Monday 5 March 2018

Four B's

NOTE: I realise I have not posted anything in three weeks.  I'm sure most people don't give a rat's ass, but there may be one or two of you who have been wondering if I'm ok.  Yes.  Real life, you know.

I may have mentioned it before, but there are four B's that I just don't do in trauma: bones, brains, burns, and babies.  Bones I leave to the orthopaedic surgeons, because while I thoroughly enjoy working with saws, hammers, and chisels, I much prefer wood to bone.  Bone is just too brittle, and wood doesn't heal.  Or bleed.  Brains are a different animal altogether - no one understands how the brain works or heals, so how the hell could I try to operate on an organ that I don't understand.  Burn patients require way too much personalised care and attention, and I just don't have the attention span for that.

And then there are babies.  I don't like working with children.  Don't get me wrong, I love children.  I love my own more than anything else in this world (with the possible exception of Mrs. Bastard), but that probably explains exactly why I don't enjoy paediatric trauma.

Ok, reading that last sentence back I probably could have worded that better.  No one enjoys seeing children get hurt, but goddammit you know what I mean.

No matter how much I dislike and try to avoid paediatric trauma, and in spite of the fact that there is a paediatric trauma center less than 30 minutes from mine, every now and then I still get one.  Some parents (and some ambulance drivers) bring their children directly to me because it is the nearest hospital.  And that is exactly what Cyrus' father did.

Even the overhead page of "Level 1 trauma now" sounded somewhat harried and panicked.  Nah, that's probably just your imagination I thought as I walked down.  My Inner Pessimist reminded me that most "Level 1 traumas now" are gunshot or stabbing victims that have been unceremoniously dumped, close to death, on our doorstep.  But not this one.  This was a fall, which was unusual.

Unfortunately all of our trauma bays were occupied by other patients when Cyrus (not his real name™) was brought in by his father.  Dad was in tears as he laid Cyrus carefully on our gurney in the hallway.  He was seven years old, just a few months older (though much, much larger) than my own Little Bastard.  His eyes were closed, and he wasn't moving.  While that sounds ominous, it usually isn't.  But it could be.  And the last several decades of working in trauma have taught me that making assumptions in my line of work is generally a Very Bad Idea.

I asked Cyrus' father what happened, and he explained that he had been running away from a neighbour's dog when he tripped and fell, hitting the back of his head on the ground.  He had initially been a bit dazed, but he promptly vomited and passed out.  And he hadn't said a word since.

Whenever I hear any sort of "trip and fall" story with a child, my brain immediately snaps to potential child abuse, but not this time.  I have a very good feeling about this sort of thing, and it was entirely evident that this was simply an accident.  I did a detailed physical exam (as best I could in the hallway), and my first finding was a contusion on the back of Cyrus' head.  This isn't necessarily a big deal.  But just as I was about to explain to his father that this was probably a simple concussion, I looked at his pupils, which were unequal.

Oh, shit.

I very calmly explained to Cyrus' father that while this may be just a concussion, I was worried that something much more serious had happened in his brain.  We brought him straight to the CT scanner, and less than 5 minutes later I saw exactly what I did not want to see:


Cyrus had a significant subdural haematoma on the right side of his brain exactly opposite his scalp contusion, something called a contrecoup injury.  As if that weren't bad enough, there was enough swelling in his brain already to cause the right cerebral hemisphere to start pushing towards the opposite side.  This is a sign of severe oedema and an indication for surgery to relieve the pressure.

I took one deep breath, knowing I was about to give a man the worst news he's probably ever gotten in his life.  I carefully and thoughtfully tried to explain as best I could what was going on, but I think as soon as he heard "severe brain injury with bleeding", he tuned out everything else.  While I was explaining the situation, my brain thought of only two things:

  1. This could have been my son, and
  2. I need to get this child to the paediatric trauma center NOW.
Our neurosurgeon was about 30 minutes away, and it would take less time to airlift Cyrus to the paediatric trauma center while they readied their operating theatre and got their neurosurgeon to the hospital.  

An hour later Cyrus was out of our hospital.  And that's the last I heard of him.

Thankfully I had no new patients come in for several hours afterwards, because my brain was stuck thinking about Cyrus and my own children.  This was a simple freak accident, but this adorable little boy could potentially die from it.  There is no reason for me to think the same couldn't happen to one of my children, and it made me consider ensconcing them both in bubble wrap permanently.  I know, I know.  Accidents happen, they are unavoidable, they could happen to anyone, that's why they are called "accidents", etc etc.  I know these things.  I KNOW them.  But my brain won't allow me to rationalise it.

This is why I don't do kids and why I respect the hell out of anyone who can.  Because I can't.


  1. I am glad my 5 kids are grown up now, I worried all the time about them getting hurt. One of my boys came down with Reyes Syndrome when he was 18 months. The hospital here in town couldn’t treat him, so we were taken down to by ambulance to UCSF in San Francisco. Had good care there and got better though I about died from anxiety. Now he is grown and in the Army so I still worry about him.

  2. I cant imagine going through that....

  3. At least the boy's Dad didn't wait, even if he didn't go to the ped trauma center.
    You did everything right & you know that's all you can do.
    I bet the boy's bummed he was unconscious for the helicopter ride.
    I heard our chopper fly over this morning. I can't always turn on the scanner to find out what's happening.
    Our Rescue service is outstanding.

  4. I'm with you, Doc. Once I had my son I couldn't treat kids anymore. It's just too close to the bone. But you did everything you could, and did it right. Bless those who have it in them to heal children, though.

  5. But how does a kid running from a dog fall & hit the BACK of his head on the ground? Unless you slip on ice or a freshly-washed floor, people generally fall forwards, not backwards. Esp. little kids.

