Tag Archives: Burn

Backdraft

back·draft

1 – a reverse movement of air, gas, or liquid

2 – an explosion that occurs when air reaches a fire that has used up all the available oxygen, often occurring when a door is opened to the room containing the fire

Missy woke up a little early and from the start she knew something was wrong. She just didn’t feel right and the world seemed just a little more confusing than usual. She tries to get up out of the bed but the weakness is just a little more pronounced than usual and she never makes it all the way out of bed. Thinking maybe it would help to bring the world into perspective Missy reaches for a morning cigarette with her left hand, but finding she can’t quite make that work she finally reaches across her body with her right arm, grabs the cigarette, puts it between her lips, and lights it while laying in bed. With the smoke inhaled deep into her lungs she starts to relax again and nod off.

There’s shouting from outside the house – someone is yelling at her. She opens her eyes and sees the flames overhead – gently rolling across the ceiling with the smoke starting to burn her lungs on every breath. She tries to get up but again the weakness is stopping her from getting out of bed. Suddenly there is light in her bedroom, as the door opens, this is quickly followed by intense heat as the flames erupt as if seeking the oxygen from the open door. Strong arms grab Missy and start to drag her out of the house. Once on the front lawn she can see the flames well above the roof as firefighters are breaking windows and drenching her house with water.

As we roll into the neighborhood my partner and I stop following street signs and just follow the smoke to the location of the medical call. We have to park a block away as the small residential street is full of fire apparatus and supply lines. We roll the gurney closer to the house, avoiding the standing water and six inch fire hoses that snake across the road. Sitting in front of a burned-out house is my patient, leaning forward in a tripod position, sucking hard on an oxygen mask, with both arms being held out to either side.

Stacy, the fire medic, is supervising two Explorers who are simultaneously taking blood pressures, one on each arm. Our county has a Fire Explorers program for youth who someday want to be firefighters – it gives them the opportunity to volunteer with a local fire unit and learn the basics of the job. Both of the Explorers seem distracted by the commotion of the fire; they glance repeatedly from the blood pressure dial to the flames. It’s obvious they would rather be squirting water than taking care of this woman.

Finally, Tracy has had enough and asks each of them for their findings – she knows I’m not going to hang out here all day waiting for kids to check a vital sign that I’m going to recheck regardless of their findings. The kid on the left gives us a report of 90 over 60, the kid on the right tells us it’s 180 over 110. I have a dead pan stare on my face as I wait for Stacy to give me a report.

Stacy is writing the two sets of blood pressures on the patient care form and handing it to me. “Yeah, I know, you’ll have to check the BP again. Basically she was smoking a cigarette in bed and fell asleep. The blinds caught fire and the whole house went up. She got caught in a backdraft when they went in to get her. She had moderate smoke inhalation without any visible burns. That’s about it. Are you good?” Am I good? Hell no I’m not good. But I’m absolutely ready to leave.

Having moved Missy onto the gurney we start the long trek back to the ambulance. We have to double back a few times because of standing water creating small lakes in the street and fire hoses blocking our way. Throughout the ordeal I’m grumbling to myself about the poor treatment of Missy. Yeah, great, they got her out of the fire, but her treatment stopped there. Stacy knows better, she’s also an RN at a local Emergency Department, yet she released her helpers to let them fight the beast while the Explorers tried in vain to take vital signs. She didn’t have a history and knows almost nothing about this patient except she was in a fire.

Once we’re back in the rig I can start over and give Missy a proper check-out prior to going to the ED. Looking her over I can’t see any obvious burns but I’m more concerned with her breathing and airway at the moment. I slip the oxygen mask off and shine a flashlight in her mouth and nose and find singed nose hairs with soot extending the visible length of the nares – not good. Soot in the mouth and on the lips – not good. Oxygen saturation of 86% on room air – not good. Wheezing in the apex of each lung with a stridorous noise starting to come from the throat – really, really not good!

As my partner prepares the Albuterol and Atrovent nebulizer to affix to the mask I put an end tidal carbon dioxide nasal cannula on her nose so I can keep a good record of her respiration trends and quality of breathing, but looking at her face something just isn’t right.

