CODE RED

It was a Tues morning. I'd just gone to bed. I was glad I wasn't on call. Despite not having to run a clinic that day, I was knackered. Just came back that afternoon from Kuching, after attending a course. I think age must be catching up. Felt so tired from all that waiting to catch my flight, taxi & boat back to Song. I'd left my hotel in Kuching at 8.30am and had only arrived back in Song at 3.00pm. 

Next thing I know, my handphone wakes me up from my slumber. One of the student MAs is on the line. "Doktor tolong datang, ada patient burn dan Doktor X tak dapat set line" 

0200 - That's when the nightmare began.

I arrived at the A&E and a golliwogg greats me. The victim is totally charred, from head to toe. His hair is singed curly. He has no more eyebrows or eyelashes. One of his eyes is semi opaque from a flame burn. The skin is a colour of cooked sweet potatoes, with areas peeling revealing raw, pink dermis underneath. What really striked me was whats left of his shorts/ underwear. It had melted into an underwear shaped plastic gunk. I think his shorts were blue...Thank God he was wearing cotton briefs underneath or else his nylon shorts would have just melded with his genitals. I can only imagine the agony he would have to go through to remove the pieces of melted plastic.

The air in the A&E smelled of cooked meat, soot & smoke. My MO looked up at me semi-defeated. "I can't get a line. I can't even see or feel a vein". The victim reminded me of a boiled sausage. Oedema or leaking of the intracellular fluids had set it and his whole body swelled uncontrollably. It looked as though he would burst out of his skin any minute now. I must admit, I'm not very good with neck lines, what more with the oedema around the neck area. In my head warning bells rang - Secure a line & the airway! Unfortunately, our clinic wasn't equipped to deal with emergencies like these. There were no femoral or angiocatheters. The only thing I could do was set in a gray branulla into both his femoral veins to run fluids. Unfortunately, this process had to be repeated a couple of times as he kept struggling and dislodging the branullas before the  sedation could kick in. My MO picks up quickly and does an excellent job of replacing dislodged branullas and keeping the victim hydrated. With fluids in, I can finally access the severity of the burn - 97% partial thickness. To reduce fluid loss and prevent hypothermia, we covered the victim with garbage bags. In proper A&Es you have burn or space blankets. Here, we make do with whatever we have, be it cling wrap, foil or garbage bags!

The person who brought in the victim told me a whole longhouse with 32 pintus or doors had gone up in flames. He wasn't sure how many victims there were but did think there were 100+ inhabitants in that longhouse. Did a mental calculation - even if only 30% of the inhabitants had injuries, we would be expecting 30+ people in KK Song. This was gonna be a disaster zone. Time to activate CODE RED! 

Unfortunately, no panic buttons like this

All staff staying in the premises were contacted. Many did not even bother to answer their phone as they were not on call. Next was to turn on the ambulance siren and let it blare for a good half hour. Even then, only a handful came. A big thank you to those who did. Upon post-mortem a couple of days later, many of the staff admitted they heard the siren but didn't bother to come down as no one had ever called a code red before and they didn't know what they were supposed to do! 

Anyway, back to the scene. By then, we had converted the waiting area into a triage zone with all the gurneys lined out. Hospitals upriver & downriver were alerted and put on stand-by mode. The district office and police were also alerted as we would depend on their boats to transport the victims. Hospital Kapit even sent down an EMS team at the first sign of daylight.

0430 - By this time, the patient started desaturating despite high flow oxygen. His airways were closing up due to oedema & swelling. Tried intubating the patient. Basically, a tube is shoved down into the trachea so we can do the breathing for him. Despite being able to see the epiglottis and vocal cords, it was tough. First, had to clear up the soot in his airway. Then started intubating him with a size 7 ETT and went down all the way to a pediatric size 3 but still failed. Even tried to nebulise him with adrenaline to reduce the oedema but without much luck either. In the end I had to make the call to to a chricothyrotomy.

 

I have never done this before. I had previously watched an elective tracheostomy being done during my ENT rotation. This was done in a controlled OT setting with proper equipment & the aneasthetic team on stand-by. Basically, you make an incision midneck all the down to the trachea and pass a tube though. So here I was with my "Handbook of Bedside Surgical Procedures" and a T&S set to do the cricothyrotomy. Read thru the procedure twice, gathered all my equipment, said a quiet prayer asking for Divine help to guide my hands and proceeded with the horizontal incision. Thank God I managed to get a size 3.5 ETT in. Secured it and started bagging. His saturation when up to 92-97%. However, his BP started going downhill and we had no choice but to start a dopamine infusion.

0630 - By this time the calvary had arrived. The EMS team from Hospital Kapit took over. The anaes MO managed to insert a size 6 ETT and get a proper fermoral catcheter in. Despite dopamine, his BP continued to plummel so in the end he was on triple inotropes. They did everything they could to stabilise the patient. We could throw away the garbage bags that was covering the patient and replace them with proper burn blankets. The police also came in to tell us there was only 1 other person unaccounted for and they were still looking for the body. The other longhouse villagers escaped unhurt or with only minor burns.

0915 - Finally the victim was stable enough to be transferred  He was sent by the hospital speeboat to Kanowit where he would continue the journey to the Sibu Hospital Burn Unit by land. Unfortunately, he took a turn for the worst during the journey and had to be stabilised in Kanowit Hospital before further transport. I think he only reached Sibu at noon. The CODE RED was called off around 0930 when none of the purported burn victims turned up in Song.

1130 - The remains of the 2nd victim was brought in. She was so badly burned beyond recognition that all that was left was her skull, torso, upper arms & thighs. Basically, she was a huge lump of coal with bone fragments (femur & humerus) sticking out. Her remaining bones were collected in a Milo tin. Despite 2 weeks in the HKL Forensic Unit, this was the worst remains/ corpse I have ever seen. Probably CSI and Criminal Minds conditioned me for what I saw, or else I would have puked on the spot. No BBQs for me for a while!  

Unfortunately, the patient succumbed 48 hours later in the ICU. According to his surgeon, he needed a reserve of 140% to survive, something he never had to start with.

Before I end, I need to give a big THANK YOU to all who responded when called, especially the EMS team from Hospital Kapit.

It is times like this when I'm forced to think out of the box and make do with whatever little we have here in Song. I thank Him for His Wisdom, His Guidance & His Strength to see me through, and the unceasing prayer support of my loved ones that buffer me in trying and difficult times.