It had been a busy, challenging day in the emergency department, and the usual fatigue was setting in as the clock rolled past nine in the evening. The ambulance crew was out getting dinner and we were mopping up from the last few lacerations and germ spewing respiratory infections. In the emergency room, one’s endurance is tested again and again. When unbelievable loads of responsibility and a ridiculous number of hours of straight physical and mental exertion pile up, reality can become distorted. This distortion can be manifested in morbid humor or just the verbal acknowledgment of the strangeness of life. When the radio tones sounded, we braced for the next impending adventure in the life of the emergency department at our small, rural, busy hospital. Perhaps a motor vehicle accident with a whiplash victim or another elderly smoker having trouble breathing. It was August of 1994 and I was craving the end of summer, relief from the heat and long days. I love winter.
"A gasoline tanker truck has wrecked and the entire vehicle is engulfed in a massive fireball. There is a wildland fire spreading off the road and CDF (California Department of Forestry) has been dispatched. CHP (California Highway Patrol) is on scene as is local fire department. Unknown survivors. Do you copy?"
Oh my God, I thought. What a disaster. Completely selfishly I thought and said to my nurse, "at least we won’t be involved." No one would survive being engulfed in a gasoline fireball. No way.
We went on tidying up, bracing for the next few hours of typical late evening earaches and stomach pains, non-emergencies in patients who just ran out of coping resources and decided to ‘get checked’ before plunging into the empty darkness of night. I knew my wife and the kids were getting to sleep now, safe and peaceful at home. I tried not to wish I were there. I tried not to hope for an easy night. Acceptance and resignation are keys to successful adaptation.
Unbelievably, and most troubling to our weary brains and bodies, the next contact with the ambulance crew came as a brutal surprise. "We are heading to your facility code 3 (full out, lights and sirens) with one male victim, the driver of the big rig, with extensive burns. He is awake and communicative and in severe distress. Unable to obtain vital signs at this time due to extensive burns, but radial pulse is palpable (meaning he had enough blood pressure to sustain life). Our ETA (estimated time of arrival) is approximately four minutes. Do you copy?"
Four minutes to compute, anticipate, prepare, arrange, and set aside any considerations that the evening would be gentle to us. There would be the matter of immediate care of the patient, pain management, intravenous fluid administered per the burn protocol formulas, wound care, and family contact. Then, getting the patient transferred to a burn center would entail the usual multiple phone calls, often pleading for help from institutions which haven’t a clue what it is like to manage major medical problems with non-existent backup or specialist availability. The next several hours were definitely spoken for.
Bud Bristoe was wheeled in on the gurney, reeking of gasoline and smoke, moaning quietly, but otherwise not moving. His breathing was halting, as if each breath brought new torment to his badly burned torso. After introducing myself, I asked him what he was feeling at the moment and he let me know that his chest and right arm hurt horribly and that he was having trouble getting enough air. A quick look at his naked body revealed at least sixty percent of his skin to be barbecued to a full thickness, third degree burn. Most of his legs, his right arm, and most of his chest was burned to a hardened state. Much of this skin had no feeling, as is the case with third degree burns, but enough nerves were spared to scream holy horror to his brain, most likely displacing any room for thought about what would come soon.
As the nurse began to establish intravenous access to his bloodstream, the route for morphine, the rain in the desert, I started the process of calling air transport and the burn center. The call to the regional referral burn center in San Francisco (St. Francis) went relatively well and the resident on-call for the evening agreed to accept this patient in transfer and agreed that air transport would be appropriate. The next call was to the air ambulance service, an extremely high quality resource out of Santa Rosa, ninety miles south of our hospital. Unfortunately, they were not available, so the air ambulance company out of Stanford was called. They could pick up the patient, but could not land in the city because of fog. They suggested we try the burn center at UC Davis. While waiting for the call back from Davis, we were able to secure a fixed wing transport out of Redding, 180 miles northeast, to transfer to Davis. Fine, great. Davis then called back and the admitting chief of service let me know that their burn unit was full of critical patients and even if they could make bed space, he wouldn’t get to the operating room for two days. I replied that I didn't think the patient would survive that long, thank you anyway. This physician suggested I try the burn center at Alta Bates Hospital, also in the San Francisco Bay Area. Aggravated frustration setting in, I decided we would have to transfer by ground ambulance to St. Francis in San Francisco, a three hour ride.
