The dark side of medicine
The lecturer moves through the slides, explaining the differences in first-, second-, and third-degree burns. He speaks about the presentation, pathophysiology, and assessment.
Thirty students around me soak up this information and jump at more: What about smoke inhalation? Does the need for a trauma consult override the need for a burn consult?
One student mentions the smell of burning hair, burning skin.
Black smoke in the air, the heavy smell of burning wood everywhere, police cars lined up around the block. Shouting, chaos: “There's people still in there!” Two-story house, engulfed in flames: no entry or exit point to be found. Sifting through bystanders, EMT patch on my arm, frustrated, shouting, “Does anyone belong to this house?!”
The speaker clicks into another slide: types of burns.
Chemical, electrical, flame, scald. Images of each flash across the screen.
Thirty students entranced by the photos, seeing the clinical aspect but not seeing the patient's pain, the patient's story, the survivors.
Seeing him for the first time: early 50s, gray-speckled hair, sitting on the sidewalk in his pajamas, looking surreal against the snowy ground. He stares at the burning house. I ask, “Sir, do you live here?” He nods. “Sir, I'd like to take a look at you, if you don't mind.” He looks up, blinks, speaks: “My wife and son are in there.”
The speaker talks about prophylactic intubation, the cooling process, fluid resuscitation. Shows more images of the burn unit and its patients.
Thirty students' fingers pounding away at their keyboards. Thirty students feeling proud they didn't flinch at the image of a victim of a scalding, a chemical burn, a house fire.
Standing next to my patient, explaining the need for further evaluation. His refusal to be transported to the hospital, adamant he doesn't move from his perch in the snow. “Sir, we're doing everything we can,” I say, referring to the firefighters 20 feet away as I wrap him in another blanket. It's 6 a.m., low 20s, snowstorm rolling in later in the afternoon. He looks at me, stares so long I squirm, states, “It doesn't matter; they're both dead.”
The speaker gives us a 5-minute break.
Thirty students talk about what they studied last night, how little time they have, how excited they are for rotations in a month.
One student mentions a burn patient she saw on shadowing: “The smell; you just recognized it down the hallway.”
Sitting next to him, not saying a word. “I tried,” he states, empty. “I tried to get back inside but it was too hot, there were too many flames.... I shouldn't have fallen asleep on the couch.... My son must have tried to get to my wife, I heard her scream.... He would've done that, he's such a good kid.” He pulls the house telephone from his pocket, all that remains of his life. “I'm sorry,” I say, but we both know it's not enough.
The lecturer talks about the need for surgery in burn patients. Their wounds need to be cleaned.
He pulls up studies, talking about the differences between early excision and late excision.
One student wonders aloud, “Is there any benefit to waiting, really? We want to prevent infection as soon as possible, I would think? Otherwise won't they become septic, increasing their chance of mortality?” Thirty others nod their heads.
Flames out, watching the fireman climb to the second floor window. He peers in, looks around, turns back to the fire inspector and motions with two fingers. Two casualties: mother and son. My patient bows his head in sorrow. “I'm sorry for your loss,” I manage, placing a hand on his shoulder.