An Unexpected Visitor

For prehospital providers, each shift brings us many new experiences, some of them funny—and some very serious.

On a warm fall evening around 8:30, we were just finishing a late dinner at the station when our 4-person paramedic engine company was dispatched to a motor-vehicle crash with a reported passenger ejection. The crew mounted the truck, donning our protective gear and traffic vests as we discussed what we might encounter once we reached the scene.

As we began to pull away from the fire house, a white pickup truck swung in front of us, blocking our path. We’d barely begun to direct the truck out of our way when the occupants emerged—including a woman holding an infant limp in her arms, blood visible around the head.

This was definitely an unexpected visitor; I was stunned for a moment, trying to get my bearings. Then we scrambled from the truck as the captain radioed for another unit to respond to our call.

Five people descended on us, all of them speaking Spanish except for one man who translated for us in broken English. As we began to assess the baby, he told us he had seen the crash—it was only a mile from the fire house—spotted the mother and baby, put them in his truck, and rushed them to the fire station.

Our patient was an 8-week-old infant with an altered level of consciousness, poor respiratory effort and rate of about 10 breaths per minute, pale skin around the face and lips, blood and obvious deformity about the head. Clearly this child was in need of emergent medical intervention.

Placing the infant on the floor, we established and maintained manual spinal stabilization and opened the airway, which proved to be obstructed by blood and secretions. A bulb syringe was used to clear the fluids and we inserted an oropharyngeal airway, followed by assisted ventilation using a pediatric bag-valve-mask device. The infant’s level of consciousness did not improve.

As we worked, the mother explained through the translator that she had been riding in the passenger seat of the family car, the infant unrestrained in her lap, when the car was struck by another vehicle. The infant was ejected out the side window and traveled about 20 feet through the air before striking the roadway.

Her description of the crash and the injury mechanism gave us a high index of suspicion for cervical spine trauma. Because of the infant’s poor respiratory status, we had been preparing to perform endotracheal intubation—but this information made us hesitate. I am an advocate for intubation of the pediatric patient in the prehospital setting, but the procedure should never be applied without first weighing the benefits against the risks. Under the circumstances, we deemed it better to avoid a difficult intubation that could increase the risk of moving the cervical spine. We therefore redoubled our efforts to maintain the airway with OPA and assisted ventilation. The infant’s oxygen saturation, initially 90%, improved gradually to 100%.

Our circulation assessment showed absent distal pulses and a weak, rapid central pulse. A pediatric vacuum splint was used to immobilize the child as we prepared for transport, placing the child in the ambulance. The mother had no physical complaints and refused treatment or transportation. A community assistance team was summoned to meet her at the hospital.

En route to the receiving facility, we established intraosseous access and verified patency. A fluid bolus of 20 ml/kg was delivered and blood glucose level checked. No new findings came to light during the rapid trauma assessment and detailed physical exam. We continued our course of treatment until we reached the trauma center, only 5 minutes away. The total time that elapsed from the infant’s arrival at the fire station to delivery at the hospital was less than 20 minutes.

As I write this, the infant remains in very critical condition with a significant closed head injury. I continue to think about this call, as it raises many issues faced by EMS providers everywhere—issues we must seek to resolve. The bystanders in this case made several errors in judgment, from traveling with an unrestrained infant, to moving a trauma victim, to leaving the scene of the crash when help was on the way. All of these errors contributed to the tragedy, although we will never know to what extent. What could have prevented these mistakes? How can we keep them from being made again?

Most EMS agencies these days have active safety education programs geared toward children, but how many of us have programs that target adults, especially parents? Especially parents who are difficult to reach, because of language barriers or cultural issues?

We need to improve communication with every segment of the communities we serve. New programs can be developed to meet this need—the Phoenix Fire Department is always designing new outreach programs to serve our citizens.

Yet we should also recognize the influence we have to educate people individually, outside of formal programs. I have often wondered why it is that, when interacting with the communities we serve, we don’t always use our opportunities for the “teachable moment,” the chance to discuss ways to live more safely from day to day. Through budget cuts and shrinking resources, it is our ability to adapt and reorganize that makes the profession we work in both challenging and gratifying.

Improving care by any means, including outreach, education, and individual efforts, is just as important as improving our response times. Far better to use every teachable moment, and hope one day to see those we serve at outreach programs, than to encounter the unexpected visitor at our doorstep.

Mr McDaniel is a paramedic with the Phoenix Fire Department in Arizona.
New Pediatric Terrorism Resource Provides Much-Needed Information

New Pediatric Terrorism Resource Provides Much-Needed Information

Content experts from around the country have been recruited to develop clinical information, equipment lists, medication dosages, protocols, and training materials for the PTDPR, which will include slides, handouts, and lecture outlines. In this resource, busy pediatricians will find all the material they need to provide guidance to hospitals, schools, EMS agencies, and the community regarding children’s unique needs in the event of terrorist acts. The resource will thereby save them valuable time while facilitating planning efforts.

Although many curricula and courses have been developed to address many aspects of preparation for events of terrorism, none of the available resources contain specific pediatric guidance or clinical guidelines, nor do they point to pediatric resources in the community or on the Internet. This reflects a problem of national significance, which CPEM and the AAP hope to resolve through this important work. Development of the PTDPR is funded by the Agency for Healthcare Research and Quality.