We gave Bud intravenous morphine, antibiotics, and fluids as calculated from the burn resuscitation protocols. A urinary catheter was placed to monitor circulation to the kidney. The urine that ran out of the plastic tube was bloody. At this point the patient stated that he couldn’t move his legs and we discovered that his body was numb up to the middle of the chest. If he sustained some kind of spinal cord injury, this was going to be the least of his problems, as strange as that seems, because his burns were lethal as far as I was concerned. Though I do not have extensive experience with severe burns, I have a general sense about major injuries. Only very rarely do patients survive this extent of third degree burns. The morbid nature of the outcome is that death comes in a day or three, many hours after the deed is done, and the patient may be fully conscious while the grim reaper creeps up to snuff out the spark. The warrior physician has a mixed and at times gruesome relationship with the grim reaper. He gets some, I get some. Sometimes we negotiate, but only when he’s in the mood. When he must have his way, I must see this and act and treat appropriate to this knowledge. Sometimes he lets me win the first few rounds, leading me and the patient off our paths. When I can translate his language for the patient, I must choose my own words carefully.
Mike Kowalski, one of the CHP officers at the scene, arrived at this point to see how the patient was doing. He filled us in on what happened. Evidently, as the tanker was heading out to the coast, thirty miles west, he was going too fast for one of the curves in the mountain road and the tanker flipped, subsequently ruptured, and exploded. His pneumatic seat pushed him up into the steering wheel locking him in the partially crushed cab. As the entire rig was enveloped in flames, he was heard to be screaming for someone to save him. Firefighters and a CHP officer eventually were able to get close enough to the cab to wrestle him out of a fiery coffin. It took all the strength of three large men. The officer, not wearing firefighting garments, found the rubber soles of his shoes had partially melted.
Bud began to complain of increased difficulty breathing. The burn of his upper trunk circled three quarters of the way around his chest and the flesh was cooked to a stiff consistency. This made it difficult for him to move his rib cage and therefore to get enough air. I saw that I was going to have to put an artificial airway in his trachea and start him on a respirator. Even if this didn’t need to be done right away, I would have to do this before leaving to make sure he would be stable during the transfer. Given the severity of his burns, I didn’t know how long he would survive. Because I would have to put him to sleep and paralyze him to take over his breathing, I thought that it was possible that he might never again wake up. The weight on my shoulders was balanced by a cosmic responsibility to do everything possible to support Bud’s being, whatever was left of it, with or without a body. He had been given quite a lot of morphine but was still in pain and quite awake, coping with every living fiber left in his brutalized body. By this time, we knew that he had a son living in the town ninety miles south. Family had not yet been notified.
"Bud, I need to tell you what we are going to do next. Because you’re having so much trouble breathing, I need to put an airway into your breathing tube and take over for you. I will have to put you to sleep to do this. Your burns are very bad and I don't know if you’re going to survive. If things don't go well, and you don't wake up after all this, I want you to take the opportunity now to talk to your son, or whoever else you would like us to call for you. Do you understand what I’m telling you?"
He said that he did and we got his son on the phone. He told him that he was hurt and burned but that everything was going to work out. Not to worry, just take good care of their dog, and be good. He reassured him with the same words several times and said good bye. My nurse Cindy held the phone in his ear, her other hand free to wipe her tears. The rest of us choked back our own. I told Bud that we were going to take good care of him and that he would be asleep in a few moments. We injected a sedative and two paralyzing drugs intravenously and every part of Bud stopped, except his heartbeat. While trying to insert the tube through his throat into the upper trachea, as I've done many hundreds of times before, I began to sweat as all the landmarks were blurred by red, swollen tissue. Although there were no other signs of heat inhalation (such as singed nasal hairs), his throat was quite abnormal and all attempts at passage of the life giving tube failed. Time was running out. He had to be given oxygen but at this point there was no effective delivery mode. We used a mask and squeeze bag over his face with temporary success. The only other way to effectively ventilate his lungs would be to place a ‘surgical airway.’ I took a small razor sharp scalpel and made an incision over his Adams’ apple (larynx), vertically, about two inches. Spreading the soft tissue with a hemostat clamp and feeling with my index finger, I located the cricothyroid membrane, a half-inch by one-inch area in the lower larynx and made a horizontal slice through it into the airway. With a clamp made for the occasion, I inserted a four-inch long plastic tube down into the trachea, inflated the balloon cuff to seal the airway, and connected the outer end of the tube to the oxygen bag. We squeezed and the chest rose and fell in cadence with the external pressure. I sutured the skin around the tube and my heart rate went back down to its usual fifty to sixty beats. My sweat began to dry.
