Burns
It was on cases like this that Scott was really, really glad he could turn down the external audio input on his helmet and it had an independent air supply and scrubbers so he couldn't smell anything.
An experimental hydrothermal power plant had gotten into trouble when management had decided to run a simulated loss of coolant failure to test their safety procedures. In a chain of events eerily similar to the Chernobyl meltdown there had been a cascade of failures compounded by bad procedures, a badly constructed plant, an incompetent manager and chief engineer who refused to be wrong and acted on his assumptions, not what was actually happening.
Later, when the GDF investigation pieced everything together, they found that the water levels in the system that fed the geothermal bore hole had run too low and the bore had effectively run dry. The chief engineer ordered a small dump of water into the system, not a return to full pressure, and without checking if there was enough water in the bore to provide the needed pressure to keep it liquid or if the safety features in the turbine room had been engaged. When the water hit the bottom of the bore hole it flashed into steam and shot up into the pump and turbine rooms.
Eight workers were dead, either from the steam or from the flying debris.
The two survivors were wishing they were dead.
"Easy now, we're here, we're here, we're going to take the pain away." The soothing litany fell from Scott's lips as he sliced the worker's boot away and prepped an ankle IV site while Alan drew up a 10ml syringe of morphine and a saline flush. The worker howled again, writhing in pain, her skin peeling off in tattered strips as one of the power plant staff that Scott had collared to help played a water hose over her body.
Finally Scott was able to get the cannula set up and her cries lessened as the morphine went in. She laid back on the stretcher, moaning softly. Both Tracys breathed a sigh of relief before bringing their shears to bear on the worker's overalls. In some spots the clothing had melted into the patient's skin, they cut around those, but everything else came off- including bra, watch and wedding band. Her face had been spared by virtue of the full face visor she'd been wearing, but she had burns down both arms and across her abdomen and chest, brindling her skin with red and blistered superficial burns and white and leathery looking partial thickness burns.
Steam burns were amongst the worst in Scott's opinion.
"Can't we, um, cover her up?" The male helper asked, averting his eyes.
"I'm sorry, but not yet." Scott answered. "Burns swell, we had to get her clothes off to avoid constriction and to make sure we can directly cool the burns. If we use any sort of towel or dressing right now it will stick to the wound. Just keep that water on her, we need twenty minutes minimum of cooling before we can think about covering anything. Can you do that for me?"
"Yeah," the man swallowed thickly, "yeah I can do that."
"Alan," Scott turned to his littlest brother, "are you okay to keep monitoring this patient? I want to check on Gordon and Virgil."
Alan glanced up from where he was prepping a second ankle IV site, a bag of saline slung over his shoulder and ready to hook up to replace the precious fluids the patient was losing through her burns. "I got this." He replied, his face pale but his expression set.
Scott nodded and patted his shoulder reassuringly before crossing the module, splashing through the rivulets of water snaking over the deck from the stretcher where Virgil had the second and more critical patient completely laid out on a potent cocktail of opiates and ketamine. Gordon was standing on a crate for the best angle to hose down the patient- a man this time, also minus his uniform and also mottled with red and white across his body, but his wounds included a hand-sized black patch maring his left thigh where a chunk of superheated metal had struck him. Full thickness burns, black and charred, were the worst- all the way through the skin layers and into the muscle tissue beneath. Conversely, despite being the most severe they hurt the least because the nerve endings were gone, not simply exposed as they were in a partial thickness or superficial burn.
"How's he doing?" Scott asked over their internal radio.
"Better now." Virgil answered shortly as he set up a saline drip. "John says the ambulances are ten minutes out, luckily for these two there's a world class burns unit in the hospital in town and it's just a ten minute drive under lights and sirens, faster than we could get there with getting landing clearance and parking Two. We should have the cooling finished and the wounds covered before the ambulances arrive but I want to keep the cooling going until the ambo crews are ready to load up. I'm just glad they both had face shields as part of their safety gear, serious airway burns swell quickly and need intubation to protect the airway. Gordon hasn't finished his RSI training module yet and I'm not comfortable monitoring two intubations on my own."
"Good plan." Scott nodded, knowing the more cooling the better for burns of this size. "Do you have a second roll of cling film?" He asked, wanting to prepare for when the twenty minutes of cooling ticked over for his patient.
"Bottom left drawer." Virgil nodded in the direction of the drawer, most of his attention on getting the bubbles out of the running line for the drip.
"Thanks." Scott retrieved the roll and went back to his patient.
Alan had his IV set up and saline running into the patient when he got there and was preparing a fresh syringe of morphine. "Time?" Scott asked.
"Twenty six minutes." Alan reported crisply. "We can start covering now."
"Okay, turn the water off and give us a hand here." Scott told the helper as he started tearing off sections of cling film. "Drape, don't wrap." He reminded.
