Wednesday, December 9, 2009

No Second Chances

In residency, I was fortunate to train at a university hospital that had a burn center, one of approximately 125 centers in the U.S. As a result, we treated victims of all types of burns. While some burns were minor, many were quite significant, requiring months of both physical and psychological treatment. Death was the result of the worst of these burns.

I was working a twelve-hour shift when an ambulance called in. They were bringing us an elderly woman from her nearby residence. She had been drinking and had fallen asleep while smoking a cigarette. A fire ensued. Both her nightgown and couch had been extremely flammable, resulting in very serious burns to her body.

"It's bad, Doc," the paramedic said, ending his call.

Within minutes, the ambulance arrived. Our trauma team was activated and between the ER and trauma teams, we were ready to treat this patient.

Remarkably, this patient came in talking and not in much pain, which was worrisome. "I want to go home!" she said emphatically, obviously intoxicated.

Her injuries were profound. The skin on her arms, her legs, and her torso, both front and back, was either charred or translucent gray, indicative of full thickness burns. She had minor redness and blistering to her face and anterior neck. Her hair and eyebrows were singed.

It's daunting to see a patient so badly burned and not in significant pain. Very disturbing. The smell of her burnt skin and hair permeated the ER.

If I may, I'll briefly explain burns. They are classified by the type and by the depth of burn. Types include electrical, contact, steam, gas burns, thermal, etc. This patient sustained thermal fire burns. Unfortunately, she also sustained secondary contact burns, where the couch and her nightgown melted into her skin. Depths of burns are classified into three categories: superficial (or first-degree) burns, partial thickness (or second-degree) burns, and full thickness (or third degree) burns. Superficial and partial thickness burns, which this patient had on her face and neck, result in pain. Full thickness burns, the worst of burns, extend through the skin and soft tissue beneath it, burning, among other things, nerve endings. Thus, the reason this patient wasn't in extreme pain.

This was bad news. She had partial and full-thickness burns to at least 70% of her body (a morbid percentage). She was going to die from these burns.

Another grim fact was that most of her burns were circumferential, meaning that they completely circled, or wrapped around, her torso and extremities. With serious burns, there is significant swelling and edema. Circumferential burns, in essence, are a tourniquet, preventing the skin from expanding and compensating for this edema. With increasing pressure from the edema, the deep blood vessels are compromised and blood flow is diminished, initially to the extremities and ultimately to the vital organs.

I knew we only had minutes to talk to her and explain the gravity of her injuries. She was in disbelief. I explained that her injuries were-life threatening and how the swelling from her burns would quickly advance to her throat and close her airway.

"I'll do whatever you need if you can just call my daughter," she said, the morbid news settling in. "And can I have a smoke? I'm nervous."

No smoke, but my attending gave me permission to quickly call her daughter. The nurse ran and got a portable phone and I dialed the out-of-town daughter's number. A woman picked-up. Thankfully. It was her daughter. The patient told me to "tell my daughter everything," so I did.

I quickly introduced myself. "Maam," I said, "I'm sorry to call you with this news, but I'm standing at your mother's bedside in the emergency room. She's been involved in a serious burn accident and her injuries are life-threatening. She asked that I call you."

"Will she be okay? Was she drinking?" the daughter asked hurriedly.

I stepped away from the patient and lowered my voice. "Well, yes, it appears she has been drinking. And I'll be honest with you, maam, she's probably going to die from her injuries. She insisted we call you before we place a breathing tube in her airway to protect it from her burns and swelling. She'll be hooked to a ventilator after that."

"Oh, no," the daughter said, hesitating before speaking again. "I haven't spoken to my mother in years. We're estranged."

How damn heartbreaking. "Do you have any other family?" I asked. "No, it's just me. I'm an only child, like my mother. My father died when I was young. We were never in touch with his family."

It's so profoundly sad how many cases emotionally play out this way.

I moved on. "Can you talk to her? Again, she asked us to call you. If there are any words needed to be said, now would be the time to say them." The daughter lived five hours away and it was doubtful she would make it in time to see her mother.

