilisation and early rehabilitation. Expert clinical skills are vital in addition to the qualities of human dignity, respect and empathy, integrity, autonomy and effective communication skills.
In addition, trauma service teams need to be able to handle the emotional strain that is involved with caring for these injured patients, as sometimes there are poor outcomes. The impact of caring for multi-trauma patients on an ongoing basis can be subtle, insidious and emotionally draining and it requires a certain personality type to ‘fit in’ to the team and ensure longevity in this chosen profession.
The injured patient
How an injury affects the individual patient depends on many factors, including the characteristics and personality of the child, the type and severity of the injury, the mechanism of injury, the child’s developmental processes and their socio-cultural heritage. Coping styles vary from patient to patient from reflection and introspection to emotionally expressive reactions.
There are tools that may assist in the assessment of post-traumatic stress symptoms such as ‘age-related’ trauma symptom checklists for children or paediatric quality of life inventories. The results from these checklists may assist the trauma service team to direct additional support services in the highlighted areas. In addition, there are therapeutic models of trauma informed care to guide the trauma service team to understand and work effectively with these children and their families.
The injured child needs time to process the injury and the events surrounding the injury, in addition to assistance with the physical, emotional, financial, and in some cases the legal impact that the injury has on their lives. It is important that they ‘fit in’ once again and contribute in a meaningful way to society. The overall aim is to maximise the quality of life and functional outcome of the child after their injury, to ensure they not only survive but also thrive, with the least morbidity possible.
They need to believe they are ‘pretty enough’ and can reintegrate and ‘fit into’ society with a sense of purpose and fulfilment.
World Health Organization. World report on child injury prevention. Geneva; 2008.
Email [email protected]