Tuesday, June 27, 2006

Background to Crushed Skull

One Sunday morning about six months ago, I was driving back from seeing an old friend in LA. I drive a pickup and can see way ahead on the road. At the junction of the 605 and the 105 the traffic was jammed. I could see ahead that there was an accident at the junction of an on ramp and the 605. As I approached, I saw only a CHP car and bodies on the ground. Understandably, I have learned over the years that doc's showing up at a medical emergency when medics are on the scene aren't always welcomed and pretty much will normally drive by knowing that medics can do just about everything I can in a field situation. This was a different situation, so I stopped. Pretty chaotic scene. First was the interception by the Chippy... I identified my self as an emergency physician and was promptly asked for some ID, which I produced. After what seemed like some reluctance on his part, he announced to his partner that "This guy says he's a doc". I went to the car most damaged and although I was already to use the Hoag triage method "START", it was clear at first glance that none of these people were going to standup and move "over-here" . Some Chippy's were maintaining airways on the adults in the front. The import vehicle had been rear-ended by a van at what must have been a very high rate of speed. So much so that the rear seat back was at a 45 degree angle from the right rear to the back of the driver side seat. The child in the back appeared to have been sitting on a booster seat with belt, must have been violently launched by the impact.

On the seat lie a KO'd 4-5 y/o male child. Essentially no blood in sight on the child. He had sonorous breathing. I carefully opened his airway and maintained c-spine inline traction. His breathing improved. That was when I felt what seemed like a broken egg shell inside of a thick plastic bag. Still totally non-responsive... must have been quite a sight from the freeway. Medics finally arrived after what seemed like an eternity. First medic on the scene and I got into it a bit when he ordered me to let go of the kid and back out of the car. I identified myself and respectfully refused saying, "I'm not going to let go of his c-spine". After a bit, another appeared with a stablization device and I backed out. I heard one medic say to the other the child's pulse was 80. I think by this time the child was getting close to herniation.

Nothing more for me to do, so I washed my hands off and continued on my way. Not convinced that the medics appreciated the head injury of this child, I called the local trauma center on a hunch that a critical trauma child might wind up there. Spoke with one of the trauma nurses who said that they knew that a critical trauma was on the way. Suggested that they might want to get a peds neurosurgeon there. She was very thankful that I had called. Called back in a few days, kid was brain dead on life support. Skull was indeed crushed like an egg shell. Spoke with the trauma coordinator RN about a potential educational opportunity for the medics on scene.... She was nice and receptive. No hard feelings on my part since it was clear to me that the child had a fatal injury. But, it did stay with me for awhile. Possibly due to being outside the imaginary security of an ED. It was one of those sentient moments after writing this short poem, that I realized I could relax a bit now...

Copyright 2006

Richard Pitts, D.O.

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