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.
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:
- This could have been my son, and
- I need to get this child to the paediatric trauma center NOW.