Burn Surgery

I was the resident in charge of the burn unit and working on my daily notes for the patients that were currently residing there. There was a 19-year-old who had suffered severe inhalational burns and brain damage after the carburetor that he was cleaning with gasoline caught fire from a static electricity spark. There was a 70-year-old who had fallen asleep with a lit cigarette and sustained 25% full thickness burns to his upper torso. There was a mother who had burned her hands and face when she opened the door to her house, smelled gas and pushed her children to safety just before her house exploded. All of these patients require intensive care, intensive wound management and attention to every detail of their progress and condition. Also, some of these patients were in the process of being grafted which required operative timing and preparation.

The call came in just before lunch that a 39-year-old highway construction worker was being flown in with 96% partial and full-thickness burns to his body. This man was working in a manhole when he accidently hit a steam pipe that ruptured. He was wearing steel-toed boots which kept his feet and lower legs from the burns but just about every place else on his body was burned. This would be a major trauma to this young man and this would predict months of recovery if he would be able to recover from such a traumatic blow. In the case of burns, the patient doesn’t stop in the Emergency Department but come immediately to the Burn Unit where the staff can start treatment as soon as possible. At stop in the Emergency Department would delay initiation of the treatment unnecessarily and would expose this patient to infection because the Burn Unit is far cleaner than an open Emergency Room. He would arrive in less than 30 minutes.

The nursing staff set up one of the evaluation rooms: scrubbed stainless steel tables lined with sterile liners and warm water for removal of any clothing that might be adherent to the skin. In the field, most paramedics know that burned clothing will hold heat and continue the burn process unless removed from the skin. They will make sure that any smoldering clothing is removed and will wrap the burns in sterile dressings and drapes. The patient’s airway will be protected and two large bore intravenous lines will be inserted so that fluids can be infused as quickly as possible. The paramedics had indicated that they had inserted three 16-guage lines into this patient and has already infused 1.5 liters of fluid. The patient was intubated, stripped of clothing and wrapped completely to prevent fluid and heat loss because of the burns. They had done an excellent job in the 15 minutes since the patient has been burned. They were 15 minutes out from the hospital.

The man arrived and we quickly set to work debriding any scorched skin and clothing from his wounds. I inserted a cordis intravenous line into his internal jugular vein for even more fluid infusion and extra IV access. We also induced a pharmacological coma for pain relief (about 60% or his burns were painful partial thickness and the other 30% were full-thickness (not painful but devastating). His face was swollen and red; his hair was gone; singed by the steam. It appeared that the pipe exploded, he inhaled the hot gas and turned to his left while covering his face. His left arm and back had the full thickness burns but his eyes were in good condition. I used an ultraviolet light with dye to assess corneal damage and found none. His ears were singed red with large blisters that wept fluid. His chest and legs had partial thickness burns that needed to be debrided too. Three nurses helped me start the initial debridement process while the respiratory therapist made sure that his ventilation was taken care of.

Full-thickness burns cause the skin to take on a leathery appearance. Since all layers of the skin are totally destroyed, this leathery eschar would need to be removed. Just under this layer would be a layer of ischemic damage that would be lost unless proper fluid resuscitation had been undertaken. Our patient had an IV rate of 1,950 ml/hr in the first 8 hours because of massive fluid loss. We didn’t want to get behind and cause further damage. After the first 8 hours, we cut the IV fluid rate back to 980 ml/hr for the next 16 hours. Overall, our estimate was that our patient was 31,000 ml of fluid down because of the extent of his burns. In addition, his body was massively stressed by the injury to his lungs and fluid loss from there. He was fortunate in that he had been in excellent health before this accident. We were able to hold blood pressure and urine output adequate in the first days after his accident.

