by Pitt, Turia
At 7 am Professor Haertsch was in the Burns Unit theatre preparing the list of operations that he and Professor Maitz would undertake that day. After speaking to Dr Allen in ICU, Professor Maitz had gone down to check on Turia. Alarmed, he immediately went back to the theatre.
‘Peter, we have to change everything; this girl has to go to theatre now otherwise she will die,’ Professor Maitz told his colleague. Changing an operating list is not as easy as it sounds. But the two surgeons took out their pens and worked out what could be rescheduled; getting Turia into that operating theatre as soon as possible was critical. Dead tissue had to be removed to try and break the cascading effect of the infection it caused.
Burnt skin loses its thermal regulation function and to stop Turia losing precious body heat, it was necessary to keep her in temperature-controlled rooms. This included the operating theatre, where the heat had to be turned up; everyone working in the theatre on severe burns cases wears special lightweight clothes to keep them cool, including the surgeons. A heat-exchange catheter was fitted intravenously into Turia via a femoral artery to warm her blood as it circulated, enabling her to undergo surgery earlier than normal.
Specialist burns surgeons Professors Maitz and Haertsch are also plastic surgeons and are accustomed to confronting horrific burns injuries; but the effects some patients have on them make an impression that stays for a long time because they are different. Turia was one such patient: a beautiful young woman whose body was about to change forever. In extreme cases like Turia’s, surgeons face the heavy responsibility of knowing that while they can achieve patient survival, it may come at the cost of a much poorer quality of life – with loss of facial appearance, loss of fingers, permanent scarring, stiffness of joints and loss of independence.
Professor Haertsch was working on Turia’s hands, with their long thin fingers, and Professor Maitz was addressing her face, trying not to take it all off. They looked at each other across the operating table. Neither had a choice; they were forced by the injury to remove what was damaged.
It was clear from the start that her fingers were going to be an issue. In burns surgery, whatever is burnt must be removed, not just the skin but tissue as well, and there’s not much tissue on a slender finger. Once removed what’s left is mostly exposed nerve, tendon and bone, which easily dies.
Burns surgeons have a policy of trying to avoid skin-grafting faces because grafts have a tendency to contract and that affects a person’s ability to close the mouth. Because facial skin needs elasticity for expression, skin contraction on the face is different to contraction elsewhere on the body. Fortunately, Turia had sustained only second degree burns to her face which meant it could be saved from grafting. And rather mysteriously, Turia’s eyes were not damaged, which is very rare when the face sustains serious burns; it was thought that she must have been wearing sunglasses which protected her eyes, but she was not.
The alar cartridges of her nose (the structure that holds up the tip and nostril flares) was burnt off. Her ears were also severely damaged.
Over the next four hours the two surgeons debrided, as conservatively as possible, Turia’s face, neck, arms, hands, both legs and feet. Sixty per cent of her body surface was removed and covered with a temporary artificial skin. The artificial skin, called biobrain, is a semi-permeable membrane containing bovine collagen; it is designed to bind to the tissue, giving it time to heal underneath. The burns debrided during this operation were only those that could be accessed with Turia lying on her back; the burns on her back and shoulder would have to be addressed in a separate operation.
Skin from an unburnt area was removed for the laboratory, where it would be put through a mesher that expands it to four times its original size in preparation for skin grafts. Her surgeons planned to start the grafting procedure as soon as Turia was hemodynamically stable; that is, once her blood circulation was functioning better.
ELEVEN
DARK DAYS
AFTER THE OPERATION, MICHAEL, TURIA’S FATHER AND GARY listened while Professor Maitz outlined Turia’s prognosis. Experience had taught Professor Maitz not to go into too much detail with friends and family because most of it cannot be digested. Just tell it like it is.
Turia had a life-threatening injury; she had full-thickness burns to sixty per cent of her body; the burnt skin and tissue had been removed and covered with an artificial skin to help it heal before skin-grafting could start. She had survived this procedure but there was a good chance that she might succumb to shock in the next few days because there was no operation more traumatic than the debriding procedure. If she wasn’t in a deep coma she would be running around the room screaming with the pain. She was currently stable but this could change in the next ten to twelve hours. She would need many blood transfusions. Inevitably she would get infections and they could kill her.
On the plus side, she was young and fit. Her face could be saved because the burns were not too deep; her eyes were not burnt either; if she lived her face may eventually look normal again. But she would need a new nose; her ears would be disfigured; she was going to lose some of her fingers, starting with the tips – but not her hands; she would lose a lot of weight; she would have extensive scars on her arms and legs. He could fix Turia but it would take time. She would be in hospital for six months and she would walk out of the hospital like an old woman.
Michael Hoskin listened carefully to Professor Maitz, a good-looking man whose confident manner had put him at ease. Michael appreciated his ruthless honesty.
‘So you think she will walk out then?’ he asked.
