So, here I am, at a school many miles from my home, with a dented boot, Sonny Jim having ridden his motorbike into my rear en route. My patient is a 5 year old boy who was hit by a Land Rover. When I say hit, what really happened is that the lad, Tim, had been leaning against a wall when the child sitting in the front seat of the Land Rover had taken the hand-brake off, and the rather large vehicle had pinned Tim against the wall.
I need to act fast here. Children don't act the same as adults: when they get injured they display very few signs of shock until the very end. So, I will have to keep my wits about me. The mechanism of injury tells me a lot - the potential for chest and abdominal trauma is high. I will need all my kit out of the boot.
Oh bum, bum and tripple bum!! I can't get my boot open! The impact with the bike has damaged the locking mechanism. Having an Estate car would be good at this stage - I would have just pulled down the rear seats and grabbed the stuff from there. But I haven't. So I can't.
Quickly, I run over to the ambulance, no kit in hand, and call to one of the fire crew, to appraise them of the boot situation. He calls to his colleagues, and my vision, as I enter the back of the ambulance to deal with a sick 5 year old boy is of 3 burly fire officers attacking my beloved car with some heavy equipment. Oh well, concentrate on the job at hand:
Tim is awake, whimpering in pain. He looks very pale, and is quite drowsy. He has an obviously deformed right thigh. There is bruising across the right side of his chest. Ok, need to get some order into this:
Airway - maintained. He is speaking, and so I can move on to:-
Breathing - looks fast, and the right side isn't moving as well as the left. A count of breaths per minute gives me 30. What's normal for a 5 year old? Can't be more than 25, can it? The EMT agrees with me. Listening to his chest with a stethoscope demonstrates very little air entry in his right side. A pneumothorax? Blood in the chest? I tap on his chest, but cannot decide whether it is dull (blood) or resonant (air). Damn! It's really not as easy when it is a child, nor when we are in the back of an ambulance... Oh well, park that for a moment, and move on to:-
Circulation - pale, weak, thready pulse, blood pressure unrecordable, obvious fracture right femur, probable pelvis fracture. This is not looking good.
Disability - he is conscious, and responsive, with a Glasgow Coma Score of 14/15. He is moving all 4 limbs.
Just then, there is a knock on the ambulance door, and the fire officer hands me my bags from my boot. I'm not even going to think about it...
I start making some decisions: time to any A&E Department is over 20 minutes. Tim is in a bad way, losing blood from a probable pelvis fracture, as well as a femur fracture. He also has a chest injury. If he were 20 not 5 there wouldn't be a choice - he would be put to sleep, and I would decompress his chest. But he's 5 years old!! Giving him a general anaesthetic will be hard enough, what with choosing the correct doses of drugs. And then decompressing his chest! I can't remember the last time I did that in such a small child! No, this one will have to travel awake. In a way this makes the journey much harder, as I will have to be prepared for the worst. I give Tim some ketamine, a sedative used for anaesthetising horses. A much smaller dose for Tim, though, and he is sleeping nicely. Very slow fluids, just to keep his blood pressure stable. Not too much, or he will start to bleed more. Equipment ready to intubate him if he deteriorates en route.
I signal to the ambulance crew, and we make our steady way to hospital. I watch Tim's vitals like a hawk, listening constantly to his chest, my fingers on his pulse all the way. I breathe a sigh of relief when we drive up to the A&E, and I hand him over.
A couple of days later I call to find out how he is: he is still fighting, having had operations to pelvis, femur, chest and abdomen.
1 week ago