A Scald in the Kitchen and a Grandmother Who Collapses

Evaluation. Toothpaste and ghee are both wrong. They are not sterile, they trap heat in the tissue, they seal in bacteria, and they make it impossible for a doctor to assess the depth of the burn; the ghee also has to be scrubbed off later, which is painful. Rubbing the area, which the child is trying to do, must be stopped.

Correct sequence:

1. Stop the burning - remove the child from the source, switch off the gas, and take off the wet dal-soaked clothing gently; do not pull away cloth stuck to skin.
2. Cool for 20 minutes - hold the forearm and chest under gently running clean tap water at room temperature (not ice, not ice-cold water, which damages tissue further). Cooling reduces pain, heat penetration and swelling. Twenty minutes is the evidence-based minimum.
3. Do not burst blisters. They are a sterile dressing made by the body.
4. Cover loosely with clean, non-fluffy cloth - a clean cotton cloth or sterile gauze. Do not use cotton wool, which sticks.
5. Keep warm, give fluids - wrap the child in a sheet, give small sips of water or ORS if fully conscious. Burns cause fluid loss.
6. Refer to hospital. Do not apply anything else while waiting for transport.

Referral is necessary because:

• The patient is a small child - a burn covering roughly 9% of the body surface measured by the child's palm (about 1% per palm) is a significant burn in a 3-year-old, whose skin is thin and body fluid reserve small.
• Blisters are present, which means at least a partial-thickness burn that needs proper dressing and tetanus cover.
• The chest is involved - burns on the chest, face, hands, feet, joints and genitalia are always referred because of scarring, contracture and breathing risk.
• There is a risk of shock and infection, and pain control beyond paracetamol is needed.

During the journey:

• Keep the burnt area covered with a clean, damp (cool, not cold) cloth and do not let it rub against the bike or clothing.
• Do not apply toothpaste, ghee, ink, turmeric or ice en route.
• Give sips of ORS or water if the child is alert, to offset fluid loss; stop if he vomits repeatedly.
• Keep him shaded and warm, and hold him securely - a fall from a bike must be prevented.
• Note the time of the burn and take any medicine details; ask the health worker to assess tetanus status.
• If the neighbour's bike is the only option, ride slowly and call ahead to the hospital or the 108 ambulance service if available.

Key judgement: an elderly diabetic who has not eaten since morning and now sweats, looks pale and feels dizzy is most likely hypoglycaemic until proved otherwise. This changes the priority - sugar, not just rest, is the treatment.

Management:

• Lay her flat on her back, raise her legs about 30 cm on a pillow, loosen tight clothing and move her to shade and fresh air. This restores blood flow to the brain.
• If she is conscious and can swallow, give 3–4 teaspoons of sugar or glucose in half a glass of water, or a sweet biscuit, then a slow-release carbohydrate such as roti once she is better.
• Never pour liquid into the mouth of an unconscious or drowsy person - the risk of choking is greater than the benefit.
• Check breathing; if breathing stops, start rescue breathing and call for help.
• Do not give insulin or any oral diabetic tablet at this point - that would deepen the low sugar.
• Refer her to hospital regardless, because a first episode of collapse in a diabetic on treatment needs blood sugar measurement and review of the dose.

Call for help earlier if: she does not become alert within a few minutes of sugar, becomes confused or unconscious, has a head injury from the fall, or has chest pain or one-sided weakness suggesting a stroke. The child and the grandmother together mean Rekha must call a neighbour immediately - one adult cannot safely manage both.