E22 David Notrica On Pediatric Trauma

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Chad Ball  00:15

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons, we hope you enjoy it.

Ameer Farooq  00:50

Dr. David Nortrica is a pediatric surgeon at Phoenix Children’s Hospital in Arizona. In this conversation from earlier this year, we took a deep dive into pediatric trauma with Dr. Notrica, from both a clinical perspective, but also from an organizational and systems level. Check out the show notes for the links to all the papers and guidelines we discussed in this episode.

Chad Ball  01:10

Dr. Notrica, thank you so much for joining us on Cold Steel. It’s an absolute pleasure to have you on. I know you’re busy at the Western Trauma Association meeting right now. So, we really appreciate it. Could you tell the listeners maybe a little bit about your training pathway? Who may not know yet?

David Notrica  01:30

Oh, sure. So, it’s funny, because you get asked, you know, what exactly is a pediatric trauma surgeon? And the answer is, it’s someone who claims to be a pediatric trauma surgeon. I did my general surgery training at Emory. And so, I was down at Grady six months a year taking every third night call. And trauma was just completely integrated into my DNA as a general surgery, training. And then when I went to do a fellowship in Houston, I had the pleasure of working with David Feliciano. And so, I mean, you know, you just don’t get any better training than that. And then, when I went to do my pediatric surgery fellowship, I went to Houston, Texas at Texas Children’s and so once I got there, I covered pediatric trauma at Ben Taub Hospital, which of course, is kinematics hospital. And so, another two years of pediatric surgery, but also covering all the pediatric trauma for Houston. And so, when I got done, the last thing I wanted to do was to take care of another injured child. And I moved to Phoenix where the pediatric surgeons didn’t do pediatric trauma. And within a short period of time, it became very clear to me that my training background might have something to offer. And in 2008, I started the first level one trauma center in Arizona, and first pediatric level in trauma center in Arizona. And so that’s kind of how I got to the point that I am now. And along the way, there were some gaps in research and some friends of mine whose names are household worlds in the pediatric surgery community said: Hey, what would you guys think about doing some pediatric trauma research and that morphed into atomic? And it kind of went wild from there?

Chad Ball  03:29

I love it. You know, it’s funny, you and I and folks like Neil Perry and Lorraine Tremblay, we’re all biased having been too greedy. But I truly will go to my grave with the beliefs that that era with you at the front of it probably me at the back of it are the four of us as is really was really the pinnacle of trauma training in the US. And we really couldn’t have it any better. I mean, every single day I do something that I learned there, it’s it was remarkable place had a remarkable time.

David Notrica  03:32

Yes and I didn’t have a sense enough to appreciate it when I was going through it.

Chad Ball  03:57

Yeah, so true. So true. Well, this is sort of a 30,000 foot questions day to be honest and it might be difficult to answer. But you know that one of the jokes of course, is that it’s not a joke. Maybe that’s unfair but really that, pediatric medicine is not just, a little kid medicine or little adult medicine. But, in that sense,  what are some of the biggest differences maybe biggest challenges between adult and pediatric care with regard to injury and trauma specifically.

David Notrica  04:36

So I can illustrate it with a story and when I was doing my general surgery training, I had a fair amount of Pediatric Trauma during my general surgery training, and I just finished a rotation as a chief, third year chief and managing pediatric trauma every single day and I went back to Grady as a fourth year resident and I was managing an adult patient with a grade three splenic injury that I wouldn’t have blinked twice about on the pain service. And, and I nearly killed the guy and this injury that was completely innocuous in kids and never would have required an operation, needed an operation in an adult patient. And I realized that the reason that it’s hard for most adult trauma surgeons to take care of injured kids, is because they are just completely different entities. And so, if you have this amazing skill set, as an adult trauma surgeon, you know, what needs to go to OR and what doesn’t. If you take that and apply it to kids, you’re not necessarily optimizing what the kids can do. And the kids have proven that they stopped bleeding, and they really stopped bleeding at a high percentage of the time, we’re talking 97% of the time.

