Winchester Country Club — fall

Location: Bravo post

Time: 12:01 Friday

Conditions: Cold, light mist

Equipmentfully stocked except only 4 glucometer strips remaining



You’re pulling an overtime shift on the A24 with Chris Samson. Chris is a good kid who’s probably going to be a doctor one day, but right now, he’s been an EMT for about two months. He rode along with you as a trainee and did okay, and he’s been on his own now for a few weeks, working with Janet Cho — about the best senior partner you could ask for.

Right now, you’re hiding at Bravo behind a coffee shop, and he’s been talking your ear off. Kid wants to know everything about everything, which is nice, but sometimes quiet time is nice too. He just hit the jackpot by asking your opinion about spinal immobilization, though, and you’re cracking your knuckles to give him an earful when the radio crackles… (click for audio)

[A24, 2-4, start a response to 158 Winchester Rd… 1-5-8 Winchester, the Winchester Country Club, on the skating rink, for a conscious, breathing 10-year-old with injuries from a fall. With Engine 2 at 12:02. A24?]

Click to expand



You’re behind the wheel, because even though you navigate like a homing pigeon in a magnet factory, you’re better off than Chris, who lives in a different county altogether. You do know how to get to the country club, at least, and have even golfed there; still, you ask him to find it in the map for the practice.

You aren’t as sure about finding the ice rink, but as you approach the gates, a security officer flags you down and does a waving thing that seems to indicate that he’ll guide you. Then he takes off on a golf cart, and you follow somewhat dubiously.

Fortunately, after a few turns you find yourself approaching the outdoor skating rink. It’s not really cold enough for this, but they have some kind of system that chills the ice, and a few dozen families are out.




Ten yards out on the ice, you can see a person down, surrounded by a few more figures. As you hop out, the guard says, “Kid fell and hurt his shoulder. That’s him out there. You gonna go out?”

You look at Chris, and shrug. “I guess.”

Together you load the first-in, airway, and C-spine bags onto the stretcher, plus a board (the irony is palpable) and your sack of splints. Then you step out onto the ice, and begin making your way to the patient, holding the stretcher like a giant two-person walker. It is very, very slippery.

Still, you manage to make it without creating any more patients. On the ground is a young male dressed in winter gear, supine, loudly crying and yelling. A couple is nearby that looks suspiciously like parents, as well as some other onlookers. There’s an awkward pause, then you finally catch Chris’s eye and jerk your head to the patient. Do your thing.



Initial Assessment

He squats down and pats the kid on a jacketed chest. “Hey buddy! I’m Chris, what’s your name?”

“David,” he moans.

“David, what happened?”

“I was skating and I went to turn and I tripped and I fell,” he reports in a rush.

The mother adds, “He’s just learning… this was his second time skating.”

“So what’s hurting you now?”

“My shoulder,” David says, gesturing loosely at his left shoulder. “It hurts so much.”

Standing idly until Chris comes up with something for you to do, you observe that David seems to be fully alert, pink, and breathing quickly but without labor. No trauma is grossly notable, but he’s bundled like a marshmallow, with a down jacket and who knows what other layers. His left arm is positioned akimbo at his left side and he doesn’t seem to be moving it.

The company from Engine 2 comes skating in behind you. “Hi folks,” says the captain.


Now what? you try to telepathically nudge Chris.






“Does anything else hurt?” Chris asks.

“My… the back of my neck,” David moans.

“Did you hit your head when you fell?” He’s still wearing a plastic hockey-style helmet. Thank god for protective parents.

“I don’t know… I think so.”

“Did you pass out for a little bit?”

“I don’t think so.”

His father adds, “I don’t think he did, I was watching the whole time. He just went down and started screaming. I told him not to move.”

“So nothing else hurts?”

“No… aaaaaaagh.”

The kid is obviously in agony, and Chris finally looks at you. “What do you think about ALS? Just for the pain?”

Sounds good to you. “Sounds good to me.”

He calls on the radio, “Operations from the A24?”

Operations answering.

“Is ALS available for pain management of a pediatric shoulder dislocation?”

A pause, then: “24, no ALS in the city currently. Do you want mutual aid from Flatline?”

Chris hesitates and looks to you. You’re shaking your head; Flatline ALS units usually take forever to meet up with you, and are incredibly stingy with narcs. Your own medics often aren’t big on analgesia, much to your chagrin, but at Flatline they’re big believers that “pain never killed anybody.”

“Forget it.”

“Negative, we’ll take it solo,” Chris says into the radio.

He starts eyeballing up and down David’s prone body. He’s obviously a little vexed; the kid is wrapped in layers like a linebacker. Finally, he looks David in the eyes and sadly says: “I’m sorry buddy, we’re going to have to cut your jacket off, okay? Tell your mom it’s my fault.”

