Sight

Acids and Alkalies. —

Burns produced by an acid other than carbolic acid, are best dressed in the beginning with dry bicarbonate of soda.  For carbolic burns, use alcohol.  When burns are caused by an alkali, neutralize the effect by washing with diluted vinegar or lemon juice, and afterwards apply an ointment dressing.

For burns of the eye resulting from the introduction of strong alkalies, irrigate freely with warm water or boric acid solution.  For acids, apply a few drops of pure albolene or white vaseline.

From “Practical Nursing: A Text-Book for Nurses and a Hand-Book for all who Care for the Sick,” Chapter XVI, Emergencies.  Published 1911.

~ ~ ~

The two calls came into the ER simultaneously.  One was from our paramedics, and the other was from the foreman of the mill.

“He’s burned?” said the charge nurse, scribbling onto a piece of paper.  “What’s the name of the chemical he was burned with?”

“Did you decon at the scene, or do we need get ours ready?” said a second nurse, phone tucked between his ear and his shoulder.

“It was a hot run?  How long ago did it happen?”  By now everyone in the nurses station was silent, listening to the simultaneous conversations.

“Got an estimate on the TBSA?  …oh, shit.”

They hung up at the same time.

The charge nurse spoke first.  “We’ve got a guy coming in from the paper mill.  Pipe running overhead broke, and this guy looked up as everything in that pipe rained down.  Mill was doing a hot run tonight, so the stuff was heated near boiling.”

The second nurse spoke.  “Paramedics are doing a thorough decon at the scene, so he’ll come in clean.  He’s still conscious, but they estimate him at 45% burned, second and third degree.”

“The chemical is called ‘black liquor,” said the charge nurse.  Everyone Googled it.

“Godfuckingdammit, it’s alkaline,” said the ER doc.

The second nurse looked up at all of us.  “He got it into both eyes.”

Everyone paused for a moment, taking a collective breath.  The second nurse continued.  “They’ll be here in 30 minutes.”

The ER doc stood, and headed to the trauma bay.  “Then let’s get ready to work.”

~ ~ ~

It was the worst of all worst case scenarios when it comes to burns, a thermal alkaline burn involving the eyes.  To have a hot alkaline solution into the eyes was almost assuredly an injury that would rob this man of his sight for the rest of his life.  Hot air and water scald tissue, but alkaline substances simply dissolve it.

We paged the anesthesiologist and his team, aware that intubation would be necessary, and that the intubation of a scalded airway could be complex enough to warrant an emergency tracheostomy.  We called in the critical care float nurse, respiratory, x-ray techs, lab, the house supervisor.  One doc called the burn center for the region, and their doctor accepted the case instantly.

The burn center, one of the very best along the eastern seaboard, was more than four hours away from us by ambulance.  It was the middle of a dark, frozen northern winter night.  We called our helicopter team.

“I have good news and bad news,” said the charge nurse, after hanging up the phone with chopper pilot.  “The good news is, they’re here in house, not down south.  The bad news is, the pilot is about to reach his end time for the shift.”

“What does that mean for us?” I asked.

“That means that if the chopper isn’t wheels up off the roof by 0600, he’s grounded.  He’s personally OK to fly; he’s been sleeping all night.  But it’s the FAA’s rules, not his.”

We glanced at the clock.  0415.  We would have just over an hour to stabilize, intubate, medicate, pack him up, and get the helicopter off the roof to the burn center.  It was our only hope for salvaging his eyes, and possibly his life.

~ ~ ~

We were tense in the trauma bay.  I remember it being very quiet as we waited for everyone to arrive.  As the third nurse of the trauma team, I was the runner, the gopher, the tasker.  I pulled everything I could think of that we might need.  Sterile sheets.  Morgan lenses and bags of normal saline to irrigate the eyes.  Foley catheter.  Large gauge IVs.  I prepped multiple bags of Lactated Ringers, and set up the fluid warmer.  I turned up temperature in the bay as high as it would go, and flicked the switch for the heat lamps.

