Two Perspectives on a Disaster
Monday May 1, 2000
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The following stories come from Tampa General Hospital's Burn Center - one from a nurse manager, the other from a clinical nurse. Their candid, eye-witness accounts give us deeper insight into a human tragedy and the efficient yet caring work of burn unit nurses when lives are at stake.
How a Nurse Manager Coped
Lori L. Desmond, RN, MS
I was en route to work when the news of a power plant explosion came over the car radio. My first thought: Where was it? Would Tampa General be affected? Continuing newscasts shed some light - fire trucks and ambulances were already responding to the accident at Gannon Station, and victims with multiple injuries were being transported to area hospitals. My beeper went off, and I stepped on the gas.
The hospital's Burn Center, it turned out, would be the primary destination for the severely burned - they were already arriving. I went up to the burn unit, did a quick scan of beds, and jumped into some scrubs. The unit coordinator and I began making calls to bring staff in. I had treatment rooms readied and made arrangements to transfer two patients to other units, then notified environmental, housekeeping, and pharmacy that we would need extra supplies. Luckily, former burn unit staffers currently working in other departments stood ready to help.
The first patient, a 57-year-old man with burns over 95% of his body, arrived accompanied by a resident and respiratory therapist. He was admitted directly to the burn intensive care unit (BICU) - odd, considering the decision not to debride his wounds. We were told that the patient was to be extubated and given pain medication, in other words, comfort measures only. The nurse accepting the patient was stunned at first. After all, she was used to going full speed ahead for every burn injury, regardless of size.
The patient signaled to her that he wanted the tube removed. Once it was out, he began to complain about the "belts around his chest," but of course there were none - the constricted feeling he experienced was caused by his burns. I asked the nurse practitioner to step in and take a look at the patient. We soon realized what was going on: The man had full-thickness burns over 95% of his body - only the tops of his feet had been spared. Comfort measures would need to include ways to help him breathe more easily; we also asked the physician to evaluate the patient for chest escharotomies to relieve the pressure.
The second patient, a 37-year-old with 50% burns, had already been admitted to the BICU and was in the debridement room. Soon after, he was rushed to radiology to evaluate head and abdominal wounds. It was clear to us that he'd need intensive nursing care. Several distraught family members had gathered at his bedside.
Our third patient soon arrived and was brought to the other treatment room. He'd sustained 20% burns, as well as contusions to liver and kidneys. While the ARNP and another nurse attended him, the fourth patient from Gannon Station came to the BICU - also a young man, but with no burns. Instead, he had a severe head wound, abdominal injuries, and multiple fractures.
With dozens of relatives and friends at his bedside to say their farewells, the first patient died that afternoon at about 2:30. I believe the burn staff had given him a measure of physical comfort, despite the gravity of his condition. Patient number two needed emergency surgery the evening of his admission for a ruptured spleen and was in danger of losing both upper and lower limbs. He had respiratory problems in the coming days and required escharotomies. On the fourth day, he coded several times and died that evening. The third TECO worker was transferred to the progressive burn floor and was discharged two weeks after admission. The fourth was transferred from the BICU to the trauma floor the second day and later underwent rehabilitation. He was discharged from the hospital May 11.
It's sometimes said that the burn population at Tampa General is statistically insignificant, since it accounts for less than 1% of total patient days. But the contribution of the burn center to the surrounding community is far from small - I'm thankful for those who are willing and able to care for burn victims around the clock. They truly are a rare breed.
Burn care requires an interdisciplinary approach. I also commend members of Tampa General's pastoral care staff for their vigilance in tending to the TECO workers' families and friends. They enabled the burn unit's clinical staff to focus on providing the injured with their highly specialized yet loving care.
Lori L. Desmond, RN, MS, is nurse manager at Tampa General Hospital's Burn Center.
Recollections of a Night Nurse
Clark Sapp, RN
When the elevator doors opened on Tampa General's sixth floor, a feeling of uneasiness swept over me - I'd known from news broadcasts about the TECO explosion what might be awaiting me in the BICU. But I wasn't prepared for the scores of relatives and friends lining the main hallway, waiting for news. All eyes were on me, eyes full of desperation, helplessness, and hurt. I knew I'd have to be in top form to care for both patients and family members.
I asked the first nurse I saw how everything was going. He gave me the details - how the hospital had pulled together resources from every department to assist the burn unit, how it was the best-coordinated emergency effort he'd ever seen. I walked by each patient's room to get a clearer idea of the task at hand. Feelings of self-doubt troubled me, and I thought, "I've been out of nursing school for less than a year - am I prepared for this?" But there wasn't much time for reflection.
I was given that night what the nurse's report called a "one-on-one patient" - a man with third-degree burns over half his body, plus trauma to internal organs (and most likely broken bones and other injuries not yet identified). I tried to prepare myself for any number of scenarios that could occur during my shift. The TECO worker had undergone emergency surgery during the day to repair some of the internal injuries. Extensive escharotomies and fasciotomies to all extremities also had been performed to relieve pressure enough to promote breathing and circulation. He'd lost a lot of blood and body fluids, and it was getting harder to sustain adequate blood pressure - even with ringers lactate IV solution running at 2,000 cc per hour for fluid resuscitation. Loss of body heat was also a problem. We managed to stabilize him, but I knew that even with excellent medical and nursing care, he'd need a miracle.
BICU staffers generally keep visitors to a minimum, especially after 8:30 PM, adhering to elaborate procedures to keep the unit sterile. That night, though, we were a little more tolerant, allowing family and close friends to see loved ones throughout the shift. We let them into rooms in groups of three or four - most, though, couldn't handle the anguish for more than a minute or two and left the beside. Some did stay longer, but stood still, as if in shock. And some prayed. I was glad we could permit as many visitors as we did. The pastoral staff members who came to comfort the families were more valued than they could imagine.
It was a stressful night: Alarms would sound, fluids would need to be bolused and titrated, medications would have to administered, and physicians updated - all under the watchful eyes of visitors who evaluated our every move.
It was obvious that my patient's family loved him deeply. I have a clear memory of his mother's face as she sat quietly in the corner while I moved about the small ICU room. I tried to tell her with my eyes that somehow it would all be OK. Tears ran down her cheeks as I handed her a box of tissues. She asked why the ones least deserving of death always seemed the first to go, but I had no answer. She told me about her son's young daughter and about the property he'd just bought, hoping to build a new home for the young girl. There wasn't much I could say to comfort her; I just put my hand on her shoulder as she wept. I hope it helped.
The few times I was able to leave the room, I could see that family members of other disaster victims were weeping for their loved ones. One grandmother even collapsed in anguish in the arms of another relative. It was sad seeing all those people hurting - in some ways sadder still, knowing that I had to separate myself from the emotional side, to an extent, in order to perform my job.
For the sake of my patients, I'm glad I've been able to detach myself from the emotional side of their tragedies long enough to provide the proper care that they deserve. At the same time, I know in my heart that if I ever became so distant from the human tragedy around me that I couldn't feel for them or for their loved ones, I would most certainly resign from nursing.
The miracle my patient needed never came - he died two days later. But I believe that what I witnessed of his suffering and of his family's struggle with loss will be with me the rest of my days.
Clark Sapp, RN, BSN, works in the Burn Center at Tampa General Hospital.
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