I've Got A Hat!

I come to a halt on the motorway, the accident clearly visible. A car is on its side, resting aginst the barrier of the central reservation. Already, cars are slowing on the other carriageway, people craning to get a look at the unfortunates. I jump out my car with the junior doctor who has come along for the ride, and we race round to the boot to collect my bag and monitor. We can hear the high pitched screams of an obviously conscious victim: good!

As we get nearer, I see a group of people kneeling down. I see the victim, and my heart sinks. I rush back to the car to get my paediatric bag, as my head screams at me, "A child! It's a child!"

Fortunately the majority of trauma victims I have to deal with are adult. The few occasions I have been called to children, they have already been past my, or anyone else's, care. Children are not just small adults. Their whole anatomy and physiology is different enough to make dealing with kids a separate speciality in Medicine. And it's not mine! I have a paediatric bag, filled with pouches, colour-coded for different ages. But that's like being asked why you think you could be a lion-tamer, and answering, "I've got a hat. It's got the words Lion-Tamer on it." I'm not a Paediatrician, despite the bag.

I run back to the scene and assess.

The child is a 4 year old girl. She has apparently been ejected from the car as it rolled. Airway and breathing are most definitely intact, as she is screaming loudly. Similarly, circulation is not immediately a problem. She is able to talk, when she is calmed down a little, and is able to recognise her father, who was driving the car at the time. I then turn to a secondary assessment, looking at injuries not immediately life thratening.

She has a large gash on her forehead. She has a severely broken left arm. More obvious, and very distressing, she has a massive degloving injury of her left leg. A degloving is where the skin (and sometimes muscle) of a limb is sheared off, much like removing a glove. Usually, and in this case, the skin is still attached, just pulled out of position. Ouch!

My assessment finished, I consider my options. She clearly has no life threatening injuries as far as I can see now, but there may be internal injuries that will only become apparent as time progresses. However, the injuries I can see means she needs very strong pain relief, and that means giving her a general anaesthetic and intubating her. That's where I don't want to be going. But I don't see I am going to have a choice. My mind begins to shut down. I can't begin to calculate doses for a 4 year old!

She has no venous access. I have to do that. Her left arm is a no go. Her right is being attended to by one of the paras, so I move down to her right foot. These needles are tiny, and so are the veins, but at least this is a skill I have mastered! My hand steadies, and the needle slides into the vein. Secured.

Suddenl, I can hear the sound of a helicopter. Not just any helicopter. This one I have flown in many, many times. The distinctive roar of the Explorer gets louder.

"Who called HEMS?" asks one of the paras. "We've already got RRD here, stand them down."
"No!" I shout, "Let them land!"

HEMS is London's Helicopter Emergency Medical Service. I have written about them before, and my usual thought is "Oh no, they're going to take over, aagain." The rule in BASICS / HEMS is smple: whoever gets there first has overall charge of the scene / patient. But that is not always adhered to by the flight crew. Today however, as they come running up, I immediately relinquish all care of the child to them. I am given tasks to do, such as support the neck, set up iv's and talk to the father, jobs I am more than happy to do.

As I sit at home later,Mrs RRD can sense that there is something wrong. She knows the job went well: the child was tubed and ventilated and flown to the local Trauma Centre. I find it difficult, but slowly I open up to her, tell her how incapable I felt, how unprepared I was to manage a patient of mine. She understands. She always does.