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.