Archives for February 15, 2008

One of Many

There are cases every physician has that are unforgettable. Most are learning experiences, when time stood still due to the situation, and a lesson was imparted, sometimes with a happy ending for all, sometimes not. The patients aren’t the only ones with scars.

Some of the others don’t impart lessons but are recalled for their sheer drama. Not the fake drama that’s more common (and not memorable), but the real drama of life and death; the ones that stay with me are the ones who ‘talk and die’, the ones I take care of who are awake and alert enough to talk to me and are dead very shortly following. I remember the talk-and-dies.

Several years ago, in my first year out of residency we got a very odd EMS report, the gist of which was ‘we’re coming in, be ready’ without any other details. We rolled our eyes and wondered about the panic that would cause such a report. Now I wish it’d been nothing.

Burned patients engender a visceral response in everyone, and medical personnel are no exception. Every one of us stood back from the EMS stretcher and took in the sight and smell while the report started and ended: 17 years old, flash fire in a closed environment that he got out of himself, hoarse voice, no IV because there wasn’t any skin unburned.

It took a determined effort to step forward and grab the EMS stretcher sheet to move my patient to the ER gurney, and that snapped the group to action, though I was only trying to get myself to do something, anything. As has happened every time I’ve been in a room with a critical patient all the hands moved with a speed and skill you couldn’t choreograph with a week of practice, while voices were muted and only what needs to be said is spoken aloud. The conversation among the team with eye contact was also unmistakable; everyone recognized this patient was most likely doomed, but there’s always a chance, and…

Thin, fit, and as burned as I’ve ever seen anyone. Awake and able to speak hoarsely the AMPLE history was negative, and the E part I didn’t have time to worry about. I told him I was going to have to knock him out and put a tube in his throat to keep him breathing because of the burns in his throat: he made eye contact and said “okay”, and I hoped it wouldn’t be his last spoken word.

The nurses and techs had completely disrobed him, and thickened, dusky gray skin went from forehead to feet, with only three areas of exception: a two-inch area at his wrists where his shirt sleeve cuffs had been, a bikini area where there’d been two layers of clothing, and his feet where his leather shoes had been.

Miraculously a nurse had gotten a peripheral IV at the wrist, which allowed us to give the medications to get him intubated, but the circumferential burns on his arm started to choke off the IV almost immediately.

A femoral central line, then an A-line went in quickly, the first for fluids, meds and access, and the A-line because I didn’t want to have a BP cuff constricting his completely burned arm. Analgesia was the order of the day, and I didn’t have to ask for pain meds to be given: knowing how I feel about liberal pain meds and not wanting our patient to feel any pain, the angels of mercy provided just that.

A quick call to the Regional Burn Center, and they agreed to take my patient, knowing as I did I was transferring them an exercise in futility. The flight team guaranteed a safe and pain-free flight, and my patient left. He died that night.

As he left the Fire Marshall had been waiting to ask me how he was going to do, and filled me in on the ‘E’ part: a 15×30 cinder block building with a door on each end and one window had had carpet on the floor. After the carpet was removed there was adhesive residue on the concrete, and someone other than the patient had the bright idea to pour 5 gallons of xylene on the floor and use an electric floor buffer to get it off. The buffer ignited the vapor when it started.

It’s the only time I’ve ever asked for a Critical Incident Stress Debriefing, not just for me but for the whole staff. I don’t know if it helped any of us, but I tried.

I think about this one. One of many.