My attending burn surgeon arrived after the patient had been in the unit for about 20 minutes. He helped with the debridement and wound evaluation. Our patient was fortunate that he didn’t need an escharotomy (incisions made to release burned skin so that the patient would be able to breathe/be ventilated).  After 35-minutes, we had infused several liters of IV fluid, placed the patient in a pharmacological coma for pain relief, undertaken mechanical ventilation and cleaned/dressed his wounds. My preceptor surgeon and I sat down with the nurse assigned to the patient to plan for covering this patient beginning the next day. We also had antibiotics started and had placed a feeding tube for liquid nutrition which is so vitally important in burned patients. This young man would be in a hyperdynamic state with the ultimate demands on his body both physically and nutritionally. In addition, we would need to start to cover his burned skin as quickly as possible. Our first cover would be donated cadaver skin.

Cadaver skin would be a good cover to start with but the patient’s own skin would have to be harvested slowly as he healed. As soon as donor sites would become available, we would use them and would harvest. On our first assessment, the backs of both calves were not burned along with his right upper posterior thigh. These would be harvested first. We would start on hospital day 2, harvesting skin from the donor site and covering the full thickness burned areas with cadaver skin. The patient’s own skin would be meshed and would be used to cover the partial thickness areas. We would also perform a tracheostomy as he would require mechanical ventilation at least two week and possibly three or more. He had been fortunate in that he had not inhaled carbon monoxide but he did inhale heated gases which had caused some lung damage. We hoped that this would heal and we would come to see that this damage was minimal in the next week.

At the first surgery, our team consisted of seven people: the attending surgeon, the chief resident, an intern, a nurse practitioner and three medical students. Our attending surgeon set about further debriding the burned areas after anesthesia had been induced. I performed the tracheostomy creation while the intern and nurse practitioner harvested and meshed skin for beginning the coverage. Once the recipient sites had been properly debrided and prepared, the meshed skin was applied with everyone having an opportunity to do some suturing. In the coming weeks, he would undergo more of these coverage procedures as his body rejected the cadaver skin and the donor site would allow more harvest. In all, it took about three weeks to get his would covered with his skin and to keep the donor sites healthy and thriving.

In addition to coverage, keeping infection at bay and nutrition, we had the challenge of pain relief. At first, we kept the patient strongly sedated. As his lungs began to heal, we gradually cut back on the sedation to allow him to breathe on his own. After 2 ½ weeks, he was doing well and we removed mechanical ventilation. At this point, he was able to talk with his family by covering his tracheostomy tube.  With is grafts and tubes, we could see that the greatest joy for this young man was having his family gathered round for encouragement. When he was pharmacologically comatose, his wife made tapes of their children singing for their father. The nurses would play these during the daily would care and dressing changes. Any person who entered his warm room (to prevent heat loss) would have to dress in sterile garb and wear a mask. In addition, the massive facial swelling started to resolve after about a week so that his children could see him from the door. His wife had carefully prepared them for the sight of seeing their father in bandages from head to toe.

When I left my burn rotation after two months, I would stop in to see him from time to time. He said some of his first memories had been of my voice and the staff speaking with him and encouraging him. During his dressing changes, we had sung (recommended by our music therapist) along with his children and that this had been of great comfort to him. He also said that he didn’t remember having a huge amount of pain until near the end of his recovery when he started to have difficulty with some mild contractures.  He continued physical therapy and when I saw him one year later, he looked fantastic. One could tell that his arms and torso had been burned but the plastic and reconstructive work that had been done on his face and ears was very nice. He was upbeat and looking forward to changing careers. He had decided to go back to school to get a degree in counseling so that he could help other burned patients.  The staff in the burn unit said that he would often visit young men who were burned to tell them his story as he was recovering. He said that he thought that recovery for a younger man was especially difficult.

I still remember what this gentleman looked like when he came in and often had to look at the portrait that his wife had supplied so that we knew what he had looked like before his accident. We also saw the incredible love and support that came from his family and parents. He had brothers and sisters who took turns sitting with him and reading to him while he was comatose. This was a very close-knit family who prays for and supports each other. We saw the incredible determination in this patient and in others that have undergone this type of extreme stress and life adjustment.  All of these patients taught me the value of appreciating how easy it is for me to do something as simple as walk across a parking lot or sip a cup of coffee in the morning. Often it takes weeks and months for a burned patient to even get out of bed.