“Okay!” he groans. From behind, his mother says: “It’s okay, okay, do what you have to do.”

You slip around to the head. “Shall we start with the helmet?”

You stabilize and support the head with both hands while Chris removes the chinstrap. As he gently slips the helmet off, you reposition your hands to support his bare head. You take a moment to gently palpate the posterior neck and head, which seem okay.

Chris unzips the jacket, and uses his shears to slice down both sleeves. Next comes a thick flannel shirt, which he leaves mostly intact, but cuts away from the left arm and shoulder to reveal the site. You can see a jutted deformity protruding forward from the chest above the axilla.

Chris asks David to squeeze his fingers with both hands, checks radial pulses, and asks if he can feel him pinching on both arms. He can. While he’s working on that, you ask the mother, “Does he have any medical problems?”

“Just asthma.”

“Taking any medications?”

“No… he has an inhaler he uses sometimes.”

“Okay. Any allergies?”



Chris looks unhappy. “I guess we’re going to board him,” he says regretfully. “Um… what do you think?”

You consider things for a moment. You certainly don’t want to roll David onto the injured shoulder. Possibly you could arrange a line of folks to lift him and slide a board underneath, but it’ll be hard to find places to grab that don’t hurt. Best bet would be…

“We should be able to roll him onto the right side if we support the arm.”

Somebody produces your backboard and places it along David’s left side while you help place a C-collar (the infant size fits best, surprisingly). Then you start delegating:

“Okay, can you guys come on the right and help roll him… just make sure you don’t grab that arm. I’ve got the head, you can just slide the board in once he’s up, and… Chris, I guess you have that arm? Just make sure it doesn’t move as we roll him?”

Once everybody’s on the same page, you count three and gently roll David to his right side. You take the opportunity to pull some of his cut clothing away, although you don’t bother exposing the entire back — it’s cold out here and you doubt there’s much to see. Then you roll him back onto the board, rearrange him, and everybody starts buckling straps.

His arm is still poking out the left side, and you’d rather not have it dangle while you lift him. “Can we support this with something?”

Somebody produces a short board splint. After experimenting for a moment, Chris is able to slide it into the lumbar void and leave it protruding to support the elbow. He packs some handfuls of gauze into the gap, creating a somewhat stable structure.

One of the firefighters drops the stretcher and gets it nearby. You position yourself to lift the board, ensuring that it’s exactly where you want it — you know any lateral movement or weight shifts will send your feet flying across the ice. The board is moved to the stretcher successfully, you tape David’s head to a couple blocks, and then cover him with blankets and more straps.

The trip across the ice is cautious but uneventful. Once you get him onto dry land, things become easier, and he’s soon loaded into the 24. It’s pleasantly warm in back, which seems about right for a kid that’s been lying on ice. Chris hops in as mom asks you, “Can I come?”

“Yep, no problem. Chris, where do you want her?”

He shrugs from the bench. “Back here’s fine.”

“Okay, go ahead and step up. Watch your head. Just have a seat back there and buckle up.” As she climbs inside, you ask her, “Is there a hospital that David usually visits?”

“He doesn’t go to the hospital much… he was born at Memorial.”

Which is nice, but they don’t deal with a lot of peds at Memorial ED. “What do you think about St. Vincent’s? They’re a little more used to treating kids.”

“That’s okay.”

To Chris: “All set?”

“Yep,” he replies.

“How do you want it?”

“… uh… whatever… just really smooth.”

“No problem. I’d throw some ice on that shoulder too.”

You shut him in and head off to the driver’s seat. Right on.





Up front, you pop the truck into gear and tell the radio, “Operations, A24.”


“We’re transporting one to St. V’s.”

24 has one patient to St. Vincent’s. 12:28.

You gently nose down the streets, gauging your speed by the rate of groans and screams from the back. After a bit, you hear Chris call over on the radio, and can barely make out his notification: “St. V’s, A24, we’re en route with a 10 year-old male who fell ice skating, A&Ox4, complaining of severe pain and tenderness in the left shoulder. There’s some deformity, no neurovascular compromise. Some neck pain as well, he’s currently boarded and otherwise stable. ETA 7 minutes. Anything further?”

“24, just the shoulder trauma?” they crackle back.

“Shoulder and blunt trauma to the back of the head. Wearing a helmet.” Chris replies.

“We copy, see you soon.”

“Thank you, Ambulance 24 is clear from the channel.”

Not bad. In the mirror, you see Chris performing a quick further neuro exam and taking a blood pressure. For the rest of the trip he just holds David’s hand and speaks gently to him.

Soon enough, you’re backing into the bay. “Operations, 24, on arrival at St. V’s.”

24 on arrival at 12:38.”

