Three children injured at a school gate with a delayed ambulance
You are the only person on duty at a school first-aid room in a semi-urban block in Tamil Nadu. At 3:40 p.m., a speeding van knocks down three children at the school gate. The nearest 108 ambulance is 35 minutes away because of a procession on the main road. You have one first-aid box: sterile gauze, roller bandages, two splints, antiseptic, gloves and a torch. Child A, about 9 years old, lies still, breathing noisily at 8 breaths a minute, with blood and vomit in the mouth. Child B is walking and crying, with a 4 cm cut on the left forearm that bleeds steadily and has soaked the sleeve. Child C sits up, pale, with an obviously deformed right thigh and a swelling the size of a cricket ball; he says he cannot feel his toes. Two teachers are with you, a crowd is gathering, and someone is trying to lift Child A by the arms.
1. In what order would you treat A, B and C? Give the reasoning for the order.
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Order: A, then C, then B.
A first - airway and breathing. Eight noisy breaths a minute with blood and vomit in the mouth is an obstructed, failing airway. In any first-aid system the order is airway–breathing–circulation; a child who is not moving air will die in minutes, whatever else is wrong.
C second - circulation and limb-threatening injury. He is pale and has a deformed femur with a large swelling: a fractured femur can bleed 1–1.5 L into the thigh, so he is developing shock. Numb toes mean the nerve or blood supply is already compromised, which is time-critical for the limb.
B last - but not ignored. He is walking, crying and talking, which means his airway is open and his brain is perfused. His bleeding is steady and compressible. Crying is a good sign, not a reason to attend first.
The common error is to run to the child who is screaming loudest. Triage is decided by threat to life, not by noise or by who is nearest.
2. State your actions for Child A and Child C, including what you must not do.
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Child A (suspected spinal injury with airway compromise)
- Stop the person lifting him by the arms. Lifting a limp, injured child by the arms can turn a spinal injury into permanent paralysis.
- Kneel at the head, hold the head in line with the body, and keep it that way while the mouth is cleared of visible vomit and blood with a gloved finger and a cloth.
- Open the airway with a jaw thrust rather than a full head-tilt if a neck injury is possible; look, listen and feel for breathing.
- If breathing is present but he is vomiting, log-roll him as a unit onto his side - one person controls the head and neck while two roll the body - and clear the mouth again.
- Do not give water or food; do not leave him alone; keep him warm and count respirations every few minutes.
Child C (deformed femur, pale, numb toes)
- Do not pull, straighten or "set" the leg. Do not let anyone sit him up or walk him.
- Immobilise in the position found: one splint along the outer side, padded, bandaged above and below the fracture but not over the swelling.
- Check and record the pulse at the ankle, warmth, colour and sensation in the toes before and after splinting; report any worsening at once.
- Lay him flat, keep him warm, nothing by mouth - he is showing early shock.
- Cover the thigh swelling with a clean cloth; no tight bandage, no ice massage on numb skin.
3. How would you use the two teachers and manage the crowd before the ambulance arrives?
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Give each person one clear job - bystanders with no role become a crowd.
Teacher 1: Go to the road, call 108 with the exact location and the number of injured children, then stand at the gate to guide the ambulance and keep a gap clear. Take the phone number of the school office.
Teacher 2: Move the crowd back at least 10 metres, take the other children into the classroom, and bring the school register so that names and ages of A, B and C go to the hospital with them. Ask the crowd to stop photographing and to stop lifting anyone.
You: Stay with A and C; you are the only person who can assess and splint.
Other essentials:
- Note the time of the accident and the time each action was done.
- Keep a list of what was done for each child to hand over to the ambulance staff.
- Inform the head teacher and the parents, and send one adult to accompany each child.
- Do not send a child to hospital alone, and do not wait for the ambulance if a private vehicle and a driver are available and the child is deteriorating - but only with the head controlled.