“Missy, we’re going to give you a breathing treatment to help you breathe a little better but I have to ask about your medical problems. First off, have you ever had a stroke?” I’m seeing the telltale facial droop on the left side with an eyelid that looks like it’s being pulled down in the corner.

“Yeah, I had me a mini-stroke a while ago. They said it’s because of the A-fibs. But I all better now.” Now that I hear her speak I can tell there’s a bit of a slur to her speech.

“So you’re saying you didn’t have any lasting deficits from the stroke; like facial droop or weakness on one side?” My partner just finished setting up the nebulizer but I need to finish this line of questioning before putting it on and obscuring her face with a mask. He moves up to the front and starts getting us out of the neighborhood; I haven’t given him a destination yet – we both know that destination will be critical with this woman – yet we need to get moving.

“You know, now that you say it, it feel kinda like that mini stroke right now. I could’t get out of bed and my arm jus’ seem like it don’t want to move like it should.” That’s enough for me. I run Missy through a series of stroke tests; facial droop, slurred speech, left side weakness, change in sensory appreciation from left to right side and minor cognitive disassociations (how many wheels on a tricycle, what color is an orange, that kind of thing).

I glance out the front window as I place the mask over Missy’s head and see that we’re just exiting the neighborhood. Rechecking her blood pressure I discover that the Explorer on the left was closest – she’s 84 over 48. I start to set up the Sodium Thiosulfate drip for the IV.  “Okay, you ready for this?” I yell up to my partner.

“Yeah, go ahead, where we headed?” He yells over his shoulder as he lights up, turns on the siren, and heads for the freeway.

“Well, you already guessed we’re going Code-3. We’re going to Hilltop ED; 44 year old female, moderate smoke inhalation, hypotensive, tachycardia, tachypnea, Albuterol/Atrovent/Sodium Thiosulfate running. She’s also got a cold stroke, unknown onset time, left side weakness, with a history of.”

“Seriously?”

“Yeah, seriously, that’s what started the fire.”

 

 

Paralanguage 3/3

Six hours later.

“Medic-40, respond code-3 for the unknown, you’ll need to stage out for this.”

“Medic-40 copies we’re en-route and we’ll stage.”

Scottie had the last tech so this is my call. Scottie is driving us through the suburban neighborhood as I navigate using my iPad. Looking down at the map; “Hey, this is the same section-8 complex we went to three weeks ago for the 18 year old who was hyperventilating. Remember – it was your tech and we found her collapsed in the stairway?” Scottie had that call so fortunately I just drove that day. It was a ridiculous situation for a girl that had nothing wrong with her yet felt she needed to take an ambulance to the ED. It’s unfortunate but that’s what we deal with some days and we just strike it up to an easy call as we escort the patient to the lobby of the receiving ED. I really wish there was more I could do to help alleviate the system from abusive calls.

Scottie pulls over maybe three blocks shy of the complex as I’m pulling up the satellite view on google maps to refresh my memory on the apartment complex layout. Trying to get my bearings I’m looking in the direction of the complex. Three police cars pass us on the main arterial with their lights on and running fast. Then, with the windows cracked, I hear multiple fire engines and trucks approaching the same block. We can see the apartment complex roof from our staging post and I can see flames coming off the roof. A few seconds later I pick up the mic; “Medic-40, it looks like this is a structure fire, PD and FD are on scene; we’re going in.” The dispatcher acknowledges and tells us to advise on conditions.

As we pull up to the complex we have to park on the street as the fire engines/trucks/police cruisers are taking up the whole parking lot. We walk up to see what’s going on and to check in with the BC to tell him where we are and help out if there are injuries. I can see the building where the fire fighters are attempting to put out a third story apartment that seems fully engulfed in flames. There’s a woman standing on a balcony right next to the fire engulfed corner apartment. A fire crew is tilting up a very tall ladder to attempt a rescue.

Just then a woman runs out of the building next to us and literally throws her three year old son into Scottie’s arms. “He was is the fire, it started in the living room, please help him!” Then she runs back inside the building. The only problem is that it’s not the same building that’s on fire. This is a confusing fire scene with all of the people standing around, presumably evacuated from the burning building. The police are holding a perimeter to limit access to the area and and fire crews are clearing apartments, fighting a fire, and attempting to do a rescue. I’ve got to get to the BC; he’s the one calling the shots here and he needs to know where we are.

