Jan 2004
No. 8
Marissa and Ricardo
by David Thompson
MSII; AECOM
This writing is graphic in nature. My only hope is that by sharing these stories it may somehow make us more alive and bring value to the experience of the patients.
-David Thompson
Our patient was slashed with a box cutter from behind his armpit around to right above his navel. The laceration was approximately 20 inches long and was gaping 2 inches wide. He was lucky that the wound, although it looked deep, had not pierced the abdominal cavity. There were 2 bleeding intercostals arteries that were quickly tied off by a surgical resident. My ER resident and I were going to close the wound using a combination of staples and sutures. The resident had just injected the anesthetic into the edges of the wound, when we got a notification that there were 3 badly burned patients coming in. Immediately, all staff in the ER dropped what they were doing and mobilized to assist with the call. We moved our lacerated patient out of the trauma bay and started gathering equipment and putting on sterile gowns.
The first patient to arrive was named Ricardo. Over 90% of his body was burned. His clothes were in tatters, and the epidermal layer of his skin was literally hanging off his body. He had no hair on his head, eyebrows, chest, legs, or genitalia. He looked like a stocky, muscular, slightly overweight man, but I could not tell if this was his normal stature or from swelling due to the burns. He came in screaming, "AAAAAHHHHHHH!!!! I'M HOT AND I'M COLD!!!! I'M HOT AND I'M COLD!!!"
His whole body was in shock, and he was shaking uncontrollably; he could not really move to any significant degree due to the pain being too severe. We immediately began removing his clothes and assessing his burns.
In the process of getting a tattoo, a tattoo gun uses a needle to inject ink through the epidermal layer into the underlying layer of dermis. The reason a tattoo is permanent is that the dermal layer, unlike the epidermis, does not undergo exfoliation. Ricardo's arms were fully covered with tattoos, but the thing was that the ink was on the OUTSIDE LAYER of his skin. This gave his tattoos the appearance of being freshly inked. His appearance was paradoxical - the combination of his swelling, bald head and his fresh-looking tattoos made him look like a tough, badass guy. However, this man was in more pain and in a more vulnerable position than most of us will ever know.
While we were working on Ricardo, his girlfriend was brought into the trauma bay by the paramedics. She looked even worse than he did. Peter looked over and screamed, "OH NO! THAT'S MY GIRLFRIEND! OH NO!!
I immediately rushed around to close the curtain to separate the two of them. He did not need to go through any more emotional turmoil at this point.
His girlfriend was named Marissa. Her body was entirely burned, literally all of it. She had a patch of hair left on her head, but her hairline was scorched and charred. The extent of these patients' burns was greater than my conception of "burns." It was not like they touched a fire or some hot substance; it was like they were ON fire themselves.
Marissa's body was spider web-streaked with black char lines where the flames had burned through differing layers of her skin. The smell was the worst I have ever smelled - burned human flesh is both awful and haunting. It was my job to remove her shoes, which were melted onto her feet. I wrenched them loose, among scraps of burned flesh that were hanging off. I then used tiny scissors to trim off the dangling scraps.
In emergency medicine, the key first steps in securing a patient can be remembered with the alphabet's "ABC" for airway, breathing, and circulation. Due to the swelling in these patients and their severe electrolyte imbalance, it was of critical importance to secure an airway and intravenous line for both of them. I assisted in holding Marissa's leg down while a resident placed a central line in her femoral vein. As this is a quite painful procedure, Marissa screamed a high-pitched wail as the resident was fishing with the needle to locate her femoral vein. This was actually viewed positively by the trauma staff, indicating that she was responsive to pain.
Since her body was going into shock and swelling, her respiratory muscles were clenched and her throat was swollen - these factors made it impossible to intubate her to secure an airway. What the residents decided to do was inject succinylcholine, which would paralyze her and make all of her muscles become flaccid. The scary aspect of this approach is that, in addition to relaxing the muscles around the throat, acetylcholine makes the respiratory muscles relax also. What this means is that the patient will not breathe for themselves anymore, so you've got to get the intubation right, and within about a minute, or the patient will suffer from lack of oxygen and could die. Miraculously, the residents got it right on both patients, and on the first try. Despite some ongoing stabilization care, the ER team had done its job - they had insured that these patients would stay alive, at least for the moment. It was 3:30am when I notified my attending physician that I was going to go home.
These patients haunted me in the following days. I had trouble falling asleep. I still have images of Marissa being wheeled into the trauma bay, shaking, spider web-streaked with char marks. Me thinking: "I can't believe this happened. I can't believe this is happening." I could not help but identify with these patients. They were 20 and 22 years old, and got trapped in the basement of a burning building. Now they are permanently disfigured, in great pain, and may even have died by now.
I continue to think about what we did for them - we kept them alive. It seemed heroic and exciting. But I have to wonder about the value of it. What will be their quality of life? Will they suffer and die anyway? Will they be able to re-join society in a meaningful way? Will they still love each other? The thought that I end with is that I suppose it is not up to us to try to anticipate how they will deal with their loss. Perhaps they will transcend their situation and come out of it in some way positively transformed. Maybe they will commit suicide. Maybe they will die despite our care. But that is not our job. We owe it to them (our patients) to allow them the opportunity to make their own choices, to have a future, to make their own decisions in how they will deal with their circumstances.
I went to visit Marissa in the Burn Unit the following Monday. It was 5 in the evening, and a nurse was covering her in blankets and bandages. Despite looking better in the ER, Ricardo was now in worse shape, and at that moment he was in the operating room having a fasciotomy, a surgical procedure to relieve the pressure from the swelling of his body. Marissa was absolutely covered in bandages, except for a small portion of skin around her mouth. Her eyes were covered with patches, and she was sedated. She'd had a procedure to graft artificial skin over some of the burns on her abdomen. The nurse lifted up the sheet to show me - it looked like her abdominal cavity was open to the outside world - disgusting. The nurse left me alone with her.
I hesitated and then said,"Hello, Marissa. I don't think you'd remember me. My name's David and I'm a medical student. I was working in the Emergency room when you were admitted. I took off your shoes. I came here today because I was worried about you. We were really scared when you came in, and I couldn't stop thinking about how you might be doing now. I'm glad that you're here. I know that this is really hard, and I can't imagine what you might feel like right now. I know that this is an incredibly difficult time, and I'm sorry that this happened to you. I just wanted to let you know that I was worried about you, and I wanted to let you know that there are people who care about you. I'm going to leave now, but I hope that I can come back and see you sometime. Hold on, and I hope that you keep getting better and better."
Post note: Marissa died the morning this paper was written. As of the following day, Ricardo was still alive but in severe organ failure.