01 June 2009

Bongi's on fire

Um, maybe that's a poor choice of words, given the topic of his recent post is on burns:

other things amanzi: leaking
on two successive nights two severely burned patients came in. i got the first. my colleague got the second. my patient had 98% burn wounds (usual story of being doused in petrol and being set on fire. someone didn't seem to like him). only where his hair had been was he not burned. that means that 98% of the sack that is supposed to keep the water in was leaking. [...]

the immediate treatment for burns is to replace the fluid that is leaking out through the wounds where the skin used to be. the amount of fluid one gives is proportional to the surface area burned or the surface area leaking. in 98% that turns out to be quite an amazing amount of fluid. and that is what we did.

Gripping post, and really blew my mind on a number of levels:
1.  "usual story of being doused in petrol and being set on fire"  Usual story?   Usual?  Meaning that this sort of thing happens enough to not be the front page story in the newspaper, and barely merits comment?  Wow.  Just wow.  We live and work in very different places, my friend.  I do not think I can illustrate that fact any more eloquently than you already have.

2.  "he could not lie in bed without extreme discomfort. but the soles of his feet had no skin so he could not stand either." He was awake?   Awake with 98% burns?   Ohmigod.  In the burn wards I've worked in anyone over 75% gets intubated on arrival, if for no other reason than the humanitarian goal of putting them into a deep morphine coma, but also because the amount of fluids they get invariably results in pulmonary edema and respiratory failure.   This is not in any way a criticism, please, but I refer to my above commentary: Wow.  Just wow.  We live and work in very different places, my friend. I do not think I can illustrate that fact any more eloquently than you already have.

3.  "the head of the firm then decided we should take him into a shower and remove all remaining loose skin."  In the shower?  Why in the shower?

4.  "my colleague knew that the end of the road was predetermined and didn't see the point in prolonging the inevitable. he only gave him normal maintenance fluid which a normal person would require. he considered more as treatment and didn't see the point in treating something that could not be treated."   This is an interesting perspective.   In my experience (which is all of a few months in the burn unit) we handled such huge burns as "comfort care" with ventilatory assistance, full fluids, and lots and lots of morphine, but little more in the way of definitive care.  I think, having now a little more experience with hospice, that your colleague may have had an excellent point.  For burn victims, dehydration is the natural mode of death, and to withold fluids simply allows natural, invetiable death to take place without interference.  And dehydration is not a bad way to go, especially if you are in searing pain.  Consciousness just slips away as the sodium rises.  It's quick, clean, reliable and effective.  Excess fluids means more oozing, respiratory distress and air hunger, and fuller consciousness to the pain.   The hospice nurses where I work make it a practice to run all their terminal patients as dry as feasible.

Pretty amazing amanzi things, there, Bongi.   Keep 'em coming!

Oh, and while we're at it, be sure to see if you can help Bongi read this "questionable" CT scan.

3 comments:

  1. thanks for the mention. but i thought i should comment.

    1. the sorts of ththings that happen here without making the news can be quite astounding. i have seen horrendous things and i think the number of things that made the news i can count on one hand. i must admit the hippo attack made the front page of the local paper. it seems wild animal attacks are more newsworthy than the usual murder stories.

    2. in the setting of the post we had very limited resources. to intubate a patient that didn't have a chance essentially meant we would be withholding treatment for someone who did have a chance. more than 75% burns was more a contraindication for intubation than indication for intubation. there is another story i plan on posting sometime exactly about this point actually. morphine was used liberally, have no fear.

    3. the head of the firm had a thing for showers. i hesitate to use the word fetish, but on the day in question i did wonder. i suppose running lukewarm water is somewhat soothing, maybe.

    4. this post fell a bit too much into the realm of black and white. i hoped most people would wonder about the grey areas. what do you do in severe burn wounds where there is a chance, but slim. do you go for it or do you withhold treatment on so called humanitarian grounds and where is the cut-off? those are the truly challenging ones. hopefully most people will dwell on this rather than the easier questions of the hopeless cases.

    the other thing that i hoped to bring across is the absolutely bizarre nature of the work we do and the nature of the things we face. in fact that was one of the stated aims when i started this blog. we live in a very strange place. we work with very strange things. we are strange people.

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  2. Bongi -- Re #2 -- I kind of figured that it was a limited resource/wise use of resources thing. God knows here in the US we overdo everything to the hilt. One mercy of not being intubated is that you can still speak (if conscious). I recall one time intubating a young man with severe burns who was unlikely to survive. He was awake & talking on arrival. Before we put him down, he was asking if he would be OK, and asked us to let his wife know. As I put the tube in, I reflected that he had probably, unknowingly, uttered his final words. It would have been nice if they could have been to his wife.


    As for the "gray zones", in my experience I see a real reluctance to "let go" and pursue comfort care for burns. When the patient's premorbid function was so high, and the injury is so acute, the acceptance of impending death is harder than for a patient who was chronically ill, and whose death was expected sooner or later. This drives much of the aggressive treatment which I have seen in the US. I've seen 70%ers survive, can't recall a higher but as I said my time in the burn unit was mercifully short.

    Yes, people are strange.

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  3. Thanks for this post...it's a bit closer to my world than most others. I enjoy them all, however.

    Bongi: I am a nurse who works in the Mozambican bush. Your words ring very true that "we live in a very strange place. we work with very strange things. we are strange people." As we travel back and forth between North America and Africa it almost seems that we live on different planets entirely. Different place, very different game. All the best in your work.

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