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.


Comments

  1. Words fail me. That poor kid. I hope he didn’t know that he was going to die. He was fortunate to have you on his team, to at least blunt or remove the pain for his final hours.

    You – and your comrades – are strong people. Thank you, Doc.

  2. 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

    So very true. This post brought back a flood of memories for me. My own talk-and-die’s, not burns. Well said, well said.

  3. I’ve been working in a clinical environment, including the Army’s burn unit, for 2 yrs now (MSIV) and have never been so completely shaken as with a kid I had yest in the peds neuro clinic. 1 1/2 yrs ago, Mom dropped off a normal 18mo boy to day care – “no one knows what happened”, but there was an acute massive subdural with no fracture (coma 17d, hospitalized 4 mo). After the hemicraniectomy, there was some improvement over the next few months, with advances in walking, talking, body control. Seizure onset 8 mo after “accident”, and all milestones abruptly lost; nearly sz-free for 2 mo with trileptal. Now seizing again, 10-15x/d with probable subclinical status throughout the past several days. He is a peculiar mix of hyper and hypotonia, with no motor control (or even attempts) except head and eyes.
    I can’t imagine the family’s stunned reaction and permanent alteration of hopes, dreams, life etc with an “accident” caused by day care personnel.

  4. Wow, intense story. I think burns were the one thing I never saw working there. I think I am glad to spare that experience until later in my career. Thanks for remembering the patient.

  5. I heard your blog radio interview with Dr. A. Liked your presence and comments althou I find myself little interested in the clinical these days. You have really captured it in this piece. It reminded me of the strong hold it always has. This moves one as much as an earlier piece you did on your grandfather and a gun.

  6. Thank you. At times, I sit down and remember those who need remembering: The child who was just walking up his driveway to go into his house when the car that lost control pinned him to the wall . . . , The old man who was sent from the NH to die with no family or friends to notify so we held his hand so he doesn’t go alone . . . , The young woman who delivered twins at home and bled out in the back of the ambulance before her husband got to see her . . . , The firefighter who stepped on the live wire while cleaning up the scene . . . etc. etc.
    They are always there. They hide behind the drug seekers and the whining Centers Of The Universe. The peek around the STDs and cough for 4 months. But they are there and they rely on us to keep those last moments for them.
    Thank you for reminding me of my obligations today. Thank you for reminding me that they are why I go back day-after-day. To remember them, and to fight like hell to keep their numbers as small as I can.

  7. Reply #6 got to me. Thank you, Ed Greg, for your powerful words. NOW I know one more reason why Mr. and Mrs. Fred are so proud of our GruntDoc.

  8. Very nice post, GruntDoc. And nice comments.

  9. Excellent post

  10. Awesome post, thank you for sharing the story.

  11. I helped out on a similar case, except this individual accidentally spilled lighter fluid on their clothes while burning some garbage. Nothing quite like that – that’s one that I won’t ever forget.

  12. The ones I have the most difficulty with are the parents who lose a child. I never have the words… and that’s probably OK… they wouldn’t hear or remember them anyway.

    I lost two infants in two days last month… one barely 2 weeks old, and one 2 months old.

    There are days when you question why you do it.

  13. I remember the many severe burns patients I saw when doing ER in South Africa before I went into paeds. It’s horrible cannulating a charred arm. Good work, my man.

    btw, did you feel the destressing debrief worked?

    Dr Thunder
    http://www.twoweeksonatrolley.blogspot.com

  14. Oh crumbs.

    And who thinks, if your 18-year-old kid decides to get an hourly job as a carpet installer/remover, something like this might happen?

    You ER doctors and ALL ER personnel — huge kudos for being there. Somebody has to be, when these things that should never happen to people who should never expect them… do.

    sorry this ended so badly. Sorry he wasn’t some tough leather guy, with at least 3/4th of his torso protected. What? little shirt cuffs? That just so weeps.

    Man, I am wishing you and your colleagues all kinds of good vibes and strength…

    tl

  15. As someone who works directly with ER docs (as a scribe), I’ve caught myself becoming increasingly cynical and less sensitive. I know that it’s a coping mechanism that helps us all get past the difficult or manipulative patients, but your post has reminded me of why I want to become a doctor and help relieve suffering. Thank you for this and all of your on and off-line guidance.

  16. First time poster, long time reader. Love the site.

    I’m not a Dr., nor have I ever played one on TV. Which keeps me from commenting on 99% of these entries, as I have absolutely nothing to offer. Until now.

    In ’01 I was on a chopper in one of the ‘stans when it went down. The pilot did a hella awesome job trying to autorotate it in, but it still tilted enough that the main rotors tore loose and then cracked the fuselage like a can opener. Introduce both a bunch of fuel and a bunch of flames, and you have a recipe for bad stuff.

    All of us got out OK, but a few of us got burned. I got lucky. Even though there were plenty of burnt holes in my BDU’s, the tissue under these holes was mostly small 1st and 2nd degree burns.

    But some of the fuel splashed onto my left boot and caught on fire. One of the guys got to me pretty quickly with the extinguisher, but it was still long enough that the cuff of the boot just completely melted onto my ankle. Our medic did what he could, but they got me back to the rear most ric tic.

    The surgeon tried to be gentle, but prying that melted leather off my ankle sucked. Even with a copious amount of morphine, it still sucked. I was screaming and twitching all over the place. They say that if it’s a 3rd degree burn you’re not supposed to be able to feel anything because all of the nerves are burned/ dead. I call shenanigans, because it HURT.

    But the worst thing was I no longer had blood getting through. If they didn’t do a skin graft, I could lose my foot. It was my left foot, which, you know, I never really use, but I decided to do the graft anyways.

    In some ways the graft hurt as much as the burn.

    Here are some wonderful before and post-graft pictures:

    Before graft:

    http://www.putfile.com/pic/7721694
    http://www.putfile.com/pic/7721695
    http://www.putfile.com/pic/7721689

    After graft:

    http://www.putfile.com/pic/7721693
    http://www.putfile.com/pic/7721692
    http://www.putfile.com/pic/7721691
    http://www.putfile.com/pic/7721690

  17. Such a sad story. Thanks for sharing it… :(