You see a lot of weird shit in Reno as a paramedic, but this is a new one. What even!!!!????? How????? 

Also, a problem on several levels! These injuries...do not, honestly, look incredibly survivable...but they're at least going to try everything they can and get her to the hospital, which is....difficult...for a patient they can't touch without oven mitts, which are not part of regular ambulance stock. Also that looks like fifty pounds of armor, and the woman herself is not exactly small, it's going to be a pain in the ass to move her, but it seems ill-advised to remove it along with most of her skin until they're somewhere a bit more sterile than the side of a highway. 

One of the paramedics will attempt to pad her hands with one of the ambulance blankets and shift the armor enough to get access to her neck and check for a carotid pulse. If she doesn't have a pulse the armor does have to come off, somehow, she's pretty sure you cannot actually perform CPR on someone wearing full plate armor like some kind of fucking historical re-enactor. 

(There is a quiet internal chant of what the fuck what the fuck happening in her head, but you get used to ignoring that.) 

She has a pulse! It's a remarkably steady and healthy pulse, really, for someone who isn't breathing and has now been lying by the side of the highway for at least four minutes (since the call) and plausibly significantly longer. A little fast.

...Okay, great, that's - surprising and also kind of what the fuck, but in a way that's better than the alternative, and she is deeply relieved not to have to try to wrangle a bodybuilder-sized woman out of scorching plate armor right this second. Maybe she only just stopped breathing? 

"Got a pulse," she says, and will whip out an ambu bag and start ventilating her. "- Bill, oy, oxygen me?" She uncoils the tubing and flings it in his direction. 

    "Gotcha." Bill connects the tubing to the portable oxygen tank. "...Do you have any theories, because I'm drawing a blank." 

"I really, really don't. ...Okay, you're the one with the tough manly hands, you're on trying to un-armor an arm for us so we can get a fucking blood pressure." 

     "Annie, do I look like someone who has the slightest idea how medieval knight armor works?" He will gingerly attempt this, though. 

The armor is not particularly amenable to being removed! The leather buckles connecting each of the pieces were negatively affected by the dip in boiling water and he'll have to cut through them. Also her skin is completely melted to it, of course. 

When they put a oxygen mask over her face she coughs, extremely weakly. It's a kind of horrifying sounding cough, like she steam-burned her lungs and then drowned.

Eeeeesh. That is...not great...though the fact that she has an even slightly intact cough reflex is a good sign. 

(Annie's internal monologue is currently a stream of yikes yikes yikes interspersed with utter confusion. She has no explanation for how someone could have ended up...drowning in boiling water???...on the side of a highway in Reno, and separately from that she still has no idea what the fuck is up with the armor.) 

They pretty urgently need to intubate her, her lungs are clearly incredibly fucked, and the near-drowning suspicion means she's probably going to vomit at some point. Annie predicts they're going to have a bit of a time intubating her without sedation, given the intact cough reflex, and they cannot do sedation until they have IV access, which requires having somewhere accessible to try to stick an IV. The woman can have 100% oxygen squeezed into her lungs via the mask over her face, while Annie makes sure the portable suction is right there in case she starts vomiting. 

"Bill, can you hurry it up a bit?" 

     Scowl. "I'm trying." The metal is presumably going to cool down eventually, but it's not doing it fast - it's probably still burning her, though it's hard to imagine it making the damage much worse at this point - and the boiled leather is not very willing to be cut by medical scissors. "...I'm going to run back in and get something better for cutting, one sec." 

She will absolutely vomit a lot of water! Sea water, if anyone is checking! 

Aaaaack great now Annie has mildly scorched the palms of her hands trying to wrestle the woman onto her side and in too much of a hurry to figure out where the stupid blanket went. She's not exactly planning to taste the water for saltiness but it does smell kind of ocean-y, which is EVEN MORE WHAT THE FUCK. Annie isn't sure she's ever had this many questions at once in her entire life. Also she kind of desperately wants an O2 saturation reading and she cannot have this due to fingers being inaccessible under stupid armor gloves. 