A nurse stuck his head in the door.  “Anesthesia wants propofol, sux, and versed ready to go for induction.”  I nodded and pulled the RSI box from the pyxis, drawing up all the meds into syringes, carefully labelled and ordered.  I slid a lead apron over my head, and tied it around my waist.  I pulled on a plastic gown, a mask, a face shield, my gloves.  The rest of the team did the same.

And then we waited.

~ ~ ~

That pause between readiness and arrival stretches on and on and on, spiraling away from you.  There’s so little to say.  Everyone knows their place on the team.  Everyone knows what their first action will be.  The scene is rehearsed over and over again in practice, in certification tests, in reality.  But until the paramedics roll down that hallway, there is just empty space, time, thought.

Warm air roared into the room from the vents.  I began to sweat through my scrubs, encased in lead and plastic.  I don’t remember exactly what I thought about in those intermediary moments, or recall the hushed conversations bubbling around the edges of the room.  I like to think I went through the ABCs of my trauma training, or did an imaginary head-to-toe review of possible interventions, readying myself for anything.

But sometimes, all you can think over and over again, as the seconds tick by, is:  let me do this right.

~~~

Time speeds up after the paramedics roll in.  The universe knows it needs to make up for the lag of the previous moments, and thus rushes the first ten minutes you have with your patient.  Everything happens at once.

His clothes are gone, cut away by the paramedics and his coworkers as they frantically rinsed the chemicals off him.  He is covered by a sterile sheet and bundled under piles of blankets to stave off the subzero temperatures en route.  He is awake, bewildered, in shock.  He is in agony.

Anesthesia moves to the head of the bed.  “Mr. Jones, we’re going to give you medications to help you sleep, and to help control the pain.  We’re going to put a tube down your throat to help you breathe while you’re sleeping.  You won’t feel any pain, or remember us doing this.  We’re going to fly you down to the burn center in the city, and they will take excellent care of you there.”

The man lying on the bed can’t close his eyes because they are so inflamed from the burn.  He nods blindly, his eyes open and unseeing, the corneas milky.  I hand the RSI drugs to the anesthesia nurse, and she renders him unconscious and paralyzed, and anesthesia slides a tube past the swollen, draining tissues of his throat, and into his lungs on the first try.  The respiratory therapist squeezes the bag, the color indicator changes from purple to gold, his chest rises evenly, and everyone in the room releases the huge breath that they didn’t know they were holding.

I start to gopher.  I start a second IV on a tiny unburned patch on his left arm.  I run fluids.  I double check the propofol drip, an enormous dose per minute running fast to keep him unconscious and out of pain.  I insert a foley catheter and secure it to the only spot on his left thigh not red and raw and oozing, the skin dissolved and gone.  His right hand is badly burned; he must have raised his dominant hand to try, much too late, to shield his face.

Another nurse has placed the morgan lenses on his eyes and opened the bags of saline.  Fluids rush over the macerated corneas, drip down into his ears, run off the table, pool on the floor.  We throw towels under our feet to absorb it, but we keep the fluids going, changing bag after bag.  I hear gurgling from his ET tube, and suction it.  The tissues in his trachea and lungs are leaking from the damage of the thermal burn.  I clear his airway, and suction out his mouth.  Fluids pour out.  I suction again.  And again.

~ ~ ~

The flight paramedics enter the trauma bay.  I see them, and glance up at the clock.  It’s 0500. We start to get ready to move him to the helicopter gurney.

Another nurse pokes her head through the door.  “There’s some guys from the mill here; any chance they can see him before we put him in the bird?”

The team glances at each other, and we nod.  “Two at a time, and it’s gotta be fast.”  I clear equipment away from the left side of the bed, and pull the blanket back from his left hand, amazingly intact.  The paramedics and the lead trauma nurse continue to transfer tubes and IV pumps to the gurney on his right side.  They unroll the enormous ‘sleeping bag’ that will zip up around the patient to keep him as warm as possible.

