Posted by: medicblog999 | July 10, 2009

Trust me, I wont lie to you!

cryingChild

Im sitting on standby enjoying a good film on my ipod (who says standbys cant be fun? Its all about gadgets!) when the MDT springs into life and the most annoying alert noise comes blaring out of it.

However, it gets my attention and I quickly gather the information that I am going to be heading to a 6 year old girl who has been knocked over by a car, is conscious and breathing (That’s Good!!!), but has apparent leg injuries.

I set off and within about 10 minutes arrive on scene. As I approach, I see a girl lying on the ground, cradled in a ladies arms (I assume, the mother), she is crying and doesnt appear in imminent danger of something terrible happening. The incident is in a small street and so I park my car across the road to stop any cars coming through, remove my kit bags and cervical collar and go over to the girl.

As I approach I am looking at everything, trying to take it all in, and do my “scene size up” before I even get to the girl.

I notice:

  • The car that hit her is half parked on the kerb, half on the road. There is no apparent damage to the front end, no bullseye on the windscreen, no dents on the bonnet (all good news)
  • The driver is out of the car and sitting on a wall, obviously shaken up, appears to be a well dressed man, doesn’t look intoxicated or altered by drugs etc (something you cant help but think about these days)
  • My car is blocking the road behind me, so I feel safe from behind, but I will need someone to watch the road up ahead and stop traffic coming right down the road.
  • There doesn’t seem to be any other vehicles involved
  • There appears to be only one patient
  • There are no police on scene yet, and there may not be any ambulance backup coming yet as the call was initially prioritised as a Cat B. Only Cat A jobs get automatic backup sent to follow a rapid response car.
  • The patient is conscious alert and orientated and looking at me as I approach, good colour and crying, therefore A,B,C and D seem all ok.

All of this in about 5 seconds, then I arrive at the patients side.

M999: “Hello, Im Mark from the Ambulance, whats your name”

Beth: ” Beth” (still sobbing and crying)

M999: ” And who is this with you, is this your mam?”

Beth: “Yeah…..”

M999: “Hello Mam, what happened”

Mam: ” We were just about to get into the car when Beth just walked out to the other side of our car and was hit by him over there” (pointing to the man sitting on the wall, looking a little bit pale)

M999: “Ok, did you see exactly what happened? Did she get thrown onto the road?, was she thrown over the top of the car? or pushed back onto the pavement?

Mam:” No, not really, she just sort of bounced off the side of the car and landed here”

M999: “Did you see how fast the car was going?”

Mam: “it’s a quiet street, he didn’t seem to be going fast, maybe 30mph”

I now turn my attention to Beth, as I ask her where it hurts I have a quick look over her. She tells me her left leg is hurting, which is no surprise as it is sticking out at a very odd angle and it doesn’t take a doctor or a paramedic to realise that she has a nasty break in her lower leg.

I quickly start checking over the rest of her as especially in kids, they become focused on the obvious painful injury which may not be the one of most concern for me. My rapid trauma survey suggests no apparent injury other than an isolated but nasty left tib/fib fracture.

Just about this time, dad turns up, takes one look at his daughter then heads straight over to the driver of the car, screaming and shouting, ready to rip his head off.

Still no police yet, so I decide to jump up and get between them.

M999: “come on mate, we don’t need this right now, Beths hurt and she needs her dad. I need to concentrate on her too, so I can’t be doing that whilst I’m trying to stop you from getting yourself in bother can I?”

Dad decides to walk away and comes to see Beth, he takes one look at her leg, then gets up and starts back towards the driver.

M999: ” don’t!, get back here now and stay with Beth, this really isn’t helping things. The police will be here soon and they can handle everything else ”

Dad finally comes back and sits down, and the focus again turns back to Beth.

I give Beth some entonox (gas and air) to see if that helps her pain any. She takes it surprisingly well, and it is giving her some analgesic relief but I know that I am going to have to pull her leg straight judging by the angle is is sitting at.

I really want to give her some Morphine, but I know that it is going to be really hard to cannulate a distressed six year old with no emla cream (local anaesthetic cream to numb to back of the hand).

M999: ” Beth, you know how your leg is really hurting? ”

Beth : ” yeah….. ”

M999: ” well, I want to take some of that pain away, I want to see if I can make you feel better….. Do you understand?”

Beth :” yeah ”

M999: ” well for me to help, I need to put a little tube in the back of your hand so that I can give you some special medicine, would that be ok? ”

Beth, takes a moment, looks at her mam who tells her it will be okay, then she turns back to me and asks…

Beth: ” will it hurt ?”

One of the main rules of looking after children is not to lie. You will get away with it the first time, but after that, all trust is gone and if you say something wont hurt again, they wont believe you and you will loose co-operation.