I turn to Scottie, “Take him back to the rig and check him out, I’ll check in with the BC.” As Scottie is carrying the kid back to the rig I keep going to look for the white hat that signifies the BC.

I finally find the BC and his two helpers on this scene; three white hats standing at the epicenter of all of the commotion. As I’m approaching them I see that one is a captain and two are lieutenants – one of which is LT from earlier in the day. So this is a three alarm fire and they brought out the more experienced captain to run the fire scene.

I acknowledge the two lieutenants and address the captain. “Captain, I’ve got one unit doing stand by on…” He cuts me off by holding up his hand as he heard something on his radio.

Speaking into his microphone. “Truck 5, cut a vent above unit 306, and one above the hallway. Engine 12, clear the first floor starting from the west. Engine 18 clear the second floor starting from the west.” Looking back at me. “I’m sorry, you were saying?”

He’s a busy man, I need to keep it short. “I’ve got Medic-40 doing a stand by on Halcyon with two medics on board. So far we have one possible patient but he came out of an adjacent building; not sure what’s going on with that, my parter is checking him out.” Looking over at the ladder against the building I see that they are half way down with the victim. “I’ll take her back to the rig and check her out. If we have any transports I’ll handle calling in other units. I’ll be on-scene until you tell me different.”

“Perfect, thank you.” He’s a man of few words. Then back to his mic, “Engine 8, lay supply lines from Halcyon to the number two exposure. Truck 3 – you’re clear to cut power.” As I’m walking closer to the ladder a fire fighter is escorting the rescued woman towards me. I’m thinking about the job that the captain is doing; coordinating six teams involved in – fighting the fire, rescuing people, searching for victims, overhauling burned out buildings. It’s overwhelming to me – I’ll stick with medicine.

The firefighter hands off the woman to me and goes back to the fire. As I’m walking her towards the rig I’m having a hard time communicating with her; she has a thick Indian accent and shakes her head when I ask some questions. She seems to have very limited understanding of English. Another woman from the crowd runs up to us as I get closer to the ambulance and starts talking with her in Hindi.

“Hey, do you know her?” I ask the young woman.

“Yes, she’s my neighbor, I was just asking if she’s ok.”

“Can you walk with us and translate for a little while?” She agrees and I hand the old lady off to Scottie in the rig along with a translator.

Looking up at Scottie, “Hey, where’s the kid?”

“His family came by and took him. He was totally fine, no soot in the nares or mouth, no burns. He wasn’t any where near the fire. Either his mother was just flipping out or she was setting up a law suite. Whatever…”

“Weird. So, this lady was just taken off of the balcony adjacent to the fire. Maybe 15 minutes of smoke exposure. She doesn’t speak English but I brought you a translator. If you can check her out I’ll see if there are any more victims.”

I walk back through the police perimeter to check in with the BC. Looking up at the building I see there are no more flames and just a few apartments seem to be burned with black soot ringing the windows like mascara. The rolling black smoke from before has turned to lighter wispy smoke coming from smoldering burnt wood that’s saturated with water.

Standing near the three BCs I quietly take in the sights; firefighters walking around with tanks on their back and carrying tools, ladders being taken down, hoses being drained and stowed on trucks. The captain is still coordinating things on his radio. “Truck 5 your clear to begin overhaul in unit 306. Engine 8 and Truck 3 are clear for station.” It’s looking like they’re just about finished.

The Captain turns to me. “We just had the one rescue from the balcony; no other vics. What do you have?”

“The kid wasn’t involved and checked out fine. His family took him. My partner is working up the woman from the balcony; minor smoke inhalation. We’ll get her transported but it’s just precautionary; she looks good. I can continue to stand by during overhaul if want us here.”

“No, that’s ok; you’re clear to transport.” He comes up to shake my hand. “I just want to say that I appreciate you’re professionalism, you guys did a good job, and that helped us do our job. Thank you.”

“Thank you sir, that means a lot to me.” I’m at a loss for any more words. That was high praise from a very competent man.