Two guys walk into the trauma bay with a nurse escorting them.  They are my patient, as he had been, just an hour ago.  Middle-aged, blue-collar, night-shift, manual hazardous labor.  Shift work, mill work.  A wife, an ex-wife, kids at home, maybe kids at college, a stupid dog or two, a broken truck in the yard, a new truck in the parking lot of the mill, bought on credit.  Carhartt overalls, Carhartt jacket, a blaze-orange woolen cap stuffed into the right-side pocket.  They have seen some terrible things in their lives, but they have never seen this.

In them, I see my patient as he was.  In him, his coworkers see themselves if not for the whimsy of fate.

They walk right up to him, and one takes his left hand.  “Jack, it’s Bill.  Tom’s here, too.”

“I’m here for you, Jack,” says the other man.

“Everyone at the mill is praying for you, Jack.  You got some of the best doctors and nurses here, and you’re going to be fine.  They’re taking real good care of you until we can get you to the city.”

“Dan went to your house to get Donna, and they’re already heading to the city, so she’ll meet you there at the hospital, ok?  She knows you’re gonna be all right, so you hang tough and stay strong.”  The second man lays his hands over my patient’s wrist.

“We’re all here for you, Jack.”

“We’re all with you, Jack.”

“You’re gonna be all right.”

~ ~ ~

It is 0520.  We slide him slowly, watching all the lines and tubes and drains, to the helicopter gurney.  I take out the morgan lenses and place a wet, sterile towel over his eyes, and then another towel over it.  Despite the terrible heat of the bay, he is shivering.  We haul sheets soaked with saline and wound drainage out from underneath him, and shove warm dry sheets back in.  We pile him with as many warm blankets as we can fit inside the sleeping bag.

It is 0530.  We are in the elevator to the roof.  The critical care nurse calmly bags him, breathing for him.  I hear the gurgle again, but there’s nothing I can do for him anymore; the flight medics will have to manage it in the air.

It is 0540.  It is ten degrees below zero outside, clear and so cold it feels as though the night could shatter with a blow.  He is in the helicopter, and the medic gives us a quick salute, and slams the door shut.  We retreat across the walkway and inside the double doors, and then we press our faces to the glass window.

It is 0545.  The bird is silent and motionless on the roof.  I glance at the critical care nurse, nervous.  He shrugs.  “Either they make it off the roof in time or they don’t.”

It is 0550.  The enormous rotors finally, finally, begin to spin up.  The high-pitch whine comes first, then the tone drops deeper, then finally a pounding, thundering beat that threatens to pull the air from your lungs.  The blades cannot possibly spin faster, and then they do.

And spin.  And spin.  And spin.  The helicopter sits on the roof, a sleek, motionless, arrow under a roaring chaos.

It is 0555.  “Lift,” I beg under my breath.  “Please, lift.  Lift, lift, lift.”  The skids remain on the roof.  I mentally begin my checklist again, everything I’ll need to get him back out of the helicopter, back down to my ER, stable long enough to get an ALS transport ambulance ready to go, everything the ambulance will need for that terrible, bumpy, traffic-filled rush to the city.

It is 0556.  “Come on…” murmurs the critical care nurse under his breath.  I’m too frightened to look at him.  I keep my eyes glued to the helicopter.

And then, suddenly, the nose comes up an inch.  The front end of the skids lift, and the thunder of the blades becomes a scream and then the helicopter tears itself from gravity and catches the air.  It rises effortlessly, smoothly, a quarter moon and a dozen stars silhouetting it against a frozen sky as it banks to the right, and heads for the city.

I glance at my watch.  It is 0558.

~ ~ ~

I shove open the double doors and walk back out onto the roof, shivering despite the warm jacket I’ve slung over my shoulders.  I watch the blinking lights of the helicopter fade into the distance.

I can’t know, then, that the helicopter will land safely on the rooftop of one of the best hospitals in the world.  That the burn team will be waiting for him on that rooftop, and will pull him into their BICU and get to work.  That, eventually, after months of surgeries and excruciating rehabilitation, he will walk again.  And that, miraculously, he will keep one of his eyes, his vision damaged but not lost.

I will learn all of this much, much later, from the other side of the country, sitting in yet another ER in yet another new and different chapter of my life.

But at that moment, as the helicopter vanishes into the horizon, I know none of these things.  And so I pull my jacket up around my ears and stare into the darkness above me, hungry to take in the world with my own clear eyes, devouring it with my own sense of sight.