Ameer Farooq  05:56

One,  maybe not even medical, aside to what I’ve observed from my pediatric rotation is that the anxiety and emotional level in the room when a pediatric trauma case comes in, maybe it’s because in Canada, we don’t necessarily thankfully see the same level as maybe what you saw in Atlanta. But the anxiety level is palpable. How do you manage that as a pediatric trauma surgeon and how is that different from your experience working in adult trauma?

David Notrica  06:29

It’s interesting because and this is what happens, you get spoiled when you work at a pediatric trauma center, is that anxiety just isn’t there. So, in part of the reason that the anxiety is not there is because every single person in that room can identify a child in shock. So, at an adult Trauma Center, there’s a good chance that only the trauma surgeon is really going to be able to define shock early in a kid. But at a pediatric trauma center, every single person in the room knows which kid is in shock and which one isn’t. And so, we spent a lot of time, to teaching and emphasizing that blood pressure is not an indicator of shocking kids. So, shock is inadequate perfusion, and inadequate perfusion and kids manifests in paleness, delay, capillary refill, a high heart rate, and cold bubbles, you touch their feet, they’re cold and they’re pulse quality isn’t good and just like adults, who have a lot of reasons for having pulse quality that may not be great, in kids, if their pulse quality isn’t good, they’re in shock.

Chad Ball  07:40

It’s interesting. You make it sound. So simple Dave. But what one of the things I think that we all ideally spend a career trying to do is condense the nonsense, so to speak, but really, to try and make trauma care globally as uniform and as high quality as we can. That’s my adult comment. My observation and pediatric trauma outside of centers like yours, is that it’s even more variable. So, what sort of advice would you have for the centers that don’t see much volume and are trying to do their best and maybe are housed with some really superb clinicians and fantastic people, but, again, just don’t have that volume that you live in every day?

David Notrica  08:28

That is a great question. And I think that there are a couple of things that centers that read a low volume of kids can do. One, you have to trust your physical examination. It won’t mislead you in kids. And so that is clearly, one of the things is that we all know how to do it, but we don’t always trust it. And then shock index has been amazing. So, what shock index does is it allows you to identify which patients are not really at risk of cramping. And that’s a good portion of patients. So, when you look at the shock index pediatric adjusted, I’m not even sure that you need that much adjustment, if your heart rate is higher than your systolic blood pressure, then you need to worry a little bit. And if it’s not, your kid is probably not in shock. So, I think that is definitely something to lean on is the shock index. The nice thing about that is a lot of times people are really uncomfortable about knowing what a normal systolic blood pressure is for kids and it’s, 65 plus times your age. Well, yeah, that’s easy for me, but when you haven’t seen a kid in a year, you’re like, what was that number again?  And shocking, that doesn’t mean much. You take two numbers and divide them and if it’s greater than one you are in trouble and if it’s less than one, you’re okay. The [inaudible] adjustment basically says, that for younger kids, maybe 1.2 is okay and once you get 13, it’s 0.9. But you don’t need to memorize those numbers, I think if you can remember 1.0 and say, the heart rates is higher than the blood pressure. Let me worry a little bit more about this kids. It goes a long way.

Ameer Farooq  10:31

It’s clear that you’ve done a lot of thinking about how to manage trauma, and it’s clear from reading your CV, that you have been very influential in just putting down the research as well to, to back up the way that you think. I’m particularly intrigued by the work that you did with atomic and the stuff that came out of that talking about managing pediatric blunt abdominal trauma, non-operatively. If you talk a little bit about how that came together, and how did we come to this idea that we can manage a lot of pediatric trauma, non-operatively, as you said,

David Notrica  11:15

I think that when the atomic group got together, a lot of us were having a little bit of frustration in that, we had a lot of information but we weren’t applying it. And I don’t just mean, the adult trauma centers, which were taking care of the majority of the kids, I don’t think that the pediatric trauma centers really had a concrete idea of how to apply this new information. And there was some groundbreaking research that had been done in Arkansas, by Sam Smith, it said, kids that are going to fail non operative management, actually show that very, very early. And we had kind of taken one direction with the APSA guidelines that didn’t push things forward. It pushed things forward and we learned a lot and we didn’t need to use that anymore. What happened was, we got together and said, Let’s take the available literature, and see if we can make a guideline that actually is easy to apply and useful in evidence based and that resulted in one of our early publications, which was the great assessment that we published in the Journal of Trauma. That was everyone getting together and figuring out what questions were important, putting together the algorithm. We started with some general algorithm and then we refined it, and we refined it. It was an iterative process. Those coauthors on that paper worked really hard so by the time that anyone outside of our group saw the algorithm, we had hundreds of hours of work, making sure that algorithm made sense and was going to be useful. So, the first algorithm that anybody ever saw was actually version 11 of the algorithm.

