Saturday, 25 July 2009

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.


  1. Very nicely written!

    Its good to see that both BASICs Doctors and Ambulance Crews have the same things going through their mind when it comes to Children....

    ...OMG ITS A KID!!!!!!

  2. Concentrate on your strengths not the stuff you're not particulary good at. The job went well. You made a difference. Think about that.

  3. I was an EMT in the early says of 911 when they just routed calls.

    Our dispatchers came from the black cab companies, and they were GOOD. We had printed street guides, and the dispatchers knew where the street guides were wrong.

    I can still hear one of them saying over the radio, "Put a three on it, it's a child!"

  4. It is always a good thing when you are willing to admit your weak in an area and let someone who is better equipped in that area take over. I was at an accident scene a few weeks ago where myself and my partner (he's an advanced EMT and I am a basic) arrived to find a doctor and several nurses on scene (we were way out in the middle of no where - about 2hrs from the closest hospital driving fast-so I am not sure where all the medical people were coming from), unfortunately they were all clinically trained so they did not know how to deal with a serious trauma patient. They also did not want to listen to EMTs. About 10 min after we arrived some ER docs stopped and offered a hand. They were the only ones who did not get in the way of my partner and I doing our job.
    The fact that you were willing to step down and help where needed showed you were confident in yourself. Good for you for not making it more difficult to treat the patient.

  5. We all have our strengths and 'areas which require further development' (never really liked the term weakness). The real strength is when to ask for help, or in this case let the more experienced practitioner take over.
    The biggest mistake some make is keeping hold of the 'glory jobs' when maybe they arent the best to be doing it.
    Even though you were happy to pass over the responsibility, I think it is worth while to state the obvious. There are some types of emergency that we would rather not go to, but we would deal with them efficiently and effectively anyway, as I sure would have been the case for this child and yourself!
    Nice Post RRD

  6. I guess even A+E Doctors need back up from time to time.

    Just like the ALS algorithm states "Summon help if appropriate"

    A good call to let the HEMS team treat the child it seems. As for feeling incapable, I was at a job in the late hours of last evening for flu like syptoms on a 10 yo F. Not distressed in the slightest but I was a gibbering wreck. My first paedi pt, who knows what I'll be like on my first paedi resp arrest or trauma. Something I am not looking forward to.

    Great blog RRD.

  7. Thank you for your comments, folks. It was very odd, being in a situation where I just froze. Hasn`t happenned to me for a while. Still, that`s what being on the road is all about...

  8. Just knowing when you are out of your depth and when to let another colleague take over is a very good skill for anyone, including doctors to have

  9. Hi there RRD, I really like reading your blog. to me you're living the dream!

    Im currently about to go into the 4th year of med school at GKT, with a massive interest in eventually going into emergency medicine and pre hospital care. i was wondering (i hope not too cheekily) if you wouldn't mind me emailing you to pick your brains on a few things so to speak as to the best way to get into prehospital care and basics etc and if there is anything i can be doing now. I appreciate that you dont have much time and wont be disappointed if you're too busy.

    Many thanks, from a budding emergency doctor (fingers crossed) !

    I realise you prob wont want to put your email address on a public website, mine is if you would prefer to email it to me.