Thursday, 11 February 2010

Danger in the Playground

"5! He's only 5!" my mind screams at me, as I drive to my latest call - a young child pinned between a wall and the bumper of a car. For those of you not regular readers of this blog, children are my one fear in pre-hospital care. They are remarkably difficult to assess, wherever you are, and this becomes even worse without all the usual diagnostic equipment found in an A&E Department. Also, injured children decompensate very rapidly. One minute they may look fine, the next they may have no blood pressure or pulse. Add to that the emotional aspect of dealing with a young child, and you have a recipe for severe anxiety.

I arrive at the school, and rush into the playground with my kit, my paediatric bag as well as my monitor. I have to keep focused, despite the urge to run back to my car and hide somewhere.

He's lying on the ground. The car has been moved back a little, and there is just enough room for me to crouch down beside his tiny frame. He looks up at me. "It hurts," he cries. Well, that's a good start!

A quick check, and it is clear that he has a fractured thigh bone, but is, fortunately, conscious and talking. But I am well aware that a little one such as Danny here can bleed out into his thigh, and, as I said at the beginning of the post, their condition can deteriorate at an alarming rate. First things first, I need to cannulate him, so that I can get some fluid into his veins. If I wait much longer, the veins will all shut down and be harder to see than they are now. He's shivering - not just from the cold but also as a sign of blood loss. Come on, RRD, calm it!!

I let Danny and his mother know what I am planning - he is crying, but I don't think he noticed as the needle went into his arm. Damn!! Whilst I am able to get the needle to puncture the vein, it won't thread through. The vein is just too small. I know what needs to happen, and I am less than happy.

In a child, if a vein is not immediately accessible and fluid or intravenous drugs are needed in an emergency, the quickest way to the circulation is via a needle inserted into the shin bone. Yes folks, you read that right. It is called an intra-osseous needle, and it is as nasty as it sounds. I have put lots of them in in my time, but all on unconscious or arrested kids. And it is looking like I am going to have to do my first one on an awake child in the next couple of minutes. My mind goes back many, many years, to when I was a junior doctor, fresh out of Medical School. Her name was Fiona, and she was 2 years old. She looked alright when I first saw her, but, only 45 minutes later, I was helping to resuscitate her. And all because the doctors looking after her wouldn't admit defeat when they were looking for a vein, and wouldn't put an intraosseous needle in early enough. Not this time...

I know the score; 2 attempts at cannulation, then intraosseous. I have one more to go. I take a deep breath, turn to the other arm. Nothing at the elbow. One tiny thread on the back of the hand. I reach for a yellow venflon - tiny and short. My hand steadies. I look at Danny's little face, then back to the task in hand. The venflon slides effortlessly through the skin. I feel a barely perceptible pop as it pierces the vein. A tiny bead of blood appears in the venflon. I slide the assembly forward, so that the plastic tubing over the needle is in the vein. Pulling back the needle, I watch as the blood flows gently through the venflon. Success!!

I've only been on scene for a few minutes. I secure the venflon to Danny's hand (certainly don't want this one falling out) and attach a bag of saline to it. Next, we turn to splinting his leg and carefully we get him on to the ambulance trolley.

Double damn!! I watch in horror as Danny's skin goes deathly pale, as he fades out of consciousness. I reach up and squeeze the saline bag, forcing the fluid in as fast as I can. There's more than just a fractured thigh bone here. I suspect that his pelvis may have been injured, so we cut away his clothing from his abdomen and legs. Oh 5h1t!! He has a 5cm wound on his lower left abdomen, deep and bleeding. He now looks as though he has multiple injuries, and we haven't a moment to lose. We pass a sheet under his buttocks, and tie it across the front of his pelvis, tight, to splint a possible pelvic fracture, and stop any further bleeding. Straight on to the ambulance, and we are off to hospital. En route, I somehow manage to get another line in, despite the fact that we are bumping along a motorway - can't do it while we are stationary, but able to at 65 miles an hour!

By the time we arrive at the hospital, Danny is talking to us again. He has had half a litre of fluid, and this seems to have perked him up. He's out of the woods for the moment, but he's got a way to go before he's going to be on his feet again.

A few hours later I give the hospital a call. He's in Theatre, having his spleen removed and the wound to his abdomen debrided (cleaned up). I say a silent prayer for him, and get ready to go home for the inevitable kid-hugging session.


  1. This is the one reason I stayed out of any type of Emergency Med field for a job.

    Children in pain and I do not mix well.

    Thank you for your service and skills!!!

  2. second blog i have read and i would like to thank you, RDD, for the very good lecture on the child's veins.

  3. I sincerely hope that my kids are never in that situation but if they are, I hope that there will be someone like you taking care of them.

  4. I second what Shelagh said - without you and your colleagues the outlook for the wee lad would have been very, very different.

  5. Any news since on the kid? Do you hear anything at all this much later?

  6. I'm only a first year and already the one overriding fear I have for when I qualify is kids... Put aside the physiological differences, I know that many many medical interventions hurt at the time (intraosseous needles being a good example) and somehow I think that doing that to a child who can't understand at the time that you have to hurt them to help them will be one of the hardest things I'll ever learn to do.
    All that said, fantastic work, both on the blog and on the streets, I came here from The Paramedics Diary and now I want to work in EM even more!