Chad Ball  13:22

That documentation, those documents that’s come from that group, David, honestly, you guys, are clearly very proud of it and you should be, and it should go to your grave, incredibly proud. Like, they really did reset the bar for care of injured pediatric patients, they are unbelievable. Extending from that, I notice, again, it’s a 30,000 foot question and it’s probably really hard to answer but for the chiefs doing their Royal College examinations or for the board exams in the US, if you were to condense, really pediatric trauma care down to a handful of bread and butter prototype statements, what would you tell them? Whether it’s don’t miss X or do Y? What are your thoughts?

David Notrica  14:11

That’s actually not a hard question. I think number one, is 40 ml per kilo of blood products is a marker for a patient who is going to fail on operative management and are going to die. And I think that having that number in your head allows you to know when I’m going to not linger in that trauma bay anymore and when I’m not going to try anymore, and I think that’s a really good touchstone for successful non operative management. So if you say, Well, I got a kid and they’re in shock so if they haven’t gotten 40 ml per kilo of blood or four units of pack cells, then maybe I should think about giving them some of that The next thing that’s most critically important is that a child that arrives in your Trauma Center, from shock after a blunt abdominal injury, the only thing that you know is that they have bled. You don’t know if they’re still bleeding. I think in the adult world, it’s much more common that if you’re in shock and have blood that you’re gonna keep bleeding. But that’s not necessarily true pediatric trauma and a lot of those kids, a good portion of those kids, get transfused and they stabilize. And they don’t stabilize transiently, they stabilize forever. I think that giving them a shot of a blood transfusion in the emergency room is good medicine. I don’t think it delays things from most trauma centers. And I think that you’ll find that some patients look a lot better after they’ve gotten a blood transfusion. So, if they’re in shock, give them blood. The other things, the last thing that’s so critically important, is to know that kids that fail non operative management, they do it early, and they do it, really, probably within four hours of injury. So, the kids who are not going to do well, you’ll know early, if you give them a challenge of blood and they don’t respond to a blood transfusion or they respond to just ever so briefly to a blood transfusion, that’s not a candidate for non-operative management, that patients failed. And so if you have those touchstones, you know that I gave blood and they got hypotensive again, you’re done. You know that you gave them blood and they stabilized, and you haven’t given them 40 per kilo, they’re probably going to make it does really help you in clinical practice. I think a lot of that is starting to show up on exams as well.

Ameer Farooq  16:47

Particularly in Canada, it’s hard to come by trauma laparotomy. And even in the adult world and that’s even, you get even less exposure to pediatric trauma operations. And yet, when you do have to do an operation, both for adults, and I’m sure for children, it matters even more that you’re well trained. How do you envision us solving that paradox going forward?

David Notrica  17:16

You know, if you were a pediatric trauma surgeon, and you don’t have a pediatric practice, you’re not gonna have the skills to do it when you need to do it. And I think the same is probably true for a lot of trauma centers, which is that you do need that acute care surgery, so that you’re operating every day. So that if you do need to go into the abdomen and take out a spleen or pack a liver or repair a retro pedic cable injury, that it hasn’t been so long since you’ve been in the OR, that you’re that you’re confident and capable and able to do that. So, I don’t think that limiting your practice to trauma only at a place that doesn’t have a high incidence of severe and or penetrating trauma is a good idea.

Chad Ball  18:02

Dave, let me ask you maybe a little bit more of a controversial question. I can only imagine that setting up from a mechanistic point of view, a level one Pediatric Trauma Center must have been, I’m sure a pleasure, but also a bit of a nightmare. How do you I mean, that’s maybe for ask the question, I will just state obviously, like, that’s a level of leadership that a lot of us probably can’t fathom. So how do you generate that interest? How do you support that interest? How do you make that happen?

