Ethanol, Eschar

When she dreams, her skin is a map, an atlas of undulations and ravines, of crevices and pools. Vast flat lands give way to bumpy roads winding and scaling towards steep pinnacles. Unpredictable elevation changes are charted from her toes to her head.

When her skin is a map it depicts a great big world with many countries. An amalgamation of cultures drifting together forming one great picture. Rough and smooth areas are joined by skin-coloured seas. It shows different-coloured terrain: red, pink, salmon, white, stitched together as one. It represents a world that has changed over time to become what it is today.

In reality, her skin is burnt. The protective layer for her flesh, and her largest sensory organ, is scarred and scorched from intense heat. It is bumpy and thick with collagen-packed scar tissue. If her understanding of chemical science were as comprehensive as her imagination, she would have understood the properties of ethanol. A colourless, volatile and flammable liquid, ethanol’s molecules are made up of ethyl and hydroxyl groups. When in contact with a heat source, ethanol combusts.

The night she comes to understand the extent of this, she is sitting with friends on a deck in Wavell Heights. It is a cold and wintery June evening. Conversations keep them warm as well as a large spread of cheese, crackers, dips, and cake. A barbecue sizzles in the background and the smell of smoke lingers in the cold air. She is at ease with people she is fond of; she breezes into the evening with a sense of calm and contentment. It seems like any other night in her life.

‘Want to roast marshmallows?’ A friend asks and drops two bags of squishy, sugary clouds onto the table. Nostalgia is a funny thing; small comforts can conjure such happiness like childhood sentimentality.

A fire is lit from its base with a bottle of liquid ethanol. The flame is almost invisible to the eye. In an instant the flame explodes into a burning orange ball right in front of her. One minute the sound of chatter and laughter from people at the party. The next, the unmistakable voomph of gas. Her skin is set alight. There is screaming, then sleep.

When she wakes up in hospital five weeks later, she sees that orange ball over and over again. It doesn’t leave her mind as she lies in bed, burnt and broken, skin dripping over her bones.

Burns are classified as: first-degree (superficial), affecting the epidermis, or outer layer of skin cells; second-degree (partial thickness), affecting the epidermis and part of the dermis, or inner layer of skin cells; and third-degree (full thickness), destroying the epidermis and dermis layers, and affecting the tissue underneath. She doesn’t need to be told that she has suffered the worst kind of burns. She comes bitterly to respect ethanol and its high level of volatility; a clear, almost invisible chemical that can cause such visible destruction.

In a blank hospital room, she loses all sense of time. There is only night and day, dark and light. She cannot see in front of her; not the clock on the wall, not the shelves of medical equipment near the windows, and not her own feet in front of her at the foot on the bed. She cannot see her bound body, bandaged from head to toe, blood seeping through the gauze on her legs. Her eyes are heavy, glued down. Her remaining senses must become acute.

Dedicated nurses work all through the night; they wake her up regularly for check-ups. A blood-pressure cuff around the right arm; Chlorsig antiseptic lotion applied to the upper lids and along the water line of the eyes; a thermometer under the tongue; and medication pushed through the PICC (peripherally inserted central catheter) line. She picks up these terms as the nurses repeat them; her hearing compensates well for her lack of sight.

The doctors surround her bed each day; they ask her how she is feeling and she gives a feeble nod each time. She feels them staring, not coldly, but in admiration either for her, their surgical work or both. They say, ‘You’re doing well, okay.’ She doesn’t know how she is doing or whether she is even doing anything. She is existing; that seems to be enough for now.

The nurses tell her that the doctors and surgeons who specialise in burns are remarkable. It is a difficult and demanding specialisation that requires meticulous work. Later in her recovery she will learn that burns surgeons are considered ‘the athletes of the medical world’ and that they operate for hours under extreme conditions of up to 39 degrees Celsius to maintain the optimal environment for patients.

Her parents tell her that these doctors and surgeons are their heroes. The nurses say they have done an amazing job of skin grafting. She has never delved into the world of medical phenomena; when she is forced to become a part of it, she finds herself in awe.

Skin grafting is an intricate surgical process whereby healthy skin is transplanted to areas where damaged skin has been excised. The transplanted tissue is called a skin graft. This process is used on extensive wounds, primarily caused by burns. In Techniques in Orthopaedics, Jillian Fortier and Charles Castiglione describe the classifications of skin grafting in detail: ‘Split thickness skin grafts include the epidermis and varying proportions of the underlying dermis. Full thickness skin grafts comprise of the epidermis and the entire thickness of the dermis, including structures such as sweat glands, sebaceous glands, hair follicles, and capillaries.’

