Arthur Williams
Cincinnati, Ohio, United States

Adapted from a chapter of the novel Krooked Ketamine (self-published, 2024) by Arthur Williams.

As a surgeon, I have performed a fair amount of skin grafts over the years. To need a skin graft, a person has to have sustained a serious injury, usually a terribly painful burn or an infection that has laid waste to a large area of skin. If the burn is not too deep, the skin will regenerate itself from the epidermal (outer skin) cells, enveloping the hair follicles and sweat glands that lie deeper, in the dermis. If the burn is too deep, then the wound will not heal and will likely need a graft.

To harvest skin for the graft, you have to find a flat area that is inconspicuous and a good match color-wise for the recipient site. The upper part of the thigh is often chosen as a donor site because it is flat, easily covered up, and provides plenty of real estate for coverage. The surgeon uses a Padgett dermatome to harvest a swath of skin only microns thick and usually about two inches wide. The device peels off the outer layer of epidermis to form a sheet of viable, leathery plastic wrap about the size and thickness of a personal check, which can be laid down on a bed of healthy, once-burned tissue and allow it to heal. But first, the harvested skin is fed through a machine that thins and perforates the tissue to create a herringbone fishnet appearance. This dramatically increases the surface area that the graft can cover and prevents fluid from accumulating beneath it.

During residency, I had extensive experience with this procedure, training at a center that was world-renowned for its care of pediatric burn victims. We cared for the worst burns on kids who should have been out skimming stones or jumping mud puddles, not suffering in a burn ward. The patients were sometimes burned over 85–90% of their bodies. Often, there was only a small spot of healthy skin that could be used as a donor site, which would be harvested, allowed to heal, and then reharvested time and time again. Sometimes the child had been playing with matches or gasoline, but it was tragically common for a parent to have caused the fire, or to have dipped the child in scalding water for some middling offense like wetting the bed or talking back. And at the end of this stage of treatment, these children often had scarred and contracted extremities that required extensive physical therapy and more surgeries and resulted in stares or shrieks from people who should know better. I don’t know how the nurses who worked in the burn unit did it day after day.

I will never forget one little girl who came in. She had been serially abused by her stepfather and had mustered the courage to report him to the authorities. So, he locked her in her room and set the whole place afire; the house and all its volatile hoardings went up like the propane locker at a gunpowder factory. By some miracle, the firefighters were able to pull her out and stabilize her before she was transported to our hospital.

I desperately hoped she would die. Sounds terrible, I know, but it was so pathetic, so awful, so inhuman to see another person in such a state. She was young and innocent and did not deserve an inch of that life. And yet now, burned and disfigured, all of the fluids she was being given to keep her alive were leaking out of her blood vessels into her tissues. The pressure inside her belly and all the muscle compartments of her arms and legs shot way up, the blood unable to return to her proud little heart, which just kept on pumping.

Her picture was in the paper the following week, the story having made the national news. In the photo, she held a little calico doll, her blonde curls framing a fantastically dimpled smile. She died a couple of weeks later, when her kidneys and other organs failed. I never thought we could, or even should, save her. I was grateful she no longer suffered. But it’s that picture in the paper that still haunts me sometimes, when the nighttime air is cool and thick with rain, and should otherwise be perfect for sleeping.