the final in my lies series.
some time ago i got the message that a patient was on the way in with burns. ok. not something i'm overly fond of, but you handle what comes your way. i sort of hung around casualties, waiting.
she arrived. burn wounds are prognosticated by surface area burned as well as depth of burn. inhalation burns are casually tossed into the equation as not a good thing. so when you see a patient with 100% burns (ok, actually 95% because her hair has protected the skin of her scalp. the hair burned away and not the skin underneath) the prognosis is zero, nada, zilch, nil anywhere in the world. another interesting fact about burns is once the skin is destroyed, including the pain receptors, the patient has surprisingly little pain.
so as i was saying, she arrived. 95% burns and not looking good. the casualty officer and i approached together.
"what happened?" i asked, more to evaluate her voice, although i admit i was curious.
"it was an accident. it wasn't on purpose." replied the patient with a hoarse, croaky rasping voice. immediately a number of things went through my mind.
1) if the singed nostril hairs had not been convincing enough, her voice confirmed that she had inhalation burns. her airway would swell massively in a few hours, causing airway obstruction and death if she was not tubed.
2) she was lying. i didn't ask if it was done on purpose. up until that moment i had assumed it was an accident. now i knew it was suicide or murder. (i omit the technical word attempted, because it was soon to be removed anyway).
3) what a bloody waste to maintain some ruse in your dying hours. give it up!
i quickly threw in a cvp. there were no peripheral veins. they were all burned away. then i performed a few escarotomies (sort of like a faciotomy but on burned skin and not facia). then a sister told me there was another one. the husband was also burned. i decided to check him out.
he had mild burns on his forearms. that was all.
"it was not on purpose. it was an accident."
at least they had both decided to give the same story. they had obviously discussed it on the way. i still didn't know if it was suicide and they were afraid of the scandal or murder and she was protecting him. battered wife syndrome causes some strange behaviour. the husband then went on to explain that as he arrived home he heard screaming in the kitchen. he went in to find her on fire. he did what he could. at about this stage tears started running down his cheeks. the casualty officer held his hand and bit back her tears. i did not. i remembered my friend and was cautious. i also found it too coincidental that he arrived home at the exact moment the 'accident' happened. maybe i'm too sceptical, i thought. but then again maybe i'm not.
we patched him up. as he left he took me aside, and with tears in his eyes, he asked me to at least make sure she didn't suffer. i said i would do all i could.
she, however, could not go home. i gave her the necessary fluids and pain meds, but i decided not to intubate. she was going to die. she was either going to die with a tube down her gullet or without. also a tube would effectively just prolong her suffering. hence i felt dnr and dnt (do not tube) were in order. but no matter what, it was not going to be a pleasant death. and pleasant it was not.
i did not follow the ramifications of the case, except for hearing that a murder docket had been opened against the husband. who knows what the truth is. i do, however know what it is not.