Bill is back, great. "Bill, can you prioritize getting one of the armor gloves off for the pulse ox?" 

     Bill snorts. "Seriously, armor gloves? They're called gauntlets." He'll have a go at this, though, while Annie attempts to flomp the woman onto her back again - this time remembering to pad her hands with the blanket - and continue squeezing oxygen into her lungs. 

If he can cut through leather he can get a gauntlet loose. (The gauntlets are in utterly pristine condition, polished and well-fitted.) Some of her skin comes off with it, of course, but that is recognizably a hand, there, badly burned, and it's even possible to hook the pulse ox up to it. 

The pulse ox says that her oxygen saturation is seventy nine percent. Eighty. Eighty one.

That...is actually pretty reassuring???? Though, again, SUPER BAFFLING, Annie didn't feel like she was really getting all that much air in successfully. 

"...Okay, I'm inclined to say scratch getting a blood pressure, pulse is strong and that does not seem like our main problem. We need an IV for sedation so you can tube her, see if you can get one in her hand? And then we should roll, get her to the hospital and let them handle the rest." Probably Renown Regional Medical Center can turn up a pair of oven mitts. From the kitchen staff, at the very least??? " - if you can't get an IV I'll try without any sedation but she's got enough of a cough reflex to make that, uh, really annoying." 

    "- On it, boss." Calling Annie 'boss' is his joke, she has two years' more experience than him. Bill will do a janky wrist tourniquet and look for IV-able veins in the woman's hand. 

The veins in her hand are strong and healthy and diligently doing their job despite the fact that all of her skin has been burned off!!

...Great. Okay. He can get an IV in really easily, the lady clearly works out. ...Securing the IV is harder, the clear dressing does not really stick to her oozing flesh at all. He wraps it in kind of a lot of sterile cling-wrap gauze instead. There's a bag of saline ready with primed tubing; he hooks it up, rams the clamp all the way open to let it flow in freely, and then pulls up a syringe of propofol. "...I'm giving her the full 10 ccs, she's a beast."  

    "Mm-hmm." Hopefully she can get the tube in without having to do a lot of awkward positioning, because she continues to not possess oven mitts. How's the woman's O2 sat reading now? 

Ninety!

She continues coughing vigorously and twitching after getting 10ccs of propofol.

...That's fucking impressive. Or something. Annie has only seen that kind of resistance to sedation before in 250-lb guys on PCP. (Which for some reason has come up twice.) She does not really want to give her any more sedation when they don't even have a baseline blood pressure reading, so she's...just going to push ahead anyway, if the woman is only coughing and not, like, actively struggling in a way that indicates she might be awake. "Bill, can you, uh, help me hold her still?" 

She's still deeply unconscious other than the reflexive coughing and doesn't resist intubation beyond the coughing. Her eyes don't look like they can open, they're sealed shut by the burns.

Yeah she looks horrifying. She's more stable than she has any right to be, but Annie does not at all trust that to last. She makes sure everything is really well secured, and then they can both put their back into it and find out if they are, in fact, capable of wrangling a not-exactly-small woman in full armor onto the stretcher. 

She's very heavy. They've dealt with heavier patients but those probably didn't burn you if you touched them. Moving her also involves shaking a lot of water out of the armor. When they finally wrangle her onto the stretcher she leaves behind a bloody gooey puddle. 

Oxygen sat is 95%!

Yeah, the process is going to involve wrapping her in blankets on top of the armor first, and also some scorched fingers. 

....Okay that's genuinely gross in addition to horrifying. Annie was more or less kneeling in it and now her pants are bloody and gooey all down the knees. 

She is...at this point getting kind of worried that the pulse ox reading is fake? Though false low readings are more common than false high readings, and it looks like it's picking up a very solid signal, unsurprisingly given that her carotid pulse is still quite strong. Annie...is confused, mostly.

