On feeling the burn

Outpatient burn has been a lovely reminder of how good a clinic can feel. The preceptors are warm and welcoming, the techs and nurses are friendly and conversational, and the patients have been the youngest and healthiest lot I have encountered this year (minus the burns that brought them into the clinic, of course).

I met with the surgical clerkship director on Friday and I commented on how the burn clinic feels different. He nodded and agreed, “That’s a reflection of the type of person that is attracted to burn.” They have the hearts of palliative & hospice care, the skills and competence of the ICU, and the relaxed schedule of a specialist.

Tuesday is scar day there, and the clinic was filled with follow-up visits and laser treatments. The follow-ups got a quick look-over and thumbs-up. Depending on the laser, they require either general or local anesthesia.

My NP preceptor told me I should check out this CO2 laser treatment with the burn/plastic surgeon. She would remove some scar banding and then laser other scars to facilitate healing and aesthetics. When I walked into the procedure room, the patient laid on the table and anesthesia was talking him through the next steps of the inhaled induction agent.

As the gases flowed, he gave us a countdown with his fingers, telling us when he lost consciousness. He stopped after seven, then began to wave his hands into the air, like a hospital-gown luau. The nurses smiled and said, “That’s our free spirit.”

Once he was fully under, the nurse anesthetist turned to ask me if I knew what happened to him. In the way that implies some good gossip is about to come my way, she made me swear not to tell anyone what I was about to hear.

About a year ago, he had hired a woman to have sex with him. She doused him in gasoline and lit him on fire. She stole his possessions and left. They ended up catching her because she returned to the scene, forgetting her purse.

The incident left him with deep second degree burns on most of his left arm (where the band had formed) and well-healed grafts on most of his shoulder and torso. He had that characteristic diamond pattern, reminiscent of expanded metal. Fitting, because that’s how they expand the grafts to cover more surface area.

Epinephrine to decrease blood flow to the area. The surgeon had me hold his arm overhead to pull tension on the band, a fibrous piece of scar tissue under the skin that forms as a result of the burn. The band pulls on the tissues and may lead to a permanent contracture, with range of motion loss and associated pain, so the goal was to treat the band before it develops into a full contracture.

With the band easily visible under tension, the surgeon inserted a needle and suture into the skin, under the band, out of the skin, back into the skin, over the band, and out of the skin. The purpose? To loop the suture around the fibrous band.

Then with a suture end in each hand, she sawed back and forth until the band gave way to the suture, and the loop pulled through the small puncture site like nothing even happened. The band lost a significant amount of tension and she continued up the length, chopping the band into little 2cm chunks.

“Aren’t you impressed?” She asked me in that German-coated accent.

I nodded yes, the only correct answer.

Then she began the lasering.

The CO2 laser pokes little random holes into the developed scar. The body fills these holes in with more flexible types of collagen, loosening up the scar and giving a more natural appearance to the skin. She reminded me of a tattoo artist, damaging the skin with a deft hand in order to create the desired effect.

She made the process look straightforward and simple.

The whole procedure consisted of soft-tissue management on a surgical scale I hadn’t yet considered. I love bodywork and massage, using manual force to slowly break up adhesion and to restore blood and fluid flow. The band removal and laser treatment took this idea to the next logical step, truly manipulating the tissues to restore mobility and retain aesthetics in the face of a traumatic stressor.

She reminded me more of a gardener than a surgeon: carefully tending her area of focus, waiting for weeds to pop up before plucking them. Place a graft, let it heal, and deal with any scarring later.

Time is her ally, rather than her opponent.

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