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.

Working and attending college…

Potential lethal combination?

Many students find themselves in the unenviable position of HAVING to work and attend college at the same time. This a a potentially lethal combination in many ways. First of all, when something starts to suffer, it generally isn’t the job and second, burnout is a strong possibility. Both of these problems can be potentially avoided if you cut back on your coursework if you find that you must work full-time. If you are a full-time employee at most jobs, you have minimal time to study in between and thus, you can’t take on a full-time course load that includes pre-med lab courses. Decide that you are going to take your time and do well in your courses while leaving yourself plenty of time to rest from both coursework and employment. No medical school admissions committee is going to give you “brownie points” for trying to do a full-time course load along with full-time employment especially if your uGPA (or postbacc) work has suffered.

Recharging your batteries

You need time to digest and assimilate the material that you are learning in your pre-med coursework. Rushing through these classes with last minute “cramming” is not going to leave you with enough time to get the material in your long-term memory so that you can apply it on the Medical College Admissions Test. You need to be able to see the subtleties of what you are studying in addition to having some time to let your brain just rest. Again, rushing through your coursework makes MCAT review on the other end a total chore instead of a progressive process that will lead to success. Take your time, recharge your brain (even take a semester off if necessary) and then come back refreshed and ready to work at very high level.

Damage control

If you are retaking courses or attempting to take additional postbacc work to enhance your application, you need to do well without exception. You can’t keep posting mediocre grades and retaking courses with the expectation that eventually you will get that A and get into medical school. If you have significant prior poor coursework to overcome, take your time and remediate one course at at time. Pair a more demanding course like Physics with something less demanding like English/Psychology. Again, if you have prior poor coursework, you can’t afford to either do poorly in your recent coursework or drop courses because you have overloaded yourself. Slow, steady excellence will bring the success that you seek.

Keeping some perspective

If you have a family to support and take care of, be sure that you allow plenty of time for them. Working, attending class and then diving for a nap on the sofa or heading for bed is not going to do much for your relationship with your loved ones. They need your undivided attention and you need to interact with them for your sanity too. Let your loved ones be your much-needed and much-desired break from your schedule. They generally don’t expect your to be on your best behavior but only want you in your basic form. Allow them to see you, hang out with you and take you away from the grind of work/study on a regular basis. You grades will be better, you will be happier and you can keep yourself reminded of why you seek your goals in the first place.

Setting goals and achieving them

The whole key to finding success in the medical school application process is keeping your eye firmly on your long-term goals. I have stated in other posts that the process is like having 100 pounds of weight to lose. It isn’t going to happen overnight and you must take small steps on a daily basis to stay on track. It’s easy to get off track by the demands of work but you can’t achieve your goals by letting this happen. This means total organization and total commitment to the task at hand, be it work your studies. If you are at work, you give your work your full attention. When you attend class, you give your classwork the attention that it demands. It’s neat to be able to multi-task but most people are not able to work at a high level and achieve those A grades that you need for medical school admission at the same time. Again, if you work full-time, don’t expect to attend school full-time. If you attend school full-time, don’t expect to work full-time. The end result is that you wind up doing both things at a mediocre level which won’t allow you to achieve your goals.

 Finally…

There are no “points” for getting this process “almost” right. The level of academic achievement that is demanded of a potential medical student is getting higher every year. The MCAT is getting more competitive as many students are taking prep courses and spending more time preparing for this exam. You can’t expect to be competitive next year with this year’s work because the bar will move higher. If you are attempting to upgrade your credentials, then you need to do a complete overhaul and put up some good academics (even one course is better than nothing). Don’t expect to be the exception to any of the rules in this process. You are not generally in a position to be objective about yourself and your abilities. Make sure that you get some honest and objective advice. Trying to self-evaluate is like asking your Mum if you are a great kid. Of course, she’s going to answer in the affirmative but it’s far better to get someone who doesn’t know you, to look over your things (like a good academic adviser who knows the pre-med climate). Allow plenty of time for getting your work done at a high level and you will see movement toward your goals without sacrificing your employment records, your sanity or your soul.