As we dialed in the respirator settings, a call came in from the Redding air ambulance. They had done their own calling and arranging and were able to send a fixed wing craft to our little airstrip northwest of town, fly the patient to San Francisco airport and from there, ground crews would transport him into the city to the St. Francis Burn Center. Our ambulance picked up their crew, brought them to our hospital, packaged Bud for air transport, brought everyone back to the airstrip, and Bud was off to the big city for subspecialist care. The only last little detail before departure was the roughly seventeen page legal document specifying all aspects of the transfer and signed in personal blood. Should this part of the care go badly, I would be personally liable for a sum of money I would have to sell my children to get. Money. How ironic. I neither entered medicine for it nor did it give me very much for most of my career. Now the threat of losing more than I could ever afford, through no more than a detail of protocol, hung as a perpetual dark ether right there next to the grim reaper.
With the great ‘wisdom’ of the government and lawmakers, lawyers, our true (*&^#@*!!) representatives, have created laws to protect patients and hospitals from a phenomenon called "dumping." This exceedingly rare event occurred once in a big city where a hospital refused to take care of an indigent patient, sent an ambulance across town to another hospital, and the delay in care resulted in death of the patient. A legislator with nothing better to do, evidently, created a draconian law which imposes devastating penalties on physicians and hospitals if the law is violated. Even if no harm comes to a transferred patient, if protocol is not followed to the letter, the legal risk is enormous. And so, we have piles of triple layer paper forms, multiple phone calls, and agreements to establish before the patient leaves our doors. Now, in our small hospital, patients are transferred all the time for services not available here. Neurosurgery, ENT, eye, thoracic and cardiac surgery, pediatrics, and Ob-Gyn all have to be sent elsewhere. We frequently transfer and we never dump. Instead of creating an intelligent law that discriminates our situation from a city hospital where several private and public facilities are in competition, everyone is put in the same boat. Our energy expenditure skyrockets with no return other than frustration and waste. This is modern medicine. We are suffocating from the same death of common sense in which a few in the legal profession has mired all of society. Most of the laws that govern hospital and physician activity are necessary in the absence of intelligence, good will, and common sense. Those of us who practice with good heart and healthy brain are simply burdened, discouraged, and frustrated by the idiocy of the rules and penalties breathing down our scrubs every day. It is getting worse all the time and unfortunately, society will lose in the long run. Many of the best physicians I know would like to throw in the towel these days.
The sudden quiet after Bud’s departure was as dramatic as his arrival. We stood still for a few moments before clean up, looked at each other, and shuddered with empathetic appreciation over what had just happened. We let in Bud’s pain and were thankful for our own health and unburned skin. I thought about what I might say to my children or my wife if I believed my last few moments alive were ticking away. Images of bravery, anguish, anger, and fear flashed through my cortical lobes. Would the finality release me to slide on out with grace and dignity or would the sudden assault on my own version of my destiny bring out screaming, raging, cosmic anger? The nurse and paramedics were going through their thoughts when officer Kowalski came back in with more history about the event. Someone had observed Bud in his rig, parked at the old Texaco station lot, slumped over his steering wheel. He remained motionless there for about ten minutes before beginning the mountain road to the coast. This was completely out of character for this man. He had been a Marine and was a skilled truck driver. He knew his territory and limitations. He was a strong man. Something was terribly wrong. The story that was to unfold over the next weeks was stranger than fiction, and at this time, about eight months after the accident, much has yet to be settled. The attorneys are having a feeding frenzy. The defendants are having a ‘bad hair day.’
