PCRF Research Alert: Decision-Making for Management of Blunt Abdominal Trauma in Children

This ongoing series from the Prehospital Care Research Forum combs the literature to identify recent studies relevant to EMS education practices.

Ahluwalia T, Toy S, Kennedy C. Use of Cognitive Task Analysis to Understand Decision-Making for Management of Blunt Abdominal Trauma in Children. Cureus, 2019 Feb 19; 11(2): e4095.

Teaching learners to think critically is a challenge for EMS and other healthcare educators. Likewise, for the new graduate to move from novice to expert requires more than merely observing a master practitioner. This is particularly true when faced with low-frequency, high-risk situations. Managing children who have sustained abdominal trauma is particularly challenging for both EMS and other caregivers who do not routinely care for critically ill pediatric patients.

In this mixed-methods study, researchers used cognitive task analysis to discover how expert medical practitioners used their knowledge and clinical decision-making to care for children who had sustained blunt abdominal trauma. Cognitive task analysis (CTA) is a strategy employed to understand specific elements of high-level thinking processes.

During the first phase of the research, seven experts from a single hospital system who had at least five years’ experience managing pediatric trauma were individually interviewed using a semistructured tool that revolved around two clinical cases to determine their thinking processes. This data was then coded into seven themes: situation awareness; clinical reasoning; clinical management; knowledge, skills, and attitudes; communication and teamwork; potential errors and novice traps; and quality indicators and safety measures.

After analyzing this data those same experts were gathered into a focus group to review the data and clear up discrepancies. During the final step of the research, a survey was sent to 11 pediatric emergency medicine physicians and 11 pediatric trauma surgeons around the country to confirm the findings of their CTA. This step was important to triangulate their data—in other words, to be sure their findings would be more reliable and valid, not influenced by local bias or regional differences.

Results

Their complete findings are very lengthy and detailed—and remarkably similar to key aspects of assessment and management of critically ill pediatric patients in the prehospital setting. Of particular interest to educators are the potential errors and novice traps they identify. Some examples they relate from each phase of care include missing sensory clues; lack of prioritizing tasks; not coordinating team activities; tunnel vision/fixation/anchoring; delayed recognition of abnormal vital signs; omission bias; incomplete physical exam; not maintaining the big picture; failure to revise; and lack of reassessment.

This paper concludes with a comprehensive decision-making tool for evaluation of pediatric blunt abdominal trauma that is divided into four areas. These sections include: EMS to hospital arrival; first five minutes of care; within the first 15 minutes; and within the first 60 minutes. Each of these sections includes overall management steps, specific expected assessments and decisions, and suggestions on what to avoid and areas to improve.

Conclusion

These findings provide a foundation for management and decision-making in this high-risk pediatric trauma situation. While their specific findings relate to care within a hospital, many of their insights are relevant to the prehospital arena. The authors suggest their CTA may help improve decision-making skills when caring for children with blunt abdominal trauma or to develop a checklist tool. It could be used as a foundation for an assessment rubric or even as an aid to blueprint in video-gaming.

While it is lengthy, EMS educators who teach both initial and continuing education programs will find many insights in this paper worth exploring.

Kim D. McKenna, PhD, RN, EMT-P, is director of education for the St. Charles County (Mo.) Ambulance District and on the board of advisors of the UCLA Prehospital Care Research Forum.

Megan Corry, EdD, EMT-P, is the program director and full-time faculty for the City College of San Francisco paramedic program and on the board of advisors of the UCLA Prehospital Care Research Forum.