This is, in part, me telling a story and in part me asking for feedback.
We were away from our usual area when the job came down, by some luck we were on the corner of the road that the call was from, “GP surgery – three month old baby – dehydration”. We were so close to the job we reached the surgery before they had finished making the call.
Into the surgery we walked and one of the receptionists led us through to the room where the patient and her parents were.
As I walked into the consulting room my heart skipped a beat and my stomach turned over – this child was incredibly ill.
She was so ill I had to carefully check that she was still breathing.
My crewmate got the child out to the ambulance (where most of our equipment is) while I listened to the GP as he gave me a history of the child. Small for her age she had been vomiting for a few days, now she was severely dehydrated. This is why she looked like one of the babies they show on the news when there is a drought or famine in another part of the world.
I actually jogged back to the ambulance – this was a child that needed to be in hospital as quickly as possible.
A 'capillary refill time' is a good measure of how poorly a child is, you press on the nailbed of the child's finger and see how long it takes the blood to flow back. In a healthy child this is less than two seconds. In this child it took five seconds for the colour to run back to her finger. Her fontanelles were sunken and she was not responding as a child her age should.
We thought about starting treatment on the child immediately, but as the hospital was six minutes away we instead decided to make a run for it.
It's not often I blue light someone into hospital with sweaty palms, but this was one of those occasions. I had a very real fear that this child was going to die in the back of the ambulance.
Straight into resus went the child, to be surrounded by doctors and nurses who could start treating her.
About twenty minutes later we'd finished up our paperwork and my crewmate went back into the resus room. We thought that they would have started treatment, but it would seem that they hadn't even managed to start rehydrating her.
I checked with one of the top paediatric nurses at our regular hospital – she agrees that the child was incredibly sick and needed access for re-hydration immediately.
There is a problem working for the LAS, something that I'm going to elaborate on in a short while, and that is that there is little further training and no clinical feedback on the jobs that we do*. As this was a 'strange' hospital, I don't have an easy way to find out the outcome of this job, or if what we did as an ambulance crew was the right course of treatment.
There are two ways that we could deal with this child – we pick her up and the only medicine we use is diesel. Which means that I drive her quickly to where the experts are – the doctors, nurses and other clinicans at the hospital. In this case this is what we did.
The second option is that we spend a little long out on the street. We could have tried to get some fluids into the child immediately. Why we didn't do this was due, in part to our lack of experience.
There are two ways we could have got fluids into her – the first was to place an IV line into a vein – this is incredibly tricky with a small child at the best of times, let alone one that was so dehydrated as her veins would have been collapsing.
The other way would be via an IO needle. This is a large metal needle that you punch through the skin and into the bone marrow of the shin. The needle is then left sticking perpendicular to the surface of the skin and secured in place. (You can take a look here for some images )
The problem with this is two-fold. Firstly you are stabbing a tiny baby in the bone. I make no qualms about this, but it's something that fills me with no small amount of fear.
But what causes this fear? Quite simply this is the second problem – In over ten years of emergency medicine I have seen this procedure carried out twice. Once when I was an A&E nurse and once as an ambulance worker. In this country at least it is a very rare procedure. My crewmate (who would have to actually do this as she is the paramedic) has never seen one done before outside of the classroom that she sat in about six years ago. Due to this lack of experience and training we don't have the confidence to perform this sort of intervention.
So we had to balance it out as to what to do – are we going to do something that we are barely trained for and have no experience of, or do we 'scoop and run' thinking that the hospital would do it straight away?
Of course, we had hoped that the hospital would have gained that blood system access straight away, so when they didn't it had both me and my crewmate wondering if we had done the right thing. If we'd put that needle in on the side of the road, would the child now be getting the fluids it desperately needed?
So I'd like to ask those of you who have experience of such things – what would you have done? Would you have done as we did, no treatment and a six minute journey to hospital, or would you have 'stayed and played' on scene for maybe twenty minutes doing something that you don't feel trained for?
I don't feel ashamed to say that it has given me a crisis of self reflection, and of confidence.
Sometime in the next two weeks I'm going to highlight the problems with training in the LAS – then offer a solution, so this post isn't really about our training. You will have plenty of chances to comment on that when I do those posts…
*Not strictly true – there is always the coroner's court.