Student Scene
 Ellen Rothman Photo by Graham Ramsay |
House Fire Exposes Gaps in Care
The EMS radio interrupted an otherwise quiet Sunday morning in our clinic emergency room on the Navajo Reservation. "This guy is burned from head to toe," came the breathless report. "His face and mouth are all black. We'll be at your back door in less than two minutes."House fires are a periodic problem in our area. More than 50 percent of our local homes lack central heating and, instead, rely on coal- or wood-burning stoves. We have occasional deaths. Last winter I learned that one of my three-year-old patients, who had introduced himself to me as "Pooh Bear," died in a house fire. But deaths are few and far between. Most fires are routine affairs that attract barely a passing notice.
The Damage Done
We had just cleared a bed when the ambulance pulled up. The medics rushed the patient into the ER. "When we drove up, he was standing outside. His clothes were in flames. We put out the fire and ripped off the clothes. Then we just scooped him and ran," the medic said.The man's entire body was charred. The skin on his chest and abdomen was starting to peel off in sheets as tender blisters ruptured, revealing shocking pink skin below. The soles of his feet were burned and peeling. His genitals were black. His hair was singed into tiny, black curls, and his ears had melted into shapeless nubs. The smoky sweet smell of charred flesh pervaded the emergency department. The only area that was not black and peeling was his right hand, where he had apparently been wearing a glove.
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It is easy sometimes to confuse poverty and substandard living conditions with cultural preservation. Oscar wasn't traditional. He was poor. --Ellen Rothman |
"OK," he whispered and turned away to look at the ceiling.
My colleagues arrived within a few minutes, and together we set about stabilizing this man for transport to a major burn center more than 300 miles away in Phoenix. The nurses were miraculously able to find veins through the charred and peeling skin. His mouth and upper airway were black and smoky, but the breathing tube went in easily. The sound of raspy breathing was replaced with slow, regular breaths monitored by a ventilator.
As I gave a report to the burn center, one of the nurses handed me a thick, blue chart, so I could provide the patient's medical information. I immediately recognized the name--Oscar Denetsosie. "That's Oscar?" I said. He was unrecognizable.
Who Cares?
Oscar was in his mid-sixties, disabled by chronic diabetes and high blood pressure and blinded by glaucoma. This last detail explained the milky blue eyes in a Navajo man. In fact, I had been the last of us to see him in our clinic just two weeks previously, my signature peering up at me eerily from the last page of his medical chart.Although Oscar lived in what could be considered the middle of downtown, like many of the other elders in our community, his home lacked central heat, electricity, and running water. He built his own fire in a wood-burning stove every day for heat.
"He always built his fire big," his niece said that afternoon. "I kept trying to tell him to make it smaller, but he always said he was too cold. He said he'd been building fires his whole life, and he liked them big."
Many providers had tried to get him a daily aide, but he was refused for services by the only long-term-care provider in our area because he was still able to walk. If he was ambulatory, the service reasoned, he should be able to care for himself. We looked for other alternatives, but his family had already withdrawn him from one nursing home because it was more than 100 miles from home. On the day of the house fire, he was actually on the waiting list for another facility, with a scheduled admission in one more week.
In our remote area, access to resources is difficult. Nursing homes, sometimes hundreds of miles away, are culture shock for our traditional elders. Those of us working on the rez value the traditional ways. But we forget that living without amenities can be more a reflection of poverty than a conscious will to preserve the ancient lifestyle. It is easy sometimes to confuse poverty and substandard living conditions with cultural preservation. Oscar wasn't traditional. He was poor.
When Oscar arrived at the burn center, he was still alive. The doctors there estimated that he had third-degree burns over 95 percent of his body. In consultation with the burn specialists, the family decided to withdraw support. They put him on a morphine drip, and Oscar expired shortly before midnight.
--Ellen Rothman, HMS '98, now practicing in northern Arizona on the Navajo Reservation
All patient names in this column are pseudonyms. The opinions expressed are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.