Professor Maitz paused for about five seconds and then, looking at him directly said: ‘Yes, I do.’
‘I’ll get her through this. I’ll be here,’ Michael told him.
But Professor Maitz, having heard the same thing many times before from family members and then seen what really happened, didn’t believe him. How could a young, fit, good-looking guy take this on? They weren’t even married; he didn’t believe the relationship could survive.
‘Michael, that young bubbling girl doesn’t exist anymore,’ Professor Maitz impressed upon him. ‘The person that will survive this may be the same intelligent person, but she will look and act differently. The physical abilities she had are gone and they won’t come back for many years. Maybe ten years; but ten years for a twenty-five-year old is a long time.’
‘But she’s my girl . . .’ Michael looked puzzled, as if astonished that his commitment could be questioned. He loved Turia and to Michael it was simple: the road ahead might be rocky but it was forward and at least he knew the direction they were going in.
As Michael was not able to communicate with Turia, Sue suggested it would be better for him to go home for a few days. So Michael drove home with his father that afternoon.
Three days later Turia was back in the operating theatre critically ill. Some of the areas of artificial skin on her legs, arms and face had become infected; they had to be excised and the areas rebiobrained. At the same time, more skin was taken from the unburnt area on her trunk in preparation for skin grafting. The following day she returned to surgery so Professors Maitz and Haertsch could debride the burnt areas on her back.
Swabs from all areas of Turia’s body had been sent to the microbiology department to be cultured so that the bacteria growing on her skin could be identified. An individual’s ‘bacterial load’ can change when they are injured and large open wounds such as Turia sustained give bacteria ample areas to feed on. When the tests results came back, Turia was found to be heavily infected with a rare bacterium, one that was difficult to control; it was not known where she picked it up but it was assumed to have been something she came into contact with while she was waiting for rescue. It was this infection that caused Turia to lose her face: when the second application of biobrain became infected she returned to theatre to again have her face debrided; from this stage it would become necessary to graft her face thus compromising her scars.
A ventilator is monitored to see how hard it is working to breathe for the patient. As the lungs become full of fluid and inelastic it is more difficult for them to inflate. Turia’s lungs were not damaged by the inhalation of smoke but by the inflammatory response to her infections. She was now too sick for another operation; her kidneys had failed and her surgeons did not want to take her back to theatre until she was more stable. Each day they would say, ‘Let’s wait another day.’ Finally, Professor Haertsch knew he could no longer wait and Turia received a tracheotomy on 23 September – nineteen days after arriving at Concord’s ICU.
Professor Maitz was overseas and Professor Haertsch had become increasingly worried about her continued infections using the artificial skin. Turia had a limited area of useable donor sites; properly prepared, donor sites can be reused up to six times; at first reharvesting can be done at about two weeks, with the length of time between each subsequent harvest taking longer. But Turia’s wound areas were not healing and there was nothing apart from dressings with which to close the wounds; in a severe case of burn injury dressings will not help in the long run. If she did not get something done soon to kick-start the healing, she would die from the results of the infections.
Professor Maitz was overseas and it was up to Professor Haertsch to find a solution. His thoughts turned to cadaver skin, which is known to have special properties that can be used to stabilise infected states. Due to the poor rate of organ and tissue donation generally in Australia, there has always been a limited amount of skin available for burns victims. The intensive care team contacted Australia’s only skin bank, The Donor Tissue Bank of Victoria (DTBV), in Melbourne. It was advised that all available skin was earmarked to be on standby for a possible terrorist bomb attack in New Zealand during the 2011 Rugby World Cup in September and October. The New Zealand authorities had taken the bomb threat so seriously they had sponsored several specialist burns education courses in the run-up to the Cup.
Not to be deterred, Professor Haertsch pressed on. With the help of the DTBV and his own international contacts, he located a skin bank in California which had some available skin. The same day it was shipped, cryopacked in a special esky-like container to Sydney, arriving on Saturday 24 September. Unfortunately, Australia’s Quarantine Service refused to release it to the hospital because the Human Tissue Acts in all Australian states make it illegal to buy or sell human tissue products.
The messages from the Concord Burns Unit to various Quarantine Service officers over the next few hours were very blunt about the urgency of getting the skin: ‘You have two options – adhere to the protocol or let her die.’ Finally on Sunday, Dr James Allen, Professor Haertsch’s registrar, gave Quarantine the bluntest message yet: ‘If we don’t get it this afternoon, this patient will die.’ The skin was released immediately.
On Monday 26 September Turia had the surgery which ultimately saved her life; from this point, the turnaround in her condition was markedly swift compared to the three-week gradual descent to near-death. Professor Haertsch and his team applied the donated skin to forty per cent of her body surface area. By then the affected areas plus the other areas where unburnt skin had been taken for skin grafts meant that her wound surface area was almost one hundred per cent.
