Authors: Kevin Patterson
Sarah was lying on the treatment-room cot. She was whimpering quietly and would not open her eyes. The nurses were getting IVs started and someone had measured her temperature at twenty-nine degrees Celsius, profoundly hypothermic. She had a blood pressure, though, and she was already on a monitor. Her pulse was 160.
Daphne’s first thought was that things could not possibly be as bad as they looked. The girl’s face was a waxen sheet of third-degree burns, interspersed by charred clothing and hair. She was gasping for air. Her burned and blood-covered brother and uncle were standing in one corner, huddled together, aghast.
Daphne started an IV line in the child’s groin. She listened to her lungs with a stethoscope. There wasn’t much air moving in her skinny and burned little chest. She blinked away tears. She looked in her mouth. Sarah’s tongue and palate were crimson and swollen. She had not completely obstructed. It would be very difficult to get an endotracheal tube into her trachea with all that swelling. She put an oxygen mask on her and hoped that the swelling would settle down. A nurse pulled a bag of warmed saline from the microwave oven and connected it to a rectal tube. She placed the tube and began running the warm saline in. She placed a hot-air warming blanket on the little girl. Someone remeasured her core temperature and it was thirty degrees.
Around the child: madness. Three nurses, Daphne, an RCMP officer, and the janitor all yelling at the same time about what they think should be done, what they can offer. The janitor wants to know if he should call the airport and initiate a medevac. The nurses think that they need more IVs. They do. This was the worst thing Daphne had ever seen. She couldn’t think clearly, could barely even breathe herself, really, and she just wanted the child to breathe, dammit,
breathe
.
They always say that it never hurts to hope, but when things need to be done, problems need to be reckoned with, hope paralyzes. It feels like it is an action itself, that the act of hoping addresses the need for hope itself, somehow. But it isn’t so, it isn’t ever so, and it wasn’t so now.
When Daphne leaned back, hoping that the child would start breathing, hoping that she wouldn’t have to try to get a tube into her lungs, she knew she was not handling this as she should. So it was less of a surprise to her than it would otherwise have been when things became abruptly worse and the child stopped breathing.
She reached for the laryngoscope that one of the nurses had been waving at her for the last several minutes. She lifted Sarah’s tongue up and to the side with it and tried to catch a glimpse of her vocal cords. The normal anatomic architecture was so distorted she could not even begin to guess what she was looking at. There was nothing that looked like vocal cords. There wasn’t a passage of any sort that looked like it would allow the
tube to pass. All she saw was hamburger, initially scarlet but now increasingly blue. She pulled the laryngoscope out and asked for the Melkor set, the kit that was supposed to allow one to surgically place a tube through the skin in front of the throat, in situations like this. There was some fussing and searching while this was found and Sarah grew bluer and bluer and her heart rate began to slow. Finally it was dumped on the child’s chest in front of Daphne and she slapped a little iodine down on her neck and felt for her Adam’s apple. All she could feel was thickened burned skin. She pushed the needle in approximately where she thought she should be. She got air. She cut the skin and pushed in the guide and then the tracheostomy tube. Her heart rate was thirty-five. She was as blue as a plum. Daphne pumped air in and out of the tube with the resuscitation bag. It wouldn’t go.
She remembered her physiology professor lecturing her class that humans are like seals, and we can descend beneath the surface and survive on stored oxygen for a time. But, like seals, when it is time to ascend, and breathe fresh air, then we must, and if we do not, then our muscles weaken and the ability to ascend is lost. Every living thing understands the idea of living on stored resources, cached fuel and food; marriages continue on the basis of previously established goodwill, and men with runs of bad luck and eroding ambition pawn their tools to pay the motel bill, and even the idea
of living on the principal sends shudders into every accountant’s marrow. These are survivable if undesirable predicaments, for a time, right up until the moment when they aren’t, and the ability to reascend is lost.
She looked at the child’s chest again. The burned and swollen skin was rising off her rib cage like a caterpillar egg case on a twig. Daphne grabbed the scalpel from the Melkor kit and made an incision from each armpit to her hip, to allow the rib cage to expand, free of the constricting effect of that thickened and swollen skin. It was possible to bag-ventilate her now. But her heart rate had fallen to twenty. Pink froth came up the breathing tube into the bag. Her heart stopped.