He turns to LT. “Can you go out to the rig and get information on the woman?” LT nods and we start walking back to the rig. They need patient info for their paperwork.

We talk about the fire and the crowd and the fire that we both went to this morning. It’s a good conversation and it seems that we’re past the point of having any bad feelings between us. I’m sure the high praise from his Captain reminded him that even good people make mistakes and our world is too small to let bad feelings continue. We’re two colleagues having a water-cooler conversation in the aftermath of a fire – quietly walking through the crowds of people, police officers, firefighters in smoky turn out gear, and the ever present street vendor selling popsicles and churros.


Peaceful Warrior 1/3

peace·ful

1 : undisturbed by strife, turmoil, or disagreement; tranquil

2 : of or characteristic of a condition of peace

 

war·ri·or

1 : one who is engaged aggressively or energetically in an activity, cause or conflict

2 : a man engaged or experienced in war, or in the military life; a soldier; a champion

In thy childhood you were ignorant and blind. And in your youth, you were lured away by sin. In the third stage, you gather riches and when you get old, regretfully you leave them all off.

Ramkali – Sikh Guru

“Sikh temple, seriously?” I didn’t even know we had a Sikh temple in the county and I’ve been working the streets for years. This is one of the things that I love about working here; the cultural diversity is never ending and continuously developing. This call is pretty far from our current post so I have time to check the notes on the call. The notes in the mobile data terminal (MDT) tell us that we’re responding to a man who burned his hand in a kitchen deep fryer.

I’ve been called to a few deep fryer mishaps and it’s never pretty. In this case I’m hopping it’s the left hand because Sikhs wear a steel or iron bracelet on their right wrist. Given that we have a long response time I expect the fire department would clip it off with the bolt cutters before we arrive. The secondary burn from the steel and constriction while the hand swells could be problematic.

Strobes are illuminating the darkness and Scottie is navigating us deftly as we speed through the suburban sprawl. I decide to see how big this temple actually is and pull up the google street view on my iPad.

“Uh, Scottie, this is a huge temple and the notes say there’s a festival going on right now. We might have some crowd control issues. If we can I’ll want to move him to the rig quick so I can work him up without an emotional crowd scene.”

I’ve run a number of calls in the Sikh homes in this part of the county and I feel they are largely misunderstood by most Americans. In the post 9/11 outrage many Sikhs were mistakenly thought of as being Muslim – one man was even killed in an ignorant act of violence. In fact, quite the opposite is true. Sikhism is an offshoot of Hinduism that came about in the 16th century. In only 500 years it has grown to the worlds fifth largest religion – and this from a religion that does not actively recruit. With its roots in the Punjab region of India, which borders on Pakistan in the northwest part of the country, the Sikhs found themselves on the front lines of conflict and protecting India from Muslim expansion. Many people in this country fail to see past the beard and turban to fully appreciate their rich history and culture.

As we round the corner to the temple I can see that my crowd concerns were well founded. Pulling into the circular driveway I see at least five hundred people in the courtyard of the temple. Parked cars have been lining the residential streets for the last several blocks and their large parking lot is full. A bearded man wearing a turban and traditional garb – covered by a reflective vest – is waving us past using a flashlight with an illuminated orange cone. Its a paradox of old world and new that somehow reminds me of a Jedi master. We pull up behind the big red truck to the side of the temple.

Half a dozen young men in turbans and traditional dress encircle us as we exit the rig with the gurney. They usher us towards the side entrance to the kitchen while providing a crowd break. They are yelling excitedly at the crowd in Punjabi; presumably telling them to get out of the way. They’re doing a great job of clearing a path as the crowd parts allowing us to pass.

There are men, women, and children of all ages. The strobes from our rigs illuminate the intricate metal lace interwoven in the women’s head scarves and the traditional curved knives worn at the men’s waists. Many people have plates of food in their hands and the delicious smell only serves to remind me that we never got a lunch break today – a feeling which is juxtaposed with the fact that the man who may have prepared some of this food is now in excruciating pain.

