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Beyond Recognition

She came to the Emergency Department, burned beyond recognition. She arrived in complete anonymity, and that is how she remains. I had just finished seeing a patient one early morning, when I heard the Paramedics enter the Emergency Room. I smelled her charred flesh, I heard her wheezing for every breath. This patient was supposed to be a "minor burn," as announced: they wheeled her past me, I saw her struggling for life, skin falling off of her face and hands.

She was homeless, and had caught on fire, we have no idea how, or why. Possibly a cooking stove, or camp fire. Her hair was a desiccated clump of char. The skin on her face was completely blistered and swollen. The skin on her hands and forearms dropped to the ground. She could hardly breathe, we started breathing for her.

We worked quickly to remove her clothing-parts of her back were blistered; these burns were more extensive than we had thought. We quickly began to think about how to best treat her. We worked to give her reprieve from the pain: we induced a coma, and started her on strong pain medication. We placed a tube in her throat to aid in her breathing: the back of her throat and vocal cords were singed black. She finally lay calm before us, unaware of the damage brewing beneath her seared skin.

Now that we had her airway secured, we could thoroughly assess her burns and try to stave off the other "burn nasties," as vocalized by the Chief Surgeon in charge of the burn unit that night: Dehydration, Swelling, and Infection. The skin holds water in the body. In order to estimate the amount of fluid she would need to maintain adequate oxygenation to the rest of her tissues, we had to characterize the extent of her burns: how much and how deep?

We quickly calculated the extent, or how much of her body surface area was burned by using the "Rule of 9's": the head and each arm is 9%, the chest and back are 18%, and each leg is 18%. Our patient had approximately 30-35% partial to full thickness burns of the face, head, back, arms and hands.

Next we characterized the depth of her burns. Instead of using the terms "First, Second, and Third Degree Burns," we now classify them according to their "thickness". Superficial burns involve the very top layer of skin only, and are usually red, like a sunburn. Partial Thickness burns involve the superficial and deeper fat layer of the skin, and are characterized by skin blistering. Full Thickness burns are burns through all layers of the skin to the muscle-these burns are the worst and are most prone to get infected and need skin grafting. They are usually white and without feeling. Our patient unfortunately had mostly partial and full thickness burns.

The fluid dripped from her fingers and arms, forming yellow pools around the bed. There was no skin to hold the liquid in her body. We acted quickly to replete her fluid loss by placing a large IV in her groin, and began giving her much needed fluid, and antibiotics.

After an hour we still had no answers as to where she came from, or what had happened to her. By this time her fingers and arms had become so swollen due to the massive amount of fluid we needed to give her just to keep her alive that she began to lose circulation to her fingers. We assisted the Burn Chief with performing an escharotomy: cutting through the thick fibrous scarring of the burns in order to relieve the pressure. Using electrocautery, we cut long, deep lines down her arms and fingers. The skin splayed open, oozing liquid.

Burns are one of the hardest injuries to cope with as an Emergency Room Physician. Not only do the victims suffer terribly from pain, and sometimes disfigurement, they also may have protracted recovery due to multiple skin grafts and infection. I visited our patient two weeks later in the burn unit. She lost her fingers, and part of her right arm. She has had no visitors. We still do not know her name. She remains on the ventilator, and infection has set in. We have been her only comfort, her only voice. The raw emotion of treating burn victims is extremely difficult to process. This patients’ situation is beyond comprehension.

She still lays in complete anonymity.
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About the Author

The Stanford Emergency Room is the center of emergency care at Stanford University.