When Sarah’s mother arrived she walked straight into the resuscitation room and was not addressed. No one could make eye contact with her. She stood at the doorway and looked at her little daughter, motionless and blue, on the stretcher, no one standing close to her, no one doing anything to her anymore. The nurses looked at Daphne, who approached the child’s mother haltingly. Robert ran past her and up to his mother, seizing her around the waist. Lukie would not look at his sister, could not even face her, and turned away from her and toward the wall, his hands over his ears, crouching.
In the treatment of thermal injuries associated with oro-labial inflammation, it is imperative to secure
airway protection with immediate endotracheal intubation, as progressive swelling of the glottic structures is usual, and subsequently renders intubation more difficult or, indeed, impossible.
—
Emergency Therapeutics
, K. Zbuk,
p.234, Edmonton, 1994
The essential tactic necessary for successful treatment of severe burn injuries is the anticipation and treating of complications before they become life threatening—escharotomies may be performed on the chest before respiratory embarrassment occurs and airway protection and volume infusion need to be performed before clinical evidence of obstruction and dehydration become manifest. Severe burns kill very quickly and their complications progress with extraordinary rapidity; these complications are predictable but they progress so fast that they are, essentially, only treatable when they are as yet unexpressed.
—Management of the Trauma Patient
, D. Woodley,
p. 118, Regina, 1978
In reviewing the management of this patient, it is determined that frank malpractice was not a feature, although several suggestions may be made to the practitioner regarding ways in which her care might be optimized. In particular, some remedial training
in airway management may be contemplated, if she is to continue to provide emergency care of the critically ill.…
—Proceedings of the Disciplinary Committee of the College of Physicians of the Northwest Territories
,
pp. 23–27, May 1997
Lukie came to see Daphne in her office two weeks later. That morning when she started work she saw his name on the appointment book and all the rest of the morning she had been thinking about what he wanted, how he was doing. She had spent the previous two weeks trying hard not to think about Sarah. In her dreams, she saw dogs eating the child as she fought, and Daphne stood by, wondering why the dogs found her so appetizing. She awoke often in the middle of the night sobbing; her neighbours around her all knew of the events of that evening. The men looked at her sympathetically, the women mostly could not meet her eyes.
When Lukie was led into her office she had no idea what to say. Though his burns were healing, he looked awful. His posture was stooped and his skin grey; he smelled bad and had evidently not washed or shaved since the accident.
“Mr. Oktuk, how are you doing?” she asked, after she had closed the door and sat back down. He looked at the floor, and then out her window.
“Not that well, I guess. You?”
“Been better.”
“Yeah.”
“Your burns look like they’re coming along.”
“They’re okay. They don’t bother me much.”
“How is your sister?”
“She is very sad.”
“Do you have any questions about what happened that day?”
“I heard that she didn’t have to die.”
“From who?”
“Someone who knows one of the nurses.”
“I could have done things differently when she got here. If I had the chance to do it over again, there are things I would do differently.”
He nodded. Still looking out the window. “Me too.”
“Yes.”
“I never thought either of them would get up and light the lamp on their own.”
“Of course not.”
“And they’ve never seen me fill a lamp inside the tent.”
“I’m sure they haven’t.”
“I try saying that to my sister and she just looks at me like she hates me.”
“She is going through some very difficult emotions right now.”
“Have you talked to her?”
“She doesn’t want to talk to me.”
“Yeah.”
Ed McFarland called Daphne to tell her that Lukie Oktuk had been found dead in his bathtub with his .30–06 between his legs. They needed blood samples for the coroner’s investigation and would she come and draw them?
She found the house easily, as the police truck was parked outside with the lights flashing, visible throughout the entire town. The house itself was old and very small, painted white and peeling yellow. Tiny windows and a roof littered with antlers. There was a porch stacked with caribou hides, and a polar bear hide was nailed to the wall. Everywhere around her there was bone and frozen flesh. Inside there were three RCMP officers and another half-dozen people who acted involved, mostly standing around and nodding gravely. There was no family, though—they had all been asked to stay with relatives for the time being.
