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Training Day

Posted 30 November 2004, 12.00 am by Duncan-O

I feel glad I drank an extra cup of coffee as I unbutton my green woodland-pattern fatigues and pull on a pair of powder-blue OR scrubs. It's my first day training in the burn ward at Brooks Army Medical Center--indeed my first day training in any hospital--and I'm still rubbing sleep from my eyes in the hopes of not making any mistakes. I'm having a little trouble pulling the surgical shoe covers on over my combat boots so I stumble a little when my hand shoots up at the call for two volunteers. The RN fixes her steely eyes first on Private First Class Kamena, then on me.

"Are you ready?" she asks? We both answer in the affirmative. "Good. Prepare yourselves for what you're going to see." She ushers us around the corner to the OR anteroom and all thoughts of caffeine are driven from my mind. Through the observation window, I see a naked man lying on the table. My eyes are drawn away from his blistered face, away from the charred, yellow-white patches indicating 3rd degree burns covering his body, and to the fasciotomy cuts running from his ankles to his groin and to his hips.

One of the many complications caused by a major burn is twofold: swelling and a loss of elasticity in the skin. In the limbs, this can cause a tourniquet-like effect that cuts off blood flow and eventually life in the extremities. The only way to relieve the pressure is to incise the skin the entire length of the burn.

The patient has similar cuts along his arms and torso. His insides are laid bare through the incisions; muscle, bone, blood vessels, and fatty subcutaneous tissue exposed to the air. A necrotic mass of tissue hangs out of his lower leg where dead muscle was already removed because of the danger of infection.

"We need your help in there, quickly," the RN's voice pulls my attention back to her already masked face. "I assume you know how to put on a pair of surgical gloves?" I wonder what I could possibly do to help this patient. I've trained to be a combat medic--tourniquets and CPR is about the extent of my knowledge. Following her closely, I glance at the ID placard on the door. PFC_______, 23. Burns over 80% of his body. He's my rank but a few years younger. I briefly wonder about his family.

The OR is hot, over 92 degrees. Hypothermia is another major danger to burn patients--they have lost their protective layer of insulation. I'm anxious to do anything to help--start an I.V., draw blood, monitor vitals--anything within my limited scope of knowledge.

"Stand at the feet and raise his legs when I tell you to. He has to be scrubbed for surgery." I gingerly take hold of the patient's ankles, taking care to avoid aggravating the fasciotomies. Ruefully, I consider the futility of my gesture since his legs are scheduled for amputation at the knee. As I lift the patient's legs above my head, a piece of equipment attached to his toe snags and pulls free. I feel like kicking myself but I inform the doctor that I just removed the pulse oxymeter.

"Don't worry. We'll deal with it," he responds.

The patient is a large one and his legs are heavy. I start to sweat from the effort and the heat in the room. I notice that other than his genitals and a narrow swathe of his chest, his feet are the only part of his body left unburned, probably protected by his own boots. Finally the nurse is done washing him off, and I lower his legs.

I stand to one side, out of the way as the room begins to fill with personnel. The RN tells us we can leave at any time, but my eyes are glued to the events unfolding in front of me.

"Blair blade," one doctor seated by the patient's left arm says with his hand extended behind him. This part, I think to myself, is just like TV. The assistant hands him the tool. It's basically a straight razor affixed to an adjustable guard so it can be employed like a cheese slicer, and this is exactly what the doctor proceeds to do. Off comes after layer after layer, not unlike peeling a potato. The doctor carefully slices a tattoo off of the patient's upper arm and then answers my question with a terse, "This is called an escharotomy. The dead skin must be stripped away--we shave until it bleeds." And bleed it does. Towel after towel gets soaked through, and soon the doctor gives up reaching for the hamper and drops them on the floor as they need to be replaced. Despite the presence of the red biohazard trash can, wasted scraps of skin begin to pile up on the floor and table.

Another pair of doctors is at work on the patient's legs. Apparently the burns are too severe to save the skin, so one is using an electric scalpel to remove patches of flesh the size and thickness of steaks from his thighs. The smell of burning flesh permeates my own mask and a thin haze of smoke hangs in the light of the overhead lamps. I glance at the monitor and marvel to myself how his pulse and blood pressure can hold steady even as they strip him of his skin.

I move to the other side of the room in order to gain a different perspective. On a side table, an OR technician is hard at work over something that looks like a miniature printing press. "What are those?" I ask, pointing to the rubbery grayish sheets he's feeding through it.

"Allografts--cadaver skin," he answers. His eyes grinning over his surgical mask, he holds a slightly darker one up and says, "See? It comes in all different colors." Thump-thump-thump and another sheet comes out, four times its original area and perforated to allow for fluids to flow. Yet another doctor hands the tech a similar-looking sheet of skin. I turn to see where this one came from, and I see him running a palm-sized stainless steel instrument across one of the few unburned patches of the patient's chest. This is how autografts are made--they are removing the last remaining virgin skin from the patient to graft it to where it's desperately needed.

The pace in the OR picks up. A sense of urgency prevails in the room as the team of six doctors moves in closer around the patient. It is time to staple the grafts in place and they must not be allowed to dry. "Allo! I need more allografts!" the call is repeated again and again. Hundreds of surgical staples need to be punched into the patient's flesh in order to secure this many skin grafts, and the disposable staplers contribute to the refuse on the floor, organic and otherwise. One doctor slips on the blood and other fluids puddling underneath the OR table as he hurriedly wraps a bandage around one leg.

And a nurse walks through the door. "Doctor, Mr.______'s mother is here. Is there someone who can talk with her?"

It all comes crashing home to me. This patient, this clinical exhibit, is the joy in someone's heart. He is someone's beautiful son, barely a man, and a cherished gift in her life as his own hangs by a thread and a prayer. Please God, don't let her come in here! Don't let her come in here and see this grisly display, this charnel house that claws at the mind and makes it beg to be released from reason. Don't let her see the light of her life sliced apart and flayed in the name of medicine!

"Not for at least another hour," the doctor responds.

Soon, it is done. I help move the man onto a clean gurney, the last time I will ever touch him. Later on, Kamena and I practice drawing blood on each other, but all I can manage is a couple of halfhearted sticks. What was novel a month ago now seems like child's play. I laid my hands on my first patient, a man who desperately needed help, and I could do nothing for him.

on 30 November 2004, 10.23 pm
Takes a whole different mentality to do that kinda work.

I know horrors like that exist.
I know how much pain burn victims suffer.

I try not to think about it.

I try not to think about a lot of things.

on 30 November 2004, 11.15 pm
Great article.

on 1 December 2004, 12.51 am
that was . . . .awesome . . .

and draining, but it just amplifies the experience.

on 1 December 2004, 3.56 pm
My second day in the burn ward was much more...human. I spent most of my time helping the nurse change bandages etc. on a 22-year old woman with cerebral palsy who had spilled lighter fluid all over herself. I think burns cause as much psychological scarring as they do to one's body, so mostly we just talked.

More gratifying than that even was helping a Hispanic woman with 3rd degree burns to her face and arm. She and her husband had no insurance, no identification, and spoke almost no English. They were scared shitless. I told them that we weren't the INS, we weren't going to deport them, and that we would only help them.

I was pleasantly surprised to find out how much non-miltary work the Army Medical Department does.

on 2 December 2004, 1.14 am
WoW, That was great.

I was on a swim team as a child , One of our coachs had been in a fire as a child. The scars on his back were unbelievable. To hear your story just made them even more incredible of what he must have gone through. He never spoke of it and we never asked. It was just something that was not talked about.

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