And finally, taking care of burned patients is the ultimate team effort. The surgical procedures take multiple hands and personnel who have the goal of getting the burned patients covered as soon as possible. In addition, the nurses, nursing assistants and environmental services personnel in the burn units are invaluable. They have some of the strongest work ethics of any area of the hospital. If the environmental services folks were not dedicated to their jobs and doing a job well, the infection rate in these units starts to climb. Every single person “counts” when it comes to getting this massively injured patients back to health.

A Memorable Patient

I have been thinking about some of my more memorable patients these days. I especially remember one of my younger surgical patients from when I was a junior resident. I was on the Colo-Rectal surgical service, which was one of the more interesting rotations that you can have a resident. Colo-rectal surgeons handle just that, diseases of the colon and rectum that have to be treated surgically. One of the nice things about the service is that the colo-rectal attendings were among the most personable and knowledgeable of my junior years. They loved to teach and they loved to have us involved in their cases at every step.

One day, a gentleman presented to clinic for the final scheduling of his upcoming surgery. He was a young man (less than age 40) with a very low rectal tumor that we knew was cancerous. His presentation had been rectal bleeding and when his primary care physician found the tumor (it was palpable on digital rectal exam), he immediately referred the gentleman to our clinic for workup and surgery. At this point, the workup was complete: CT Scan, blood work and chest film. We reviewed everything and the patient was scheduled for AM admission, given pre-op orders and sent home to report back to the hospital two days later.

Two days later, we greeted the patient and his wonderful wife in the holding area. They had followed the prep instructions to the letter and he was cleared by anesthesia for the case that we would be doing. We had planned an abdominoperineal resection which involves wide excision of the rectum to include the lateral attachments and pelvic attachements and the creation of a colostomy. In the performance of this procedure, abdomen is opened and examined to see the extent of spread of the disease if any. Since we had a CT Scan that was two weeks old, that showed no evidence of spread of disease to other organs, we were confident that we would be able to remove the tumor, fashion a colostomy and get this patient on to recovery.

To have a colostomy at such a young age is life changing but to die of rectal cancer would be a tragedy and thus the patient was eager to get the surgery over with and get on with chemo and his recovery. He had been very eager to learn about colostomy care and life with this procedure. We open the abdomen and to our shock, the cancer had spread to his liver. As I moved my hand over the liver, the extent of the numerous tumors was quite evident. We all scanned the CT to see if we had missed something but we had not and neither had radiology. The tumor did not show on the CT Scan.

At this point, I helped my chief resident close the abdomen while our attending went to deliver the devastating news to this patient’s wife. The cancer was unresectable and the patient had little chance of living more than a few months with the extensive liver involvement. The next day, we ordered another CT Scan and sure enough, there were multiple tumors throughout the liver in addition to the tumor in the rectum which really hadn’t changed much in size.

The next two days, I rounded on this patient and wrote notes. I made sure that his pain was under control and I met many of his relatives who were just wonderful and very grateful for everything that we had done for the patient. I felt horrible because we all wanted to do more but there wasn’t anything more that could be done from a surgical standpoint. On post op day 3, the patient was ready for discharge from the hospital. He was scheduled to see a wonderful oncologist and the possibility of enrollment in an experimental protocol was there but still, it was difficult to see this situation.

A week later, the patient came back to clinic for removal of his surgical clips. His incision was well healed and he joked about the small shave prep that had been performed. His lovely wife said that every day she had with her husband was a gift because he had been badly injured in an accident three years earlier and given little chance of survival but he did. She said that she was so happy to take him home and that he was a well-loved man.

I heard that this patient died peacefully at home six months after the surgery. His wife sent us an obit notice and wanted us to see that she had directed all donations go to the American Cancer Society. She thanked us again for the great care and the time that she had with her husband. Those words stung then and they still sting as I think of that lovely family from time to time.