As you roll inside, you’re directed toward one of the pediatric rooms, where cartoon animals dance around light blue walls. Moving the stretcher alongside, you and Chris lift-slide the backboard onto the bed. The nurse and pediatric emergency doc trot in at the same time and descend upon David, clucking and reassuring as Chris says from the corner, “David… he’s 10… he’s been learning to ice skate. Took a dive to the side and bumped his head, but he was wearing a decent helmet” — he has it in his hand and holds it up — “didn’t seem to lose consciousness according to his dad, but started having awful left shoulder pain and some pain in the back of his neck. Head and neck look okay, but the shoulder’s sticking out forward. Not open or anything. Uh… he’s C-spined… I gave him some ice for the shoulder but he said it made his hand tingle… we’ve got the arm more or less splinted how he’s comfortable, nice pulse and neuro function. No real history, just asthma. Allergic to penicillin.”

They seem to hear, but they’re already in there clearing the back (there’s a brief debate about whether the shoulder is a “distracting injury”), and they get him off the board in minutes, although they keep the collar on for later imaging. An IV is quickly established, and a milligram of morphine helps David settle down.

As you clean and coil up your straps and board, the physician is explaining to mom that this type of thing is very common. You wish David luck — he seems much happier now — and escape with the gear. In the hall, you make up the stretcher, pile everything on top, head out to the truck and tuck it away.

“Where the hell is all our ALS?” you grumble as you slide into the driver’s seat.

Chris is tapping at the computer. “… saving lives?”

“Yeah, right.” You do your best Steve imitation of a grump. “They might not’ve done anything for him either, but I guarantee you that Flatline wouldn’t have done shee-it. In fact, we probably would’ve been here already by the time we intercepted.”

He nods. “I think that went okay. What do you think? You ever pulled somebody off ice?”

“A few times. You gotta take every situation as it comes. Anything farther or riskier I probably wouldn’t have tried to go out there — you never want to go out onto thin ice, for instance. We probably could’ve dragged him to the edge, but that wouldn’t have accomplished much.”

You jump in and grab your seatbelt. “Nice work though. High five?”

You high five. The kid’ll do okay.



Diagnosis: simple clavicle fracture

The most common fractured bone among kids is the clavicle, or collarbone. It usually presents with severe, sharp pain, particularly with movement, and can be caused by direct trauma, or often by falling onto an outstretched arm (thus transmitting force up the arm and into the clavicle).

Pain management is almost universally undervalued and underperformed by paramedics, and in the case of pediatric pain even more so. Splinting will often help if effectively performed, but it may require high levels of creativity to splint strangely-arranged limbs in a position of comfort.

Astute observers will notice that St. Vincent’s, although a pediatric ED, is not a pediatric trauma center. However, an isolated shoulder injury is not criteria for diversion to a trauma center in virtually any system. Many clavicle fractures won’t even be operated upon.

Be careful on ice.


  1. chris ballet says

    Why would you backboard this kid? No need

  2. If the transport was longer, what do you think about O2 as a pain management tool? I thought to myself “Okay David, I’m going to put this mask on your chest (pointed toward the face for blow by) and when the pain is especially bad, or we hit a sharp bump, put it over your face and take a deep breath, it’ll help with the pain.”

    O2 has noted analgesic properties, no one has to break the sacred seals on the drug bags, and it gives the pt a role to play in his own treatment thus giving him something to focus on. Aaaand even though there are no signs of cranial herniation it gives the pt a leg up if something develops later such as swelling suppressed temporarily by being in a cold environment.

    • Oxygen as analgesia is certainly a widely-taught concept, and for some, widely practiced. But I’d be surprised if you could find any evidence showing that it’s particularly effective, and anecdotally most folks’ experience supports that. If there’s any effect at all, it’s probably almost 100% placebo. Some people can sell it pretty well, but it seems a little unethical to flat-out lie by saying you’re giving someone the greatest medicine ever and it’s going to annihilate their pain, even if that’s the recipe for the most powerful placebo effect.

      The idea that it “can’t hurt,” even when looked at purely under palliative grounds, isn’t necessarily rock-solid either. Oxygen can be pretty uncomfortable (try it for a bit), and also can indicate to patients that they’re “sicker” than they thought, increasing their anxiety.

      In short, it’s certainly something in your toolbox, but I would say it’s something far less effective than usually portrayed in EMT class, and you typically see it used less and less as providers gain experience. Often, I think, it’s treatment for you, not the patient. (“We should do something!” “What can we do?” “Um… oxygen.”)

      Are you hinting that supplemental oxygen might reduce intracranial pressure through vasoconstriction?

      • Not really, no. I don’t know a lot about how O2 changes vessel diameter. I was thinking about how you hyperventilate a pt. with signs of TBI. But in this case with no signs I thought shooting for a solid 100 sat would be nice if the cold had been slowing down swelling to the brain.
        Im now going to go read up on oxygen lol.

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