- © 2004 Canadian Medical Association or its licensors
It was my first real night of clerkship. Memories of a slow, urban summer were fading after three days of plane-hopping from Ottawa to Sioux Lookout to Pikangikum. After a busy day of clinic in the nursing station, my supervisor and I were watching the evening news. Another American soldier killed in Iraq, Peter Mansbridge proclaimed, and I shivered.
The head nurse knocked on the apartment door.
“Doctor, there's a young man in the ER who's been burned in a bush fire.”
He turned to me.
“Melissa, do you want to see him first?”
I was instantly nervous. Certainly I had heard horror stories about burns, but at this early stage I had little idea of how to manage an actual case. Still, a shaky confidence nodded my head yes.
I trotted down the corridor to the ER. I pushed my way through the little crowd gathered there and tried to steel myself as I pulled aside the curtain.
The smell of gasoline permeated the room. A thirteen-year-old boy lay on the bed sobbing and shuddering, his right leg, forearm and hand a raw, blistered mess. He was young, so young. Owl-eyed children peeked around the curtain while men stood and stared, stoically. Nurses hovered about the room, starting IVs and setting up sterile fields. The youngest, Erica, stood beside the bed holding the boy's uninjured left hand, her words a soothing river.
His name was David. As one story goes, David was sniffing gas in the bush, spilled some on himself, and then went up in flames when he tried to burn his gas bag. An alternative account was that a fellow sniffer deliberately threw gasoline on David and lit it.
Finally, the nurses noticed me standing there. In response, I turned and ran right back down the corridor. Earlier that day they had joked that I looked about sixteen years old. Bolting down the corridor, that was the age I felt.
I stumbled into the apartment and saw the doctor still concentrating on Peter Mansbridge. “It's pretty bad,” I said breathlessly. They need you.”
We ran back to the ER.
“Get these people out,” the doctor menaced in a controlled boom. “I don't want these children having nightmares.”
The curtains were drawn and the doors closed.
“Give him Demerol 50 mg IV now.”
He then made his way through a quick history. David found it difficult to concentrate on the questions, although his howls were now less agonized and more fearful.
“Can you feel this?” the doctor asked as he touched his gloved finger to spots on David's scorched flesh. David shook his head each time. Mercifully, the Demerol was working. Humming a tuneless song, the doctor began to peel sheets of grey, seared skin away from David's thigh and throw them onto the floor.
Then, amazingly, he began to teach. I was standing at the foot of the bed, my back pressed against the cupboards, unconsiously putting as much distance as I could between myself and this nightmare. I wished fervently that I knew what to do.
“Use the rule of nines to calculate the burn area. Nine percent of the body area is the front of the leg, nine percent the back,” he began. He finished his talk, and then started to grill me.
“What is the burn area? How much fluid do you want to give him? Which antibiotics should you use?”
I fumbled for the answers, struggling to keep my face neutral and my voice steady as I ripped open endless packages of dressings. In his eyes I read a warning: This is what a doctor does. The patient comes first; deal with your own fears later.
John, a white-bearded nurse with the build of a Hell's Angel, was busy wrapping David's weeping limbs with antibiotic cream and gauze. He shook his head angrily, wearily.
“That's life up here. It happens all the time. All the damn time.”
Why does it happen all the damn time?
Substance abuse and poverty in this northwestern Ontario town are widespread. Second only to alcohol abuse, gasoline sniffing is a serious problem. However, not only is inhalant use legal, but it is also a cheap and accessible diversion from the troubles of everyday life. Pikangikum became the suicide capital of the world in the year 2000 at 36 times the Canadian average, a reflection of this pervasive funk. Ninety-five percent of homes lack running water. One dim, crowded dwelling the size of my garage often houses three generations. The problem has been described to me as “nothing to do” and “nothing to look forward to.” So children turn to the gas bag.
Gas sniffing is not a benign pastime. When dusk falls, shadowy groups of teenagers make their way to a stretch of dirt road known as Gasoline Alley and inhale from fuel-soaked rags and bags. The addictive fumes hit their bodies much the same way alcohol does, inducing several hours of euphoria, hallucinations, lethargy, blurred vision, appetite loss and slurred speech. Frequent users suffer from headaches, fatigue and vomiting, and develop nose and mouth sores, nosebleeds and throat and ear infections. Still more chronic use may cause permanent damage to the eyes, liver, kidneys, bone marrow, heart and blood vessels. Sniffers can actually die after just one use — death on the wings of cardiac arrest following a fatal arrhythmia.
David was stabilized and sent by Air Ambulance to the Winnipeg Children's Hospital that night. The next evening, my supervisor and I were invited to a dinner party at the nurses' trailer. Roasted chicken, steak, potatoes and broccoli were proudly offered up, with chocolate and lemon pudding for dessert. A feast, we all agreed, for fresh food is in short, expensive supply in Pikangikum.
Afterwards, our bellies full and mugs of steaming tea in our hands, we began to dream about the future. John began.
“My wife and I, we're going to ride from Winnipeg to Thunder Bay and back next week. Should be a good trip.”
The thought of two middle-aged, leather-clad motorcylists flying down the Trans-Canada made me smile.
“I'm taking some time off,” Erica said. “Going to Montreal to do some window shopping,” she laughed.
Now it was my turn. For most of the night I had been sitting in silence, thinking about the events of my stay in this far-flung settlement and wondering how David was doing, miles away from this comfortable, happy kitchen.
“What do you want to be when you grow up?” Erica asked, jokingly.
I thought for a second, and then answered.
“I want to be a doctor.”
First they laughed, the hearty kind of laughter that flows so easily among friends; then they nodded at me with understanding.
Melissa Lem Fourth-year Medical Student University of Ottawa Ottawa, Ont.