If her skin is not a map, then it is the skin of Frankenstein’s monster, stapled and stitched together, piece by piece, to form a new creation. Split-thickness and full-thickness skin grafts cover her almost all over. ‘My face, my neck, my chest, my arms, my hands and my torso,’ she recites to the people who are brave enough to ask. When she becomes brave enough, she traces her fingers over her left arm; it is rough and soft at the same time. It doesn’t feel like an arm. It definitely doesn’t feel like her arm, or as her arm should feel. Or, at least, as her arm used to feel. She cannot detect her fingers running the length of her forearm. It takes a while to convince her skin that it is being touched. She is told to keep trying as this process of desensitisation helps the mind adjust to the lack of feeling in the damaged tissue.

Third-degree (full thickness) burns involve nerve damage, since epidermis and dermis layers of the skin are destroyed. She is told the feeling in these areas may never come back. The crux of her elbow is spared and the edge of her damaged skin borders it. If her skin is a map, her ‘normal’ skin is an island in an ocean of burns; untouched patches of land with skin grafts surrounding them.

Nurses dress her open wounds in sticky, yellow occlusive gauze called Xeroform. Bandages are methodically wound and wound around her limbs each day. Her left ear is black; she knows this because the nurses tell her as they carefully sponge it and dress it with more Xeroform.

If her sense of impending death were as perceptive as her imagination, she would already know that the skin on her ear was now eschar: dead tissue forming a dark scab that would eventually rot and fall away. It has met its end like the rest of her skin; charred black and dead, in need of debridement. It will heal, they think, but she has come to accept loss as an inevitable matter in the life of a burns patient.

Every couple of days her bandages are unwound and gauze, thick with congealed blood, is peeled from her wounds. She is lowered into an industrial-size bath. Her most acute pain is numbed with oxycodone hydrochloride, a narcotic analgesic that makes her head fuzzy. The water is hot and bubbly with antibacterial soaps. She breathes in and out, relaxing into the enveloping warmth. The nurses chat to her as they sponge down her wounds ‘What kind of music are you into?’ But she is in her own tropical lagoon, floating in a pool of dreamy blue; gentle waves lapping at her skin. She is weightless, drifting effortlessly here and there. Her skin is rejuvenating, regenerating in the pure water.

Her raw wounds are soothed and healed. A fresh, salty scent fills her lungs as she levitates on the water’s surface. There is nothing around her; she is solitary, quiet and revived. With every wave that washes over her, the scarring on her body fades a little more until every bump and crevice has disappeared. Her eyes close as she floats along in her reverie, the warm water carrying her. ‘Are you okay?’ a nurse interrupts. She opens her eyes and nods; she is okay, given the state of things. The bath water looks dirty and tinged red. Her eyesight is blurry but improving.

Back in her hospital room, the nurses lay out utensils, bandages, gauze and scissors, along with sheets for her to lie on. She is transferred onto the bed and they begin their work. Her legs are always treated first. They are the colour of beetroot in the areas where skin has been harvested for her skin grafts. They are ‘donor sites’, she is told. A donor site is the area from which unburned layers of skin are taken to create a skin graft. Once harvested, the area is left to heal.

Her legs are raw and inflamed; they feel naked and vulnerable. The lines depicting where the skin has been cut away are perfectly straight, meticulously shaped. One day a nurse notices her looking curiously at her right calf. ‘You have an infection in your leg,’ she says. Apparently it is quite common to get a hospital-acquired infection but this information doesn’t put her at ease.

An elongated scab extends the length of her lower leg; it is black and ruby red, jutting out from her worn-away muscle. The most gruesome eschar she has seen. The nurses cover it in Kenacomb ointment, an anti-bacterial cream, and bandage it up out of sight.

In early July she looks in the mirror for the first time. If her skin is a map, her eyes are two pools of light in a desolate wasteland. Her features are gone, covered by sheets of new skin. She traces her forefinger along the suture line of the grafts, they look different to anything she knows about skin grafting. Stretching from her brow bones down and over her cheek bones and bridging over her nose is a sort of pale mask. They call it Integra.

The surgeons explain, in layman’s terms, that Integra is a scaffold that replaces the epidermis of the skin when it is damaged, and regenerates dermal skin cells. It is a synthetic material made from bovine and shark particles that acts as a template underneath a skin graft. On top of this, a normal skin graft from a donor site is set.

