GWOT I - Burn Ward
"Even burns to a small surface area can be incapacitating for the casualty and strain the resources of deployed military medical units. It is crucial to remember that burns may represent only one of the casualty’s traumatic injuries, particularly when an explosion is the mechanism of injury. Resuscitation of the burn casualty is generally the most challenging aspect of care during the first 48 hours following injury, and optimal care requires a concerted effort on the part of all providers involved during the evacuation and treatment process."
-- Emergency War Surgery: Chapter 26, Burns
(This resource is freely available - pre-Firecracker - at
https://medcoe.army.mil/borden-tb-ews)
Getting back with loads of medical supplies did not change the essential nature of the problem.
We had a lot more hurt people than we had the ability to care for.
We had the space. At a word from the Site Location Executive, the entire rest of the nearby offices had been cleared. They were too distracted by the moaning to work well anyway.
The infirmary had gotten the metal tables and the handful of hospital beds we had been able to loot.
So a lot of the excess patients ended up on sheets on the floor.
The Facilities folks had a small supply of lumber, which they used to make a few beds until ordered to stop, for lack of materials.
The more solid and larger furniture desks had also ended up as infirmary beds. But we were still short.
New looting priority - go find furniture, lumber, beds. Problem was that a lot of such things were in use by all the other survivors and refugees.
Just training people to be emergency nurses was very much on the job training. I'd shown that first assistant how to place a urinary catheter. She'd taught others. Now it was a copy-machine effect. Not wiping the head of the penis meant urinary tract infections. Most women can tell you that's painful. When you're already badly hurt, infections go systemic and kill.
Then there was the paperwork. For lack of paper, printer access and time, we'd gone to electronic charting. The simplest way imaginable. An electronic document for each patient - Site did not do Microsoft Word or any other competitor's products - in which basic details were recorded, or in medical terminology charted. Laptops mounted in the hallway - if it was one thing Site wasn't short of, it was laptops.
Many of the documents told the same basic story.
###
Janice Sanchez, DOB 2-31-1999
Chief Complaint - GSW to lower left quadrant, abdomen, high powered rifle
Vitals at admit BP 94/66, pulse 124 strong, O2 sat 94
Two IVs. Transition to small sips by rag when out of IVs.
Exploratory surgery performed on Day 2. Bowel surfaced and colostomy for inadequate remaining to close. No exit wound, internal lavage.
Vitals on Day 4 BP 103/72, pulse 110 intermittent, O2 sat 96. Urine 500ml and dark yellow.
Strong sewer smell from bowel, infected. Lavage every 4 hours with sterile water. Hydration with boiled water and sugar solution. Sativa drops for pain control, ineffective.
Vitals on Day 6 BP 140/50, pulse 160 and weak, O2 sat 92
Delirious and had to be restrained. No urinary output.
Time of death Day 7, 0430 hours, no code.
###
There were better stories. Miraculous recoveries. But there were also worse ones. Minor wounds becoming infected. Inadequate supplies, especially medications.
By far, the worst were the burns. By far.
Without the vet surgeon, who we all called Doctor now - and she had learned to stop flinching when we did - so many more would have died.
For example not at random, one of our early burn casualties from the Firecracker had burns across his chest. He'd been unlucky enough to be out jogging in Redwood City, and even unluckier to be taken by a well meaning friend to their apartment in San Jose instead of directly to Stanford Hospital. By the time we'd gotten him, he was already having trouble breathing and was chewing on a washcloth in between weakly screaming.
You see, the burns were closing up around his torso and he was finding it difficult to inflate his chest.
I would have had to watch him die.
The vet surgeon sighed, walked up to the gurney, said "Restraints and mouthpiece" and the moment we had his arms and legs tied down and a boiled mouthpiece in his mouth, she whipped out a scalpel and started cutting all around his chest and back as if she had discovered her new vocation as a serial killer.
I found out later that the medical term is thoracic escharotomy.
But suddenly he could draw breath with which to scream much more effectively.
"See, Echo 18, you said to read Emergency War Surgery," she snapped. "Burn Ward."
We didn't have enough fabric sheets and after one set of sheets had stuck to the missing skin, we now put people down on the next best thing. Butcher paper when we could, newspaper when we couldn't. Meat is meat.
We were very short of IV sets. They were no longer disposable. They were reused. But after the top is pierced and a needle is used to refill with a boiled water and sugar solution, they're certainly not sterile anymore.
The IVs had to be stapled to the skin. We didn't have the professional sutures. But it turned out that a binder office supply stapler would work, and it was what we had.
