Burning - burn treatment

Whole Earth Review, Spring, 1986 by Sallie Tisdale

BURNING

SOME SAY THE WORLD WILL END IN FIRE,' wrote Robert Frost. For some of us, it does. We are drawn to flames, punish with fire, and revel in it. War is fire and so is execution, the pariah strapped into a chair that vibrates with electric flames. Millions are burned to ashes after their death; the Hindu wife is thrown alive onto her husband's pyre, her only hope. We burn witches and heretics at the stake, to cleanse them; we dissolve waste, the unwanted, in baths of acid. A mother, driven to distraction by her child's crying, dips him in a tub of scalding water, tosses a cup of hot coffee in his face.

Fire is both joy and pain--it warms us, cooks our food, grows our crops. "Among all phenomena, it is really the only one to which there can be so definitely attributed the opposing values of good and evil,' wrote Gaston Bachelard, the philosopher. "If all that changes slowly may be explained by life, all that changes quickly is explained by fire.'

A group of recovered burn victims calls itself the Phoenix Society. Each year two million Americans are burned; three hundred thousand are burned seriously. Their unchosen pain becomes a source of teaching: for the unburned to repeat, observe, approve. It is pain as a religious joy, as a religious damnation. Whether the outcome will be ruin or rebirth for any one of these lightning-struck innocents is impossible to predict: destroyed by fire, the past disappears, and the future becomes a new world on the other side of the tunnel of the burn unit, through which the victim must crawl all alone.

Relatively few hospitals have specialty burn units. In those that do, the burn unit is the hardest place to enter, the most guarded, the most protected. A friendly surgeon may take a visitor by the hand into the operating room, a class of psychology students may forage through the pediatric floor; but few visitors get into the burn units out of curiosity. In part, this is because of the urgent need to prevent infections, but it is more than that. No casual wanderer would be glad to stumble across the burn unit unawares.

Burn treatment is, with rare exceptions, the most extensive treatment medicine offers, and often the most expensive. These uncommon beds start at over $1000 a day, minus the frills. In the burn unit, terrifying and exquisitely painful procedures are done in the name of healing; hideous wounds are repaired as best they can be. It is hard to watch, hard to hear, hard to do.

Burn patients are wrapped in white--muted, stilled, suspended. They are attended by people in green and yellow suits, hair caps, shoe covers, masks, indistinguishable by sex or intention. The two societies mingle in an exclusive club, a family of initiates, a world removed. There is a muffled quality to the machine sounds --the whoosh of ventilators, the beep of monitors--broken by moans, words, the hush of double doors sighing open and closed, an occasional cry or scream. And unlike the creeping cataract or growing tumor, burns appear suddenly, abruptly, without warning. The injury becomes a crucible, and the burn unit a proving ground.

A major burn is possibly the worst thing that can happen to a person's body, the worst of all physiologic catastrophes up to the point of death. The treatment is fraught with oddities. Our skin protects us from infection and ultraviolet rays, helps to balance bodily fluids, and provides much information about our environment. Without skin, the human body becomes frenzied and confused. Without skin, the fluids mix and shift, fleeing vital organs and then filling them, changing blood pressures and chemical compositions rapidly, disastrously. A large burn can evaporate almost three liters of water every day. Burns "bleed white,' draining precious quantities of salts, proteins, and nutrients. Untreated, a person with major burns will die of shock in a few hours. In the desperate metabolic rush to stop the steady flow of fluid out and the tide of shifting waves within, the body becomes catabolic, eating its own protein mass. Even after weeks of seeming stability, a person can suddenly sour and die.

Loss of skin is more than a physical disaster. It is the loss of our point of contact with each other and the world, with our shape and form, our view of ourselves--and others' view of us. Burns remove the borders we use to take up space, define our shape, push air out of the way. The helplessness that follows goes beyond the extraordinary dependence on nurses, doctors, and machines; it is a helplessness of spirit, self, identity; it is like a death.

The first hours of a burned person's new life are taken up by "resuscitation,' the clearing of pathways for air, the focused beating of the heart. Then the team of physicians and nurses settles into a complex routine of care, which will often last for months. The hole in the body must be plugged, or else we drain away. In the days after the injury, the dead skin and muscle shrink and the tissues swell with fluid, and if a limb is surrounded by burn, its entire blood flow can be squeezed shut. They call this "circulatory embarrassment.' Then the burn must be sliced open down its length, like splitting a hot dog before cooking so it doesn't bubble and burst. A chest embraced in this way by dead tissue--called "eschar'--may be sliced with an H or other design, like Zorro cutting his enemy's silken shirts. These cuts don't bleed very much, don't hurt much; there's too little left of blood vessels and pain fibers. This shrinking, too, can pull up joints short and tight, ending motion, making seams and seals where there were none before; between chin and chest, between lips, between eyelids.