She imagines Integra as the roots of a tree, anchoring down, its xylem and phloem cells growing through beneath the bark. Her own white blood cells and fibroblasts, found in the dermis, have regenerated and grown just the same.

Her grafts look smooth and flush to her bone structure, not thickly scarred like the rest of her skin. The outer edges join up to the rest of her facial skin, which gives way to her shaved head. She is bewildered at the possibilities that exist in burns care. She reads a newspaper article dedicated to the burns medical team at her hospital and the difficult work they do. The article mentions skin donation. She wonders whether or not grafts from other people’s skin work in the same way as her own. She reads: ‘Queensland Skin Bank, established five years ago, one of only two in Australia, [is credited with] improving survival rates of burns patients through reduced infection risk.’ Apparently ‘The donated skin acts like a “biologic dressing”—or a big natural band-aid—protecting patients from germs infiltrating their wounds until their own skin can grow back underneath’.

Later in her recovery she meets a man involved in a boat fire with 90 per cent burns to his body. He tells her, ‘My arms and legs were burnt through to the fat. My feet were the worst—I still have limited feeling in them.’ He explains that most of his body is covered in cadaver skin: ‘Fifty packets of skin were used. I only have two donor sites on my shoulder and the back of my neck.’

She asks him what it feels like to have somebody else’s skin all over. He replies, ‘When you spend 42 years with the same-looking skin and then you wake up and everything is changed, it gets too much. I still have a lot of trouble looking at myself.’ However, he adds, ‘The doctors and nurses were great though, they love their job. I’m lucky my accident was in Queensland and I had these guys looking after me.’ She imagines that he must feel like Frankenstein’s monster, experiencing a dichotomy of inability to come to terms with the way he has been created and a feeling of gratitude towards his maker.

In August she is recovering; her skin is healing, toughening, and becoming a part of her makeup. If her skin is a map, the divided countries are becoming one, thriving together in a big, cultured community. Her grafts are melding into her ‘normal’ skin until she has trouble defining the borders that once separated them. She stretches her limbs out daily, building up her muscles after months of disuse, striving to be strong again. A physio-therapist visits her every day to stretch her skin in all directions, pulling it into shape so that she can move properly. They intend to get her to ‘full range’ of movement.

Scar contractures are inevitable in deep burn injuries. The Indian Journal of Plastic Surgery says that ‘Contraction is an active biological process by which an area of skin loss in an open wound is decreased due to concentric reduction in the size of the wound.’ At times she feels trapped in a web of skin, the tightness pulling her, restricting her. She manipulates it to allow herself to escape its hold. She pulls her skin and presses hard until it blanches under the pressure of her thumb. As she lets go it feels softer, moulded to fit the contours of her muscles.

Innovations in skin grafting continue to develop long after she leaves hospital. Laser treatment becomes an outstanding option to reduce scarring, and alternative dermal scaffolds such as MatriDerm are accessible. Alternative and additional treatments progressively improve the appearance of scarring, break down collagen in hardened areas, and leave burns patients with soft, elastic grafts. Burns treatments are proliferating, thriving in possibilities. She knows that her doctors and surgeons are at the helm of these innovations. The newspaper article quotes one of her surgeons, saying, ‘It’s the patients who keep me going and have done for three decades.’ She feels connected to them, thriving with them.

Shortly after leaving the care of her nurses, she reads a research paper reporting that:

The mortality and morbidity from burns have diminished tremendously over the last six to seven decades. However, these do not truly reflect whether the victim could go back to society as a useful person or not and lead a normal life because of the inevitable post-burn scars, contractures and other deformities which collectively have aesthetic and functional considerations.

She contemplates this mortality and morbid-ity a lot, and whether or not she will lead a ‘normal life’. She contemplates ethanol and eschar, burns and baths, contractures and cadavers; all of the elements that have shaped her. She contemplates skin and how it can be regenerated, changed, stretched to create a culture in which it can grow.

But when she dreams, her skin is always a map. It is etched with tracks and channels and the veins of cities. It unfolds into a detailed and beautiful picture, labelled with places where others have left their marks. It encompasses alterations, changes in direction, alternative routes, all mapped out for the world to see. It is a beautifully complex depiction of charted land. It shows tears and worn-out edges, rips and faded spaces. It reflects a remarkable journey through changing terrain. It details the new and the old, the touched and untouched. Her skin is a map, destroyed by fire and redefined by brave explorers. •

This piece first was first published in Tincture Journal issue 17, Autumn 2017.