Lukie lay in the tub with the rifle in that portion of his mouth that remained. The right side of his face had been sprayed over the wall like red stucco. The left side of his face was still present, but ballooned out like a comic-book drawing, from the bullet’s shock wave. The eyeball bulged as if with horror at the rest of the body’s circumstances, and the profile seemed overall to suggest apoplectic horror. Daphne chewed on her mitten for a
second and then she kneeled down on the plastic sheeting that had been laid over the floor. She opened her bag to extract a syringe but she couldn’t find it for her tears. She kept groping in the bag for a likely-feeling object but everything felt the same and not at all like what she was looking for. She wiped her eyes for a long time and then when she opened them again they were clear. She found a twenty-millilitre syringe and an eighteen-gauge needle. She put the needle into his heart and tried to draw blood, but none came. His heart had emptied itself into the bathtub. She tried his groin, looking for the femoral vein, but nothing came. Lukie’s cold waxen flesh had drained like a bled steer. She put the needle into his intact eye and drew out the acqueous humour. It would suffice. Lukie looked less animated now and less human, his eye withered like a fig. She closed his lid over it.
Daphne and her two friends were sitting around a blanket, wearing cat’s-eye sunglasses and sleeveless cotton blouses and skirts. Arms streaked white and pink like dispensed peppermint toothpaste. On the blanket: a Tupperware container of potato salad, a loaf of French bread, and a can of smoked oysters. A Discman with little speakers, sounding strained. The three women were looking out at the water and squinting. Daphne smoked a cigarette
and looked at the horizon. She was as pale as a Noxzema Girl. She had slathered SPF ten thousand on so thick little pools of coconut-scented lotion were collecting in the sand beneath her elbows, the odour wafting upward with all the sweetness of the South Pacific. On the hairs of her upper lip, small beads of perspiration glistened and stung. In the heat, her cheeks were reddened. She put the cigarette out in the sand and blew out the last of the smoke. She took off her sunglasses for a moment and wiped her forehead. The other two remained still.
Hannah said, “I’ve got to get out of here. November by the latest. I can’t spend another winter that depressed, that bored.” She put her sunglasses on again and leaned forward, hugging her knees, adopting the same position as her friends.
Laurel said, “Summer is so great, though, that it fakes you out. It makes you think, What was I whining about again? and then winter hits and you can’t move for another eight months and you’re stuck in that dreadful little city.” A seagull picked through a garbage bag that had washed up on the shore. It found a disposable diaper within and began extracting it optimistically.
Hannah: “Appalling.” The seagull’s activity had caught the attention of its brethren and a circle of gulls appeared overhead, calling loudly. “And minuscule,” she added.
Laurel: “You can’t even become a big fish in a small pond. There isn’t enough plankton to get any bigger than anything else.” They all watched the seagulls.
“That’s what fish eat: plankton, right?”
“I think so,” Daphne said.
“The small ones anyway,” Hannah said.
“How about whales?” Laurel asked.
“They’re not fish,” Daphne said.
“But they eat plankton, and they’re big.”
“True,” Daphne said.
Hannah: “And there are whale sharks; they’re fish, they’re big,
and
they eat plankton.”
Daphne, still staring at the horizon: “I think we can agree that plankton serves as the nutritional underpinning of the whole aquatic food chain.”
Laurel, to Hannah: “But I take your point, that not all fish eat plankton directly.”
Hannah: “Sure.”
Laurel, like anyone, hated being corrected.
The lake was the eighth-largest body of fresh water anywhere in the world. This fact surprised everyone when they learned it. It wasn’t a place that presented its grandeur in any way that was obvious. In the summer, only a few weeks after the last of the snow had gone, and even while there was still ice floating in the northern basin of the lake, columns of tent trailers began their migration out to the southern end, where the beaches and ice cream stands were. For hundreds of miles, white sand stretched on between the trees and the water; it was only the surface tensions of sex and parental concern
that kept the glistening mass of sun-lotioned humanity together. There were no boundaries to confine the blankets, and the sand stretched on either side into distant sharpened points. It was an astonishing place, and for all the regrettable fashion decisions and aesthetic failings, the scale of the forest and the lake still dwarfed the beet-faced people at its southern tip.