    We know did everything you could for that boy, Doc, but maybe he was a child abuse victim... IJS

    1. Sometimes while running away from something, people turn back to look at what they are running from. Sometimes people even run backwards. He could have stumbled and spun or twisted.

    2. For all we know there could be snow where doc is. In the mountains around my house here in LA when it rains early in the year it snows. Snowed up there this weekend even. So slipping on ice isnt out of the realm of possibility.
      Or just slipping on a puddle.

    3. yep, feet go forward, head goes back. it can happen when running, too.

    4. I know falling backwards can happen. I'm just used to seeing oldsters do it when they slip on ice, not kids. The kids in my life are like little ninjas, they run & jump on things & never seem to fall. One is taking parkour classes & some of the stuff she can do is insanely cool. Kids to me seem like they're made of rubber, they fall & bounce but never break. But then I don't work in the ER.

    5. and I have it on good authority I was in the ER getting my head examined three times between the ages of three and five.

    6. Actually, at about the same age, my daughter was at a birthday party, and fell (or was accidentally pushed) off the back of a chair, hitting her head on the wood floor in a similar way. Vomiting and light-headedness meant a trip to A&E, but luckily no bleeding,.

  6. Is there any way for you to follow up with the other trauma center to see how he fared?

    1. probably not. don't know where Doc is (and don't need to know) but where I am, once we hand over a patient to the next level of care, we cease to need to know anything further. unless the patient or patient's family feels we need to know, of course - which the reading audience might consider if you ever experience a miraculous save by emergency responders. most of us become emotionally invested in any significant patient care situation, and then we don't hear the outcome.

  7. parents always get panicky when baby is crying. medics are always relieved. a crying baby means there are several bad things that they aren't suffering from.

    1. Because medics know a silent baby tends to be even worse

    2. silent casualties are never a good sign, screaming ones are usually not suffering from really bad things

    3. if they are crying, you know their heart is beating, they are breathing, and they are conscious.

  8. This is definitely one of the more shocking stories I've read on this blog.

  9. I've been checking in here every day, so I'm glad to see a new post. No worries, though. Life is busy.

    I'm so grateful my two got to adulthood without major injuries. The small ones were bad enough! And it enrages me when people say "we survived without bike helmets/without car seats/riding in the back of a pickup truck." You tit, what about the many, many kids who didn't????

    I'm hoping for an update on the Jahi McMath situation. Any news there?

    1. I apologize for the off topic remarks in advance but just wanted to answer Lisa's question:

      If you hop over to The Medical Futility Blog Professor Pope has downloaded several new court filings. Plaintiffs are attempting to try the issue of whether the current AAN and AAP guidelines are the accepted medical standard to satisfy CA statutory definition of neurological death before determining whether or not Jahi currently satisfies that criteria.

      In Rosen's Joinder in UCSF Application he argues they are doing this to avoid submitting Jahi to a new brain death evaluation because they have already admitted that she would still be found brain dead.

      The court filings can be found under the header Brain Death and sub-header Jahi McMath. Rosen's Joinder contains the most detailed information.

      On April 19 the judge will determine whether or not to allow Plaintiff's motion to bifurcate. Plaintiffs wish to show that the current accepted medical standards to determine brain death are not sufficient to satisfy the broad definition under the UDDA.

    2. Professor Pope just posted the the latest case management statements. Plaintiffs are refusing to submit Jahi to an independent brain death examination because they object to the apnea test. Defendants argue that all of their evidence is old and doesn't reflect Jahi's current neurological status. Her most recent testing was done in September 2014 and those results showed no cerebral electrical activity, no blood flow to the brain and no cerebral mechanism to hear sound.

      Defendants argue that the family's assertion that Jahi developed breasts after suffering brain death is disputed by pre-brain death pictures, her alleged menarche is based on two instances of bleeding in August and September of 2014 and is not supported by her medical record and the latest videos they rely on to prove response to commands are nearly two years old.

      The Case Management Conference on March 16 should be very interesting.

    3. This is reminding me somewhat of the Schiavo case. Teri's parents submitted (well, posted online!) films of Teri following a balloon with her eyes, responding to her family...But of course the issue was different. Everyone admitted that she was alive though profoundly damaged. The issue was actually whether or not she had previously said or indicated that she would not want to be kept alive artificially under those circumstances, so some of this was legally irrelevant.

      Anyhow, upon autopsy it was found that the parts of her brain which would have received visual signals was missing, so she could not possibly have seen anything. If Jahi cannot, because of brain injury, process sound, then any idea that she can respond to requests from anyone are clearly erroneous.

    4. if only judges were a vertebrate subspecies.

    5. Ken,

      You have won the internet :D


    6. I'm frightened that a jury may actually decide whether this girl is alive or dead....this should be left to qualified medical doctors.

  10. My daughter has primary adrenal insufficiency. Every single injury is a worry. I never realized how often children hurt themselves and how bad it could be until I had to deal with worrying if I needed to give her an emergency injection of hydrocortisone everytime she goes bump. (only has happened twice, syncope once and uncontrollable vomitting once) Thankfully, we're close to a hospital and the ER docs are very understanding of our frequent trips.

  11. This would have me in tears!

    I suspect you have to build up an immunity to human suffering to be a medic of many sorts - I could never be an oncologist for example - but dealing with seriously ill children must be very difficult, especially if you have children of your own. Since we had kids, I can barely watch a movie where children are in peril or read the paper when there are reports of kids suffering.

    A friend of a friend works with paediatric palliative care. It's a hugely important job but how she makes it through the day I just can't imagine. It would drive me to despair.

    I will assume that your little Cyrus had a pressure-relieving op' and recovered completely after a few days and a bit of healing time. Just because I don't want to imagine any other outcome!

    We _had_ noticed that you had gone AWOL Doc' - glad everything is OK.



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