Little Big Man

We are all familiar with the saying "Actions speak louder than words." It is most often used to connote something favorable and positive. Unfortunately, this quote was the first thing that popped into my head while treating a recent patient.

I had been walking down the main ER hallway, another crazy shift in bloom, when one of my favorite nurses poked her head out of a room.

"Doctor K," Carla asked, "are you free to help me out with this patient?" I didn't even need to give her an answer. When Carla beckons, I come running. Plain and simple, she is that amazing.

I walked into Carla's room to find a patient lying in bed, hands to his face, crying out for his mother. Heartbreaking. His mother was kneeling beside him, whispering quietly in her son's ear. Tears were streaming down her face, too.

The patient was seven. A sweet, scared little boy named Eddie. Eddie had been rushed to our ER to be treated for burns to his face and body. From the doorway, I could see several small blisters with surrounding redness on his bare torso.

What were the circumstances that resulted in these burns? Apparently, Eddie did not come from a good socioeconomic situation and, as a result, lived in a crowded apartment with his mother and several other family members.

The day Eddie was brought to the ER had been an especially cold one. While his family sat watching TV in a room off of the kitchen, Eddie, hoping to be useful, went alone into the kitchen. He had decided that he would warm up the apartment. He grabbed a cigarette lighter and successfully persevered in his struggle to flick the lighter's flame. With his free hand, he turned the oven's dial to "ON." Ready to be a big man and provide heat for his family, he opened the door to the gas oven. Slowly, while holding his arm stiffly in front of him, he advanced the flame into the oven.

Whoosh! A sudden flash of flame was born and jumped out at Eddie, surprising him. He instinctively yelled out as he backed away from the heat. The pain and redness to his skin was immediate. The family called 911 and, after shutting the oven door, turned off the dial. Their quick thinking stopped any further flames from spreading. Eddie, with his mother accompanying him, was brought urgently to us.

I was able to determine that Eddie's burns were "minor." His airway and breathing were stable and his burns were either first degree (superficial, like a sunburn) or second degree (partial thickness, or to the layers just below the skin surface). When you are seven and in pain, though, any burn is considered "major" in my book. Suffice it to say, Eddie's burns were significant but not life-threatening.

While giving him pain medicine, some IV hydration, and soaking his wounds, we discussed Eddie's case with our regional burn unit. They requested we transfer him to their facility for overnight observation. I agreed wholeheartedly. He was a child in pain. He deserved to be treated cautiously, tenderly.

"Eddie," I asked, after we had made him comfortable, "what made you decide to light the oven this way?"

"Mama and Aunt Pammie do it all the time," Eddie said, shyly looking over at his mother. She was now sitting in a chair, beside his cot, stroking his hand.

"To cook?" I asked, rubbing this brave little kid's shoulder.

"No. We light it and keep the door open so we can stay warm." With the colder weather, it turns out, Eddie's family supplemented their apartment's warmth this way. Eddie, after seeing his mother and aunt light the oven several times, thought that he could do it, too. My heart broke a little, in that moment, looking at this thoughtful little boy who sustained burns because he was trying to help his family. He gave his mother a feeble, lopsided grin, the morphine adding to his charm.

"Baby, it's okay," the mother said, stroking his hand. "Aunt Pammie and I should have never done that." She turned to me and continued. "I'm not going to get in trouble, am I?" Although the question seemed self-serving, I was genuinely impressed with her concern for Eddie. She handled her little man with appropriate and abundant love. She even insisted on helping Carla with Eddie's treatment. I felt only good energy with her, discerning nothing suspicious. Eddie, it seemed to me, had a mother that truly loved him.

"No, you're not," I assured her, "but let me have our social worker talk to you about your living conditions and see if there is any available help for your family. Maybe have them come out and check the place out for you."

"Thank you," she said, "We could use some help trying to get the landlord to fix some of them windows."

So, as it turns out, Eddie's injuries were not a result of being negligent or careless. They stemmed from imitating the adults in his life, who were completely unaware of the lessons they were teaching him.

Eddie's situation got me to thinking in that deep, reflective way. How many times through the day do I, as a parent, verbalize to my children what I feel are essential life lessons when, in actuality, my witnessed actions carry more weight than any of my words. Actions that can be both good or bad. Conscious or instinctive. Helpful or harmful. Deliberate or unplanned.

Witnessed or unwitnessed by young eyes. My kids' eyes. Your kids' eyes.

Eddie ended up recovering quite nicely from his injuries and his family was very appreciative for his treatment and good outcome. They could not, however, have been nearly as appreciative as I was of the important lesson they reminded me.

Thank you, Eddie, the little big man. It's not everyday I get a life-lesson from a seven year-old.

As always, thanks for reading. Next posting will be Wednesday, February 3. Thanks for your votes and support in the Medgadget Weblog Awards...much appreciated.

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.