It is always patients like this patient that remind me to give my best always. We don’t know if we will be the last physician or the physician that will make an impact on our patients. This patient gave me so much by just putting his trust in our team. I see him often when I have to deliver bad news to a family or to a patient and I hope that he is at peace. His wife said that his death was peaceful and that his 10-year-old child was with him as was his mother and father. I can only hope that all of my patients can leave behind their disease in peace when the time comes. I am certain that the oncologist made sure that he was pain free as much as possible.

It’s this time of year when I think of some of my more memorable patients. The ones who show me how to live by being a great example with their lives. I am a very fortunate physician.

Caffeine, useful or not??

One of my simple pleasures is a fresh-brewed cup of coffee. I love the fragrance and I love the taste of this wonderful beverage. The smell of coffee brewing wafts into my bedroom as I am getting out of the shower each morning (I have an automatic pot). I love to clutch my first cup of the day in the darkness of early morning. That first cup is as consistant to my morning ritual as my toothbrush.

When I reach the hospital, I usually grab another cup (not mug) that follows me through morning rounds. You can see our small styrofoam cups lined up on the railings outside the room of the patient where we are making morning rounds. While the medical student (or intern) is presenting the patient, I am calmly sipping my “Rounding Joe”. When we enter the room to examine the patient, the cups sit on the rails outside for easy access as we move to the next room. There are unit secretaries who will time their fresh pot of coffee when we come on AM rounds. I love those people to death. This is my second cup of the morning.

After AM rounds and delivery of the days plans to the interns and medical students, I head off to the OR for my daily cases. In between cases, I usually sip water because dehydration is more of a problem in the operating room than the need for caffeine. I will usually consume a 20-oz bottle of water between each 3-hour case. The interns will update me on their morning work or any new admissions to the service between (and sometimes during) cases.

In the late afternoon, we will generally round with our attending on service. This is another opportunity for a small cup of coffee. Sometimes a small piece of chocolate will be a welcome addition to this afternoon ritual especially if we are having an afternoon conference. As you can see, I am up to three cups of coffee at this point in my day.

After 4pm, I do not consume any beverages that contain caffeine. I will dring water during my workout and will drink Crystal Light if I feel the need for a bit more than water. I keep a Brita pitcher on my counter and a Brita cooler in my refrigerator. Most of the water that I consume is room temperature but my fiance loves ice-cold beverages. Growing up with an English mother who never “iced” anything for us, has resulted in my lack of need for ice that has followed me into adulthood. If I am drinking coffee with dessert, it is decaffeinated.

When I was a medical student, I often drove into work with a travel mug of freshly brewed coffee. During class, I would continue to sip from this mug until it was empty. I might refill it during a later class or switch to Diet Coke, my other caffeinated beverage of choice. My classmates loved Mountain Dew but too much sugar for me. I never needed the sugar “buzz” to go with my caffeine “buzz”.

We had a Starbucks located across the street from our medical school. This was a great source of fresh coffee for those late evening group study sessions or for taking a beverage break. Again, I would not drink caffeinated beverages after 4pm. My Starbuck’s coffee treat had to be without caffeine. Starbucks was our gathering place for discussions because it was a change of scenery.

At our Mortality and Morbidity conferences, we have a fairly full breakfast available as this conference begins at 7:30AM. For me, this means a half cup of coffee and a bit of fruit or a small piece of quiche. There are also great breakfast breads and bagels too. If I was going to be “grilled” in M & M, at least the grilling would not be on an empty stomach. There are loads of breads, quiche, bagels, fresh fruit and eggs in addition to the Krispy Kremes too (leave those alone).

Caffeine and specifically coffee has been an intergral part of my career. I enjoy tea (Earl Grey) in the early afternoon sometimes or iced tea for lunch but that steaming cup of coffee in the darkness of early morning is my favorite. On a cold winter morning, at 4am when I have been operating all night, I sip my cup of “Joe” on the rooftop patio while I breath some fresh air to clear my head. It’s all good.