M999: “Yeah, it will hurt, but only for a tiny amount of time. You’ll say  ouch, but then it will be all finished and I can start to take some of the hurt away from you

Beth ” Ok then”

As quick as I could and not without a  little bit of relief on my half, I managed to get the 22g cannuala straight into a vein on the back of her hand. She didnt even flinch. I quickly made up 10mg of Morphine in 10mls of saline and gave her a loading dose of 2mg IV. I also finally hear the sirens of both the police and my back up crew. After a few minutes, Beths pain had started to ease, and my crew mates had arrived. I told Beth that I was just going to have a chat with my friends and tell them all about how brave she was.

I went over and gave a quick handover, then one of my colleagues and I returned to Beth to tell her what we were going to do next. I had already cut away her trouser legs, socks and shoes and noticed that her left foot looked a little dusky and I couldn’t feel a pulse in her foot. The skin was intact over the site of the break but you could almost see the end of her tibia pressing hard against the underside of her skin. This left us with only one choice……to pull her leg straight before we splinted it.

M999: “Beth, hows the pain in your leg, does it still hurt?”

Beth: ” Yes, but its a bit better now”

M999: “That’s really good……….Beth, there is one more thing we need to do, and I’m going to tell you all about it, because it may seem a little scary. You know how your leg is poorly and doesn’t look like it usually does? (She lifts her head from her mothers lap and glances down at her deformed leg, before burying her head back in her mothers lap) Well, what I have to do now is make it look like normal again. To do that, Im going to have to give it a little pull, just like when mam tries to take your shoes off at home. Is that OK?

I said it to Beth, but at the same time was making eye contact with mam who looked absolutely mortified about what I was about to do. I gave a silent nod of my head to mam and she said OK.

Beth: “Is it going to hurt?”

M999: “Yeah,it is, but remember when I put the tube in your hand, that only hurt for a tiny bit didn’t it?”

Beth: “Yes”

M999: ” Well this is going to be a bit like that, its going to hurt, it might even make you shout out, and if it does you can shout as loud as you want, but I promise that after its finished, you will feel a little bit better.

Beth:  “Really?”

M999: “Yes really, you can trust me. I haven’t lied to you have I? I’ve told you when it was going to hurt and when it was going to get better, and this is no different…….so shall we just do it?”

Beth: “Ok”

M999: “Right then, you cuddle into mam. Dad…..Do you want to come in here too and hold Beths hand?……………………”

I positioned myself at her foot and placed one hand across her foot and the other around her ankle. My mate from the ambulance held onto Beths thigh and prepared to give some counter traction.

M999: ” Okay Beth,here we go. 1…..2…….3!

As smoothly and quickly as possible I brought the leg back into line whilst maintaining traction along the length of the leg. The leg straightened well and the end of her Tibia which was pressing against her skin disappeared a bit deeper into her leg, reducing the risk of it breaking the skin and causing a higher risk of infection. Beth let out a scream, but it was all over in 3-4 seconds.

Mam and dad were both crying.

Beth took some deep breaths, wiped away her tears and said

“Its okay mam!”

We placed her now much straighter leg into a vac splint and I check for pulses in her foot again. They had returned and her foot had started to pink up again. We loaded her onto the stretcher and I gave her a little more morphine to keep her comfortable during the 20 minute journey to hospital. She seemed much more at ease once we were on the vehicle and she became quite chatty, when she wasn’t drifting off into a nice relaxed opiod nap.

I still cant believe what a brave girl Beth was. She actually helped me through that incident. I can look back on that job now and think how well it went. But that was down to Beths compliance and acceptance of what I was wanting to do with her. I have known many adults kick up so much more of a fuss with similar injuries than Beth did.

She was truly remarkable.

That is why I will always tell children what to expect. It doesnt always work, but the vast majority of the time, it does.

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Responses

  1. Thank goodness Beth got hurt there. I have no protocols for pain management in children and, even if I did, only IV morphine.

    And I’m not lying either.

    Great post Mark and good work!
    Can’t wait to see all the options you have open.
    HM

  2. Best post I’ve seen anywhere in a while Mark, well written.

  3. Nice job. I had a similar job involving a 6 year old who had multiple #’s and dislocations in one arm. She was fantastic as well. Come to think of it I’ve had to give IV Morphine to a few kids recently and they were all as good as gold. Far better than a lot of adults. Like you say honesty is the best policy. I usually lightly pinch the back of their hand and say it’ll feel like that. I know some Paramedics who wouldn’t even contemplate cannulating a kid but are more than happy to dish it out to any adult. I try to treat every kid as if they are my own. It’s also good that we’ve got Oramorph as an option as well. Good job mate.

  4. Nice job 999.

  5. Well written post, almost as if I was an observer next to you.

    Thanks for writing up the job in such depth. It’s the closest invovlement you can get apart from running the call yourself.
    I haven’t had much to do with paeds at all in my massive 15 weeks of experience out on the road, so I’ll keep this in the back of my head if I come across a similar situation.

    Keep up the good writing!


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