David Notrica  18:36

So you take every bit of political capital that you’ve amassed over the last decade, and put it on the line? Because the reality is that people will do it if they trust you. And people will do it, if you can convince them that their reason to do it, is right. So, when I went to special specialties, and I went to pediatric surgeons and said yes, this is going to negatively impact your life, yes, you’re gonna have to spend the night in the hospital to be a level one trauma center. I said, I explained that the reason that you went into medicine, and that you were given this great opportunity to operate on kids was to save lives, and you can make a difference. And let me show you how. And then we took the numbers of what the observed mortality was at the time and what the expected mortality was at the time and showed them how in our catchment area, how we can make a difference.

Chad Ball  19:35

It’s amazing that very simple but powerful narrative was sort of enough to galvanize everyone forward. Like that’s really cool.

David Notrica  19:43

Well, for most people that was enough and then the other thing that happened was when we started to get pushback from specialties that really thought that this was going to impact them negatively to a point that would interrupt their lives. We had to listen to them, when they said, we don’t want it, you had to ask them. Tell me why tell me what your concerns are. And let me see if I can mitigate those concerns. And everybody had a different set of concerns and one that I wouldn’t have necessarily anticipated or assumed, you have to ask. So, when the urologist started pushing back a ton, about being a trauma center, unlike, like, urologist, it’s not that common of a thing. And they’re like, well, we’re worried that the trauma is going to constantly bump our cases, because that’s what we experienced during residency. And so, we had to address that, we had to address that, how we could have a trauma center and not have it impact the elective surgeries. For the orthopedic surgeons, you know, their biggest concern is that they couldn’t get OR time. And so, we had to address those. And so, every specialty had different concerns, you have to ask what they are. Sometimes they’re a little bit hesitant to tell you what their concerns are, maybe they’re worried that it will be seen as self-serving, or maybe they’re worried that it’ll be taken in the wrong light. So, they don’t necessarily want to be forthright with why they don’t want to find a center, but you have to push them, and you have to kind of get to the bottom of it. Once you start hearing what their objections are, then you need to make legitimate concessions and legitimate rules or work or resources available to make it so that those things don’t come true.

Chad Ball  21:39

That’s amazing. I mean, again, I’ll just state it for a second time. You know, that’s a level of leadership, Dave, but that is rare, and it’s unique. And you should be proud of it. Maybe last question, I will ask surrounds, going to specialty meetings, whether that’s trauma meetings, or like adult trauma, whether it’s pedes meetings, I’m getting to know you now for a reasonable number of years, Dave and I watching you at these meetings, I get the sense that you really deeply enjoy it, that you really find the benefit of going to conferences and interacting with folks. I was just wondering, given that level of passion, from your point of view, what do you see the benefits of these meetings as normally at your relatively senior stage, but for trainees and fellows and junior staff, and so on.

David Notrica  22:35

If If you practice surgery, your entire career, the way that you do on the last day of your general surgery training, or your last day of your fellowship training, you will not be doing a service to the people that you care for. And so, the need for continuing medical education is real. And I’ve encountered surgeons who practice the same way they did when they finished their training 20 years ago and those people are an embarrassment. Okay, you just can’t do it, you have to go to the meetings, you have to see what’s current. And not every idea that gets floated in a meeting as a good idea. But some of them are. And at some point, you have to realize that you’ve got to change with the times. The truth is that in 2020, there’s almost nothing that I do the same way that I did in 1999. Now, laparoscopy was groundbreaking change in the way we practice medicine and laparoscopy kind of came of age in the 90s. And by the time 1999 came around, it was completely accepted, but not necessarily well done. So, things had to change. The critical view of safety for gallbladder surgery had not been described, and now it’s like not only do we do safer gall bladders, but we actually have a method that we can teach trainees that if you’re seeing this view, that you’re going to be a safer surgeon than if you’re not seeing this view. And I don’t see that’s going to change for the next 20 years. I think that it was absolutely true 20 years ago and 20 years from now, you’re not doing to do operations the same way that you are in 2020.

Ameer Farooq  24:36

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback.  So, feel free to email us at podcast.cjs@gmail.com, or connect with us on Twitter @CanJSurg. Thanks again.