Venting

I remember doing a case with one of my favorite attendings. This person was a colo-rectal surgeon who would talk through out the case. I was an intern at the time but I remember him saying that his talking was just “venting” and that he hoped it wouldn’t bother me. I looked at him with amazement because his “venting” was putting to word, many of the thoughts that I was having as we went through the case. I had felt honored to be able to scrub this case with him because usually, one of the chief residents would have taken this case but everyone was tied up and thus I asked if he would mind if I scrubbed with him. He said that he was happy to have me there.

The Teaching

He explained the fine technical points from skin to skin allowing me to mirror many of the things that he was doing. He pointed out anatomy and explained why he loved mobilizing the rectum and why colo-rectal surgery was always a rush for him. I was mesmerized by how fascinating going through this case was. In short, I was being treated to the first of many one-on-one mentor-trainee sessions with this young colo-rectal surgeon. His enthusiasm for his craft and his ability to teach me what he found amazing was delightful. From that point on, I always held a special reverence for colo-rectal surgery.

He marked out the incision line for me and handed me the scalpel. He showed me how to make sure I had just the proper amount of tension and counter tension as we entered the abdominal cavity. He showed me how to explore the abdominal cavity and how to palpate the liver for cancer mets. He pointed out the fine points of living anatomy as we located the tumor that we knew we would be able to resect.

His next lesson was how to put two ends of bowel together. Today, he said, we would do a hand-sewn anastomosis. Sure the stapler is nice to use but once in a while, a hand sewn anastomosis is a good thing to do. He showed me how to resect the section of colon leaving plenty of margin and the fine technique of location the numerous vessels that fed this wonderful organ. Again, the living anatomy is a wonder to behold and being able to see how this tumor would be removed was great.

We carefully sewed the remaining ends of the colon together using Lembert stitching. He talked, he vented and I watched and listened. Together we completed the case and at that moment, I understood why operating on the colon is both fun and something of a challenge. I had to always keep the anatomy in mind, the technique perfect and move in an efficient manner. I remember laughing at him describing the “big honking vessels” that we would be ligating and why one doesn’t want to even think about ties not holding. He said that when he started residency, he would lose sleep over thinking that his ties were not secure.

Technique

One of the great things about doing a case with an attending like my colo-rectal professor is that he does vent the things that go over and over in my mind. Are my ties secure with every knot? Are my hands going in the right direction? Have I identified the vessels correctly and ligated them using proper technique? After all, surgery is a practice which has to take place over and over for years. Even now, year’s later, when I don’t have to think about every suture or every tie, I still mentally revisit some of the cases that were turning points in my training for various reasons.

There isn’t anything magical about surgical technique but there is something magical about having the knowledge, background and education to use that technique properly. This is what I learned across the table from my colo-rectal professor. He vented and I listened to all of those pearls that he would verbalize. For me, his venting was golden and some of the best teaching that I ever encountered. He was an extraordinary teacher and he would often tell us that if he was in our position, his venting would drive him crazy. Well, that was never the case for me. His venting made me see the artistry of colo-rectal surgery and why having impeccable technique was paramount for these patients.

The best teaching

It’s no accident that the lessons that I remember best came from my first two years of surgery. By the time one reaches third year, there is a comfort level with being in the operating room. The lessons of my first two years were magical and have not left me. Those late night cases with the chief residents, moving through the abdominal cavity on a laparoscopic case or the first time I was able to close the abdominal cavity and feel confident that I had done this correctly, were memorable for me.

I was fortunate to be exposed to some of the greatest professors of surgery under a variety of circumstances in addition to having some of the best chief residents who were willing to give me their best too. There is much joy in this type of learning and a great amount of joy in venting.