We had to keep the room warmer than we kept the rest of the infirmary. Most of it was kept slightly cool. But we had to bring in heaters to keep the burn ward warm, because the patients couldn't tolerate either cold or blankets.
They all - male or female, burned genitals or no - had to be catherized so that trapped urine would not explode their bladder and kill them.
When they could tolerate oral fluids, they got oral fluids.
Only when they could not - and they had some chance of survival - did they get our precious reusable IV.
Then they got to visit Hell.
Hell was a stainless steel table, canted slightly right by bricks under the legs, which drained to a floor drain. What had been a janitorial sink hose bib was fitted with a dishwashing style metal faucet with hand trigger. The water temperature was carefully set to 88 degrees with a thermocouple.
We had a very limited supply of cleaning agents that could be used on burns. The preferred was Hibiclens. Weakly diluted Dawn hand/dish soap was an alternative. More than once we had to use ordinary plain soap, unscented, because we had once again ran out of everything else.
We had to clean and debride the burns, removing foreign material.
We had grossly inadequate pain medications. The handful we had, we had to reserve for those cases where pain fueled shock would certainly kill, not maybe kill.
So we scrubbed raw wounds, as gently as possible, which was not very.
The vet surgeon had had to teach classes. I had had to keep order, because people kept trying to hit her or worse. Not the patients. The trainees.
I had no trouble whatsoever. I'd seen it at Stanford, on an industrial scale.
I also have something missing in me.
A screaming person is just information. Whether I am hurting them to gain compliance, or hurting them to save their lives, I just don't feel what other people call empathy or sympathy or emotional resonance or half a dozen other psychiatrist words.
After screening several hundred employees, we found several that were like me, and another several who liked hurting others. One of the latter worked in user interface design. Another was a marketing specialist. Two were physical therapists, who were also in demand _as_ physical therapists for our many with lesser injuries.
But coding came first. Anyone who could code, had to code. Second jobs like saving lives were secondary.
Whether they could endure doing it, or liked doing it, was besides the point. We needed people who could Do The Thing.
The sadists quickly were glutted. They could hurt people as much as they liked without hurting them enough to help them. So I even had to goad the sadists into doing what was needful.
Needful.
How I hate that word.
So those lucky few could look forward to coding ten hours a day with two hours of holding down screaming people and washing them, hurting them very badly to give them their only chance at survival we could offer.
I could do the thing. And I took my turns. But I had so much else to do, that my time was rationed carefully. I did the kids.
Some of the burned adults chose to die instead. We enforced upon them two sessions. We explained why, and that killer infection would follow if we did not. We showed pictures, at first from textbooks and then from our facility, what happened when infection led to sepsis led to gangrene and death.
Burned extremities had to be elevated. Burns had to be inspected, carefully, by an actual medical professional with surgical training. We had exactly one of those. So she had to look at every burn, every day.
She had been a vet because she wanted to help hurting animals. She really didn't like to work on people. She didn't mind hurting people as much as she minded hurting animals. But she still didn't like it.
The Infimary Staff Lounge became our not-so-secret hiding place from the horror that was now our lives.
We talked. In shorthand. She grew to hate me as much as I grew to hate her. Because when her resolve faltered, and she was merely human, I made her keep Doing The Thing. And I in turn despised and resented her weakness, that made me become as sadistic to her as we were to our victims.
Patients, I mean.
But we were both initiates of the mysteries. Not of death, we knew that one.
Of sadism. Deliberate, cruel sadism. Making people live when it would be so much easier to just let them die.
It was not just debriding. It was autologic grafts - the only way to avoid rejection was to transplant a person's own healthy tissue over the burned area. It was amputations. It was worse things I won't talk about.
And it was classification as expectant.
When sepsis took over, we were done.
Next.
The Firecracker had filled every hospital and burn center with the survivors, from Alaska to Houston to Maine and Florida.
The very important ones got the handful of beds at Valley Medical Center San Jose, which had been the comprehensive burn center for the region.
Unauthorized ambulances approaching VMC were shot at. To miss at first. But they meant it.
Children got priority at UC Davis after Oakland Children's Hospital was evacuated.
So we had no tertiary facility to send burn patients to. They lived or died, right here, with what help we could give them.
Little enough. But we tried.
People who were burned later - in the truck bombing, in the massive attacks, in outbreaks of violence, in ordinary accidents in a post apocalyptic world - got the same treatment.
It did not change the essential nature of the problem.
We had a lot more hurt people than we had the ability to care for.
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