Finally we turn the corner to the kitchen to find my new patient. He’s a man in his forties wearing a white traditional shirt and matching turban. His right hand and forearm are wrapped in a trauma dressing. His face is silently contorted in pain yet he doesn’t make a sound. Damn! It is the right hand.

As the fire medic unwraps the dressing so I can have a look I catch a minty smell. The arm appears to have circumferential partial thickness burns to approximately four percent of overall body surface. Yet it’s difficult to visualize the surface because of a white ointment that appears to be slathered over the arm.

I know the firefighters wouldn’t have put anything on it so it doesn’t really make sense to me. “What’s all the white stuff?”

The fire medic looks up at me with a totally straight face and deadpan delivery, “Toothpaste.” Seriously? Toothpaste?? what the hell?!?

Okay, I’ve seen people put some strange stuff on burns but this is a first. In the last few years I’ve seen: mayonnaise, butter, and yellow mustard. It seems people are always treating burns like a hot dog, although I’m still waiting for sweet relish. But toothpaste is a new one.

I listen to the description of how it happened as I cut his shirt off and move him to the gurney. I’ll leave the turban on for heat retention as he’ll get cold and start shivering here in a few minutes; covering the head helps to hold in heat. I see the bracelet that was cut off of his wrist sitting on the counter, pick it up, and put it in my patient’s good hand. He’s still stoic yet seems to appreciate having it back. He inspects the perfect circle that is now broken and frowns as he puts it in his pocket.

The bracelet is called a kara and is worn by both male and female initiated Sikhs. It is one of the five external articles of faith that identify a Sikh as dedicated to their religious order. The Sikhs wear the kara as a reminder to have a calm spirit and life – it’s an expression of eternity. In India, warrior Sikhs are still seen wearing several karas of large sizes, designed to be used as a weapon in hand to hand combat. It’s an integral item in the martial training that was developed by the warrior Sikhs. I wonder if he assigns significance to the fact that bolt cutters have severed the perfect circle and thereby thrown mind, body, and spirit into a state that is less than harmonious.

Once he’s on the gurney I stick to my original plan and start moving quickly to the rig to treat him further. As I head out of the kitchen my six escorts jump into action and make a path through the crowd. I wish I could take these guys to every call with me as they are doing a great job of expediting my egress from the temple.

After loading into the rig I tell Scottie we can start driving. All of my treatment can be done en route to the hospital because hot oil burns have a way of getting worse with time. I’ve watched blisters form in front of my eyes while transporting similar hot oil burns. Treatment at this point is fairly straightforward: irrigate with sterile water to minimize the heat of the oil and get rid of the toothpaste, get rid of the trauma dressing and apply a sterile burn sheet, load him up with as much morphine as I can, and treat for any signs of hypothermia.

The body’s reaction to a moderate burn is to shift fluids to the tissues to replace fluid loss from the burn. It’s called third spacing as the fluids are taken out of the circulatory system and shunted to the peripheral tissues.This can reduce the blood pressure and cool the core, thereby inducing hypothermia and dropping the blood pressure.

It’s a long ride to the burn center – I have to go out of county as he meets burn patient criteria. Having a circumferential burn to the fingers and wrist could result in swelling, yet the skin is no longer elastic so it could restrict circulation or burst like a grape. A burn center is better equipped to deal with this than a basic ED.

My treatment is basic at this point and he has been stoic throughout. I can still administer a few more rounds of morphine yet as I go to administer he holds up his good hand and refuses additional pain meds.

Laying on my gurney In the back of the ambulance, arm elevated to reduce swelling and so he can feel the cool air if the air conditioning, this brave man refuses pain medication. His face softens from its original squinty-eyed grimace and he relaxes his back to lie more comfortably. With turban in place and a peaceful look to his face I see a tear trickle from the corner of his eye and travel down his face to get absorbed in his beard.

Acceptance is the bridge. Accept the pain, accept the wounds, accept yourself as you are. Don’t try to pretend to be somebody else, don’t try to show that you are not this. Don’t be egoistic, and don’t go on pre-tending and laughing while your heart is crying. Don’t smile if your eyes are full of tears. Don’t be inauthentic, because by being inauthentic you are simply protecting your wounds from being healed. Your whole being will become rotten.

Osho; ABC Of Enlightenment