Working quickly, they had sections of cling film carefully laid over the burns. Scott tore off smaller sections to drape each finger individually and once the cling film was down he laid towels over the top of the relevant areas to afford the patient some dignity. The water went back on as well, more gently to avoid washing off the cling film. All the time Scott and Alan kept up a running commentary for their patient, explaining what they were doing and why. It gave her something to focus on, knowing what the next step was going to be.
Finally the ambulances arrived, the pre-warned crews already rolling out their stretchers to whisk the patients off to hospital. Scott took a minute to make sure the helpers knew how to access the post-emergency mental health line the GDF had set up for the physically uninjured victims of an emergency and trudged back to the module to help clean up.
He hated burns cases.
I'm unsure what other countries use, but we've moved away from 1st degree/superficial (red and blistered), 2nd degree/partial thickness (white and leathery), 3rd degree/full thickness (black and charred) terminology at the first aid level, it just confuses people. Size, location and pain are a better way to decide if an ambulance is needed or not.
If it's a big burn- larger than half the patient's arm- or affects the airway or the patient is in significant pain, call an ambulance. Otherwise it can go to an A&E clinic.
Your first aid for burns is simple- 20 minutes of cool running water to pull the heat from the burn and cling film draped over the wound to cover it. That's it. If you can make it happen it's going to have a major effect on the long term outcome of the patient by stopping or slowing the cooking.
If you don't have access to fresh running water you can use anything you'd normally drink or swim in until you get to the water- soft drinks, juice, milk, alcohol, sea water, swimming pool water, etc. With the swimming pool, move the water over the burn. If you hold it still you get a layer of warm water that forms around the burn and it actually insulates the burn. The cooling period must be a minimum of 20 minutes. It's so critical we'll actually wait on scene until it's done, we don't have taps in the back of the ambulance.
Drape the cling film, don't wrap it. Burns swell, cling film doesn't stretch and it can actually cut off circulation. The purpose of using food-grade cling film is actually pain relief- it acts like temporary skin and keeps the air off the exposed nerve endings. Fresh off the roll cling film is actually quite sterile, it won't melt if there's any residual heat and it won't leach anything into the wound like a plastic bag or shipping wrap might
Get clothing and jewelry off the affected area before it starts to swell. If something is melted in, leave it and cut around it, don't try to rip it out.
Electrical burns are treated exactly the same way but there's going to be two sites- the entry and the exit, plus an internal burn connecting the two. Those ones must go in front of a doctor at A&E at minimum because if there's any chance it's crossed their heart it can scramble the heart's electrical system.
Chemical burns- generally speaking stick them under the water tap and leave them there. Most chemical burns are best dealt with with water, but if you are working with something that reacts badly with water you should already have the specialist handling training. If in doubt, look up the Material Safety Data Sheet/Safety Data Sheet/Material Data Sheet for what to do. If you can send a copy along with the patient it saves time at the hospital.
Any suspicion of airway burns- such as they just came out of a burning building, soot stains around the mouth and nose, black phlegm, increasing coughing or hoarse voice, singed facial or nose hair- get an ambulance. You can't cool an airway burn, that's called drowning, it needs medical attention.
You lose a surprisingly large amount of fluid surprisingly quickly from a burn so keeping the fluids up to fend off shock is important- an ambulance will set up an IV to get saline into them. Oral fluids are not a good idea, part of shock is switching off the stomach and they tend to throw up. Please don't pop a blister if you can avoid it- one it opens up the wound further and two it's fluid loss. Please don't pull off any tatters of skin, if it comes off while you're flushing that's fine, but please don't actively peel them like you would an old sunburn.
As an aside, I've collected a list of folk remedies that people have suggested in my classes as potential first aid for a burn. The answer to all of these is NO: butter, oil (cooking oil, sesame oil, coconut oil, olive oil, Bio-oil and used motor oil), flour, cornflour, eggs, toothpaste, fish skin, potato skin, raw potato, tomato, hair gel, aerosol deodorant, turmeric, colloidal silver, honey, pawpaw ointment, cabbage leaves, salt, talcum powder, yoghurt, chicken skin/fat, banana leaves, ice, vanilla extract/essence, calamine lotion, aloe vera, after sun gel, mayonnaise, soy sauce, muscle cooling spray, hair spray, aloe vera.
All these things are bad because either they don't help or make things worse. Whatever you put on a burn has to come off at hospital- cling film doesn't stick and the approved liquids are all water soluble, any traces of them left in the wound can be washed out. Oils and what not congeal, the powders have to be scrubbed out. Also a bunch of them carry big infection risks.
Things like pawpaw ointment, manuka honey balms and colloidal silver can be used to assist the healing later, under medical advice, but not for first aid. After sun gel is a glorified moisturiser for sun burns, which are a kind of radiation burn. It won't help other kinds of burns.