I heard the daughter sobbing as I walked back to the patient's bedside. "Here's your daughter," I said to the patient, placing the phone to her ear.

All around this patient, it was organized chaos. She was receiving excellent medical care--attention to her burns, aggressive IV fluid hydration, and pain medicine. Preparations to intubate her were underway.

We, however, were in our own bubble. I was only interested in one thing--allowing this conversation between mother and daughter to occur. I stood by her cot, near her head, holding the phone as close as I could. I turned my head away, in essence to give her some privacy.

The patient sobbed. "I'm so sorry, baby." "I know, I know." "I love you, too." "I'll see you when you get here."

How sad to summarize all your regrets and feelings into a thirty second conversation.

This patient had been in our ER less than five minutes, tops, but by the time we hung up from her daughter, she was already getting stridorous, a sign that her airway was compromised. We needed to intubate her. I repeated our concerns and she agreed. Her eyes searched mine and she whispered, "It's bad, huh?" "Yes, maam. I'm so sorry, but your injuries are very bad."

We sedated her with adequate medications and successfully intubated her.

After the intubation, as expected, her swelling and edema worsened. Ultimately, this restricted her breathing and compromised her blood flow. Her vital signs became unstable. Before transferring her to the Burn Unit, the trauma team performed escharotomies. These are linear lengthwise incisions through the skin and soft tissue, along the lateral sides of the patient's extremities and torso. This procedure helped to relieve the increasing pressure from the swelling. Despite this, she continued to decompensate.

I learned a lesson that day. Yes, she received excellent and necessary medical treatment. But making that phone call, well, in the end, it was that phone call that was probably the most important thing we offered this patient in her hour of need.

Sadly, she would not be a miracle patient. And there would be no further reconciliation. Her daughter arrived just hours after this patient had passed.

As always, thanks for reading...the next post will be Friday, December, 11. It will be lighthearted.


ERRN4U said...

Touching story.

moplans said...

you are exactly right. that phonecall was the best thing you could have done for her.

Cal said...

I am relieved to hear the next post will be lighthearted! I agree that indeed that phone call was key and the most important part of the treatment, and I am glad that you gave as much consideration to her soul and you did to her body.
(Thanks for stopping by too)

rlbates said...

Thanks for sharing with us.

Maha said...

How tragic for the patient and her daughter. I'm glad that you managed to reach her daughter so that at least they could talk one last time.

IrishPoet said...

wow doc, that's an incredible story and I'm left (almost) speechless by the narrative...I'm a nurse working at a pain clinic but fortunately never have to deal with such trauma, physiologically or emotionally, as you ER docs do. Thanks so much for sharing this and for your other so glad my friend the BlissChick recommended your blog!

IrishPoet said...

PS- as a former hospice nurse, I appreciate your conscious presence to be able to call her daughter and allow them to have even those few seconds together to that brief amount of time they were able to reconcile whatever had kept them apart for years, and that is worth more than all the medical intervention you could provide...many blessings to you

SeaSpray said...
This comment has been removed by the author.
SeaSpray said...

This post moves me more than you could know.

You *DID* Do *THE* most IMPORTANT thing in helping them connect. They got to say they were sorry and that they loved each other.

You gave them both a precious gift..they both said the 2 most important things apology and love.

YOU did the right thing, most compassionate.

mommy-medic said...

Congrats doc- even though nothin gin your drug box or hat of tricks would change the outcome of this patient, you were able to give the patient and her family what they needed most- Closure! I'm sure the daughter cherished that final phone call.

Louise said...

I am slowly making my way through your archives, and am powerfully moved by many of your stories. I also learn so much from your medical explanations; thank you.

Have you ever read the blog of a woman named "Nienie"? She was badly burned in a plane crash about a year ago, and is recovering now. Her story is painful, and hopeful, and difficult, but she is alive and raising her children. Her positive attitude is a thing of beauty.

If you're interested, it can be found here:

Ashley said...

As a premedical student, I love how you take time to clearly and directly explain different medical procedures and details. For example, the background info you provide about burns helps the typical reader to have a better understanding of the medicine behind the situation. Keep it up! I just came across your blog today and I'm quickly and eagerly reading my way through :)