After Turia’s first operation, Michael had returned to his parents’ place feeling more confident. He liked the fact that Professor Maitz had been so candid; he’d laid the cards out and Michael knew what Turia faced. For the next few days he rang the hospital every twelve hours for an update.
When he received the disturbing news about the recurring infections with the artificial skin and the failure of some of the initial skin grafts, Michael immediately went back to Sydney to talk to Turia’s surgeons.
It was the first time Michael had met Professor Haertsch. He was told Turia was going to need more operations but first her temperature had to come up as it was too low. Michael understood that they were still deep in rocky-road territory.
Michael did not go home that day. He took up residence in Genji’s spare room and so did his father; Gary bought a double bed and stayed during the week to give his son the support he felt he needed for those first few weeks. He went home to spend the weekends with Julie, giving her grim updates on Turia’s progress and describing their son’s remarkable devotion and determination that the young woman he loved would come through. If anyone doubted Michael’s words that he would ‘be there’ for Turia, they were now about to be proved resoundingly wrong. Michael bought a little blue Hyundai Getz to make it easier for the sixty-minute each way journey across Sydney to Concord Hospital to be with Turia, a journey he made every day for the next five months.
Gary was profoundly moved by Michael’s unfailing belief that Turia would make it. The surgeons were heroes, Michael told him; they’d fix up her face. She’d walk out of the hospital; they had a future and they could have a normal life. During those early weeks Gary spent hours with his son, walking and talking, and never once saw him falter.
Michael knew his girlfriend and Célestine knew that her daughter was made of gritty stuff, and they made an unspoken pact to work together as a team to help her recover. After the first three days on Genji’s couch waiting for news of Turia, Célestine had returned to John and the boys in Lake Burrill; Turia was still in a deep coma and Célestine knew it was best to look after the boys until she could communicate in some way.
In the meantime both Turia’s father and her partner – the two Michaels – kept Célestine informed from Sydney. The news that she would have to have skin grafts to her face and neck following the second lot of infections with the artificial skin was a shock to everyone; but the main thing was that she was alive.
Célestine came back to Sydney after that. She knew Turia would be heavily sedated but Michael Hoskin had said Turia was responding to nursing commands by turning her head or wiggling her toes. Somehow Célestine knew she had to find a way to communicate with her daughter.
By then, Turia had been moved to her own intensive-care room. Célestine arrived with John and Genji. As they gowned up to enter the sterile room Genji, who had already been to see his sister a few times, spoke sternly to his mother:
‘Mum you are not to cry. You have to be strong.’
‘You think I’m a coconut head! I’m not – I’m a patient warrior,’ she told him firmly.
Before she went into the room she looked at her daughter through the little viewing window in the door. It took an extreme effort not to cry but she walked in, aware that Turia would not be able to respond properly but determined to get through to her somehow. She sat on the side of the bed.
‘We are going through this journey together; you are not alone. That’s all that matters.’ She then started massaging Turia’s head gently through the bandages with a soft and soothing technique called effleurage that she had learnt in the previous week especially to help Turia. ‘Do you like my effleurage, darling?’ she asked. Turia nodded her head. Célestine was thrilled. She could communicate!
Célestine stayed in Sydney, sleeping on Genji and Angela’s couch. After a few visits to Turia with Genji and Michael she came up with a proactive plan to move her daughter’s recovery forward. She’d noticed that, with best of intentions, Genji and Michael were repeating the same words: Genji was saying, ‘This is the calm before the storm’ and reminding Turia of things they did as kids: ‘Remember the time I wanted you to jump off the roof and you wouldn’t?’ Michael was telling her how much he loved her and what a great fut
ure they would have together. Her father was repeating the same positive ‘You can do this’ message.
‘She can hear you and she’s not stupid,’ she told everyone. ‘She will get bored with all that after a while; everyone who visits must read to her.’
Michael was delegated to read Turia poetry; her father, who had returned to Ulladulla but was driving to Sydney at weekends to visit, was told to read her interesting bits of news and articles from scientific magazines; Célestine elected to read Turia’s favourite books. Genji didn’t want to be told what to do – he would read or say whatever he thought appropriate.
There was a TV and DVD player in her ICU room and they got her some movies to watch – Célestine believed that even if Turia was heavily drugged, it was important to keep her brain active.
But this was before the breakthrough with the donated skin, and Turia was not out of the woods. When she had to have a tracheotomy after three weeks and her grafts were continually becoming infected and her wounds wouldn’t heal and her kidneys failed – those were very bleak days. They were again told to prepare for the worst. They were in the realms of last resort; the hospital was importing skin from the United States and waiting its delivery.
Professor Haertsch had given Michael his mobile number and – after the operation to cover the infected areas with the donated skin on the Monday – Michael called him; the operation had gone really well. They were another step up the ladder to where they could say Turia would live.
Of course he knew there would be more operations. But to Michael, every operation was just another one out of the way; another step forward to her living.