Volatile

I have been in the operating theatres for six of the last ten working days. In those six days, I have assisted in twenty eight operations. Some of those procedures were the straightforward, common procedures such as thyroidectomy and laparoscopic cholecystectomy; but others were on a much larger, life-altering scale. There's no such thing as a small operation, says the chief resident. What he means is there is routine surgery that's common, but all of them can potentially be life-altering and lethal.

The days have been long; it's definitely no holiday, as many people in the years above me mentioned the elective term to be. Colleagues spoke about having long weekends, half days and other luxuries. I don't quite know what they were doing on their elective, but it could not have been very productive for them. Thirteen hours a day on average with no break for food, water, bathroom or anything. Back to back, nonstop surgery. When I was not in theatre I was in the Burns unit organising admissions, changing dressings, drawing blood and sampling fluid from surgical drains. And I still can't get over the fact that general surgeons look after burns victims.

Due to the shortage of doctors, nurses have began adopting certain clinical responsibilities of medical practitioners, such as dressing wounds. So when I turned up knocking on the door of the hospital saying "I'm ready to work," they were very happy to have help. But I'm no cavalry. However, they were happy to assume that I was and appointed me responsible of the Burns unit on the non-operating days.

I was not prepared to work in a Burns unit at all. My mother told me stories of the horrific burns she had seen when I was young; and the thoughts were enough to knot my intestines enough to ignore food for a couple of days.

It was also discouraging to be conscious of my complete lack of knowledge in the management of burns. But I was and am not in any position to argue with anyone in such a system. I have been asked to serve a population of patients and it's not in my nature to discriminate, even if my stomach is jumping around like a five year old on a trampoline.

There was a stench of bandages, creams and flesh in the air. The chief resident introduced me as "the new doctor on the team" to the nurses working in the Burns unit. They had infinitely more knowledge and experience than I did; so I don't know why he felt the need to gently hint that they'd be following my lead. The nurses wore turquoise coloured scrubs that had Intensive Care stitched on the breast pocket.

After the general surgery team left to continue rounds on the other wards, there was an awkward silence at the reception desk. I broke the tension by clarifying that I would be following their lead, not the other way around. They were quite happy with that, as any nurse would be. "Okay then, wear your mask, gown and glove up."

There were ten patients on the ward and another patient in the Paediatric Intensive Care unit that required dressing changes. I followed the senior nurse into the first patient's room. He was young, and lay in a semi-upright position with his hands thickly wrapped with bandages, resting on two large pillows on each side. She showed me how to take the old dressings off slowly, so not to lift the delicate remnants of dermis and tissue along with the ointment-smothered gauze. She then proceeded to open a scalpel blade and started to remove raised, necrotic skin from the surface of the first patient, who couldn't talk. My body went numb as I watched her slice skin off the young man's arms, chest and face. I asked the patient if he felt pain with the removal of tissue and felt a little more at ease when he said no. The nurse explained that areas of full thickness burns could not perceive pain. The sensory nerve endings were obliterated.

Another nurse created a sterile field for us and opened up a few heavy sponges, saturating them with chlorhexidine. The senior nurse asked me to rub the sponges together so to create a lather and we used this to clean the patient's skin by dabbing gently. This was to prevent infection from accessing the living flesh under the eschar (i.e. dead tissue forming a scab or dry leathery surface replacing healthy skin). He sniffled in pain as he felt the sting of alcohol on exposed skin. He couldn't cry or talk because of the tracheostomy our senior colleagues provided when he came in.

Up until that point, I was oblivious as to why the patient's arms were positioned the way they were. My lack of knowledge was really frustrating me and I promised to devote a few hours of my weekend reading about burns. When the senior nurse asked me to turn his arms so that his palms were facing up, it was clear what he was hiding - the skin on his forearms and elbows were completely divided along a longitudinal incision and the underlying muscle tendons and ligaments completely exposed. When full thickness burns are circumferential, the surgeons divide the skin along these lines to prevent irreversible ischaemia to the distal peripheries. I almost passed out. Knowing the patient was conscious and awake, able to see his own underlying flesh and flinch in agony as I dabbed his muscle layers and fascia brought tears to my eyes. But for his sake, I had to put my emotions aside and focus on getting him clean as soon as possible so he could rest.

We dried his skin with clean sponges and covered all the burned flesh with cream and ointment, depending on the depth and tissue layers exposed. After that we literally draped him with gauze and the junior nurses bandaged him up.

"Was that alright?" asked the senior nurse as we got out of our gowns.

"It was fine," I lied.

"Okay then. Wash your hands and do the same with the remaining patients."

Four hours of wound dressing was emotionally exhausting. The majority of the patients were not passed their thirties and a tragic proportion of them were children.

It was awful. I felt so guilty for wanting to ignore these people out of fear of being squeamish. They needed help so very much. And I didn't realise how complex their management really was.

There's so much to learn and I do feel I owe these people a debt of volumes of study and attention. They need so much help, support and depend on us not only to survive the massive acute pathophysiological changes, but also to mobilise and return back to normal living, whatever that may be to someone who is cosmetically destroyed. The psychosocial support is the fundamental component of ensuring these people can develop hope again; and I pray that their loved ones still see the same person before them when they are released with the unspeakable reminders of survival nobody would ever want to bear.