What we know, through newscasts and the grapevine, is that earlier on the day of the accident, a large petroleum refinery in the Bay Area was having a toxic leak of very nasty stuff. The prevailing breeze swept the chemical through a populated area and into the storage tank area of a second refinery. Bud was filling his tanker with gasoline at this time and had the same exposure as many citizens who became very ill, some needing hospitalization. Being the tough disciplined individual he was, Bud did not give in to a little case of neurologic and metabolic poisoning. Off along his assigned route, to his unexpected destiny he trucked. So, one version of reality holds that his pause at the crossroads was to rest his disoriented, poisoned brain before tackling a dangerous curved mountain road. Lacking full use of his faculties, he miscalculated the turn and bank of the road and met his fate. He, and peripherally we, are parts of a huge lawsuit against the oil company that released the chemical. I can't imagine that it will be settled until the sharks have had their bellies filled. It’s all the same to Bud.
Several days after the accident, I called the burn unit to get the verdict. The chief of the burn service came on the line and called me a "goddamn hero." "You saved Bud’s life! Establishing a secure airway and getting enough fluid in his system prevented a rapid death and if our surgeries go well, he’s going to come back up there to thank you in person!" I was confused. How could he have survived this degree of body wreckage? And what about his paraplegia? What spinal insult had I missed and how was he going to recover from that?
"We don't actually know why he is paralyzed or why he had blood in his urine. The scans of his brain and spine are normal. We think there is already a slight improvement. Time will tell. You folks are to be commended for doing a top quality job. You’ll hear from me again. I’ll let you know how he’s doing."
I was amazed. There are times when being wrong is just fine, and this was one of them. I am at a stage in my professional life in which the above quoted praises feel good for a minute or so, then it’s back to ordinary reality. I know that I did not do anything out of ordinary, out of standard care for this patient. The fact that he was still alive was because of how he responded, not because of extraordinary intelligence or skill on my part. I’m always glad when things work out, but I would be foolish to base my well being on positive outcomes for all my patients, just because I did the right thing. And, this hero business, it certainly is not who I am. If I save a life, I feel blessed with a sacred opportunity and privilege. If hero status is thrust at me, I pull back. After all, one is only heroic for a moment at most. Those who place hero status on another come to expect more of the same. Praise can lull one into self-centeredness that obstructs the ability to care for others. One of the most basic lessons in emergency medicine is that, in spite of doing all the right things, by the book and beyond, some people don't do well. Humility and gratitude are one’s best responses to good outcomes. Humility and grace go well with bad outcomes.
Bud died after a month of intensive care. Ultimately, all systems failed. Whether this was because of the basic lethality of the burn or because his body had been exposed to a very toxic chemical, we can never know with certainty.
Two of the CHP officers who helped pull Bud from the wreckage have been having difficulty breathing ever since. They are being evaluated by a lung specialist and most certainly will be one of many plaintiffs represented in the legal proceedings. At this stage of medical technology, it is impossible to know exactly what role the chemical (second hand) exposure played in their respiratory difficulties. Eventually, someone will make an educated, legal guess and money will change hands. These remains of the feeding frenzy will have no effect on anyone’s respiratory system. I see Mike and Al, the CHP officers, at the local health club where we get down and sweaty in painful efforts to hold off our own grim reapers. We chew the fat about local criminals and the bizarreness of life these days. We recognize that we are agents of society, appointed and empowered to deal directly with negativity, with the soiled underbelly of the species, for the betterment of the community and its citizens, and our jobs are very trying. Twenty five years ago, long haired and wide-eyed, I would not have been able to conceptualize my brotherhood with ‘cops.’ Age and change, growth or death.
I will never forget hearing Bud tell his son that everything would be OK, as the sand ran through his clutching grip, as we tried to hold the devil at bay with morphine, saline, skill, and good intentions.
As Kathryn and I drive to the coast for a day of ocean
cleansing and cool weather relief from the scorching summer heat in
our valley, the
34 mile road begins its first sweeping turn before heading up steeply.
Three miles in, on a gentle curve, the trees to the right are dark and
leafless. The dry brown grass of summer has a different texture than
further up the hillside. The fireball has left fossil evidence of the
night of light and heat and incredible pain. My abdominal muscles tighten
as if bracing for impact. I slow down to look and feel and to minimize
the chance of a wreck, however remote at the moment. The vividness of
my past, and Bud’s night with me, needs the vast ocean, the cool
mist spray, and the unending sounds of breaking surf to soothe the pain
and to round the sharp edges of hellish discomfort.
All Rights Reserved © 2004 Jon Sterngold