Bill drives. Annie stays in the back monitoring the patient - keeping a finger on her radial pulse, since the breastplate is still in the way of where they would put ECG electrodes - and squeezing the ambu bag every five seconds to ventilate her lungs. She radios ahead to the hospital. They're bringing in an unidentified woman, age unknown, severely ??scalded or steam-burned??, vital signs surprisingly stable but she has third degree burns over her entire body surface area and Annie does not really expect her to stay stable for long. Sometimes very fit healthy people can compensate surprisingly well for catastrophic injuries....for a while...and when they do inevitably crash, they deteriorate fast and hard.

Bill is driving fast. 

Iomedae is having a bad time.

She's no longer suffocating! Some oxygen is entering her lungs and they are not too thoroughly steam-burned to get anything out of it! They are only mostly full of salt water and dissolving lung tissue! Her heart is beating, only a little fast. ..she is losing an astonishing amount of fluid to blood/pus/goo because of how she does not have any skin. In a bunch of places the burns are worse than third-degree and the resulting tissue damage is pretty horrifying.

If she were conscious she'd reassure everyone that she just needs a place to rest and a glass of water but she is, in fact, very very deeply unconscious. 

Yeahhhhhh this continues to look...not really survivable. Except it's somehow even more upsetting, now that it's clear how hard the woman is fighting to survive. 

The woman's oxygen saturation is excellent, though admittedly this is because Annie is bagging her with 100% oxygen, and she can feel the resistance she's pushing against to get air in and out of the woman's lungs. You eventually learn to recognize the feel of fluid in lungs; Annie's teacher used to say 'it just has that texture' and she is pretty sure 'texture' is not the word here but she doesn't really have a better description of it. She has a go with the suction catheter, trying to at least get some of the water out, but she's gentle with it, trying not to make any of the internal damage worse. 

They make it to the hospital. There's already a crew of ER staff waiting for them in the ambulance bay. ...Someone, rather remarkably, has turned up a pair of oven mitts. They rush the unconscious woman to the trauma bay, slide her over to the ER gurney, and - great, time to attempt to at least remove the armor from her arms so they can get a blood pressure reading? ...With sterile fields underneath and non-adhesive dressings ready right there, it's a bad idea to leave those burns exposed to infection sources for a second longer than necessary. 

The armor is disgusting and also difficult to remove from her arms. Skin and tissue comes up with it. She twitches. 

Blood pressure is 95/60!

...Oof. They'll get her arms bandaged and place a couple more large-bore IVs - and an arterial line, taking her blood pressure manually is not great for the tissue damage - and run fluids as fast as possible. She can get broad-spectrum antibiotics administered, and a lot of stat bloodwork drawn including a type-and-cross for a blood transfusion, she's clearly lost a lot of blood - still losing it - from the whole not having skin problem. Getting her shoulders more or less exposed does at least mean that they can do a janky 3-point ECG electrode placement. It's not a very good reading, with the weird placement and her lack-of-skin oozing so the electrodes have trouble staying on, but there's now a heart rate tracing up on the monitor. They try to get a temperature reading. 

Removing the rest of the armor is...probably not a good idea right here and now? They might want to literally do it in the OR, actually, and once she's more stable and they have some units of blood ready; taking away the pressure on damaged tissues could set off much worse bleeding. In the meantime they'll...pack ice around the armor still on her, to at least cool it down faster and prevent it from causing any more ongoing burn damage. 

She's running a fever. 103. Her heart is steady at 70 beats per minute. 

The initial bloodwork comes back - a little surprising.

Her hemoglobin is low. That's not surprising. Her white blood cell count is high. That's not baffling. Her sodium is low and her potassium is high, her inflammatory indicators are high - all as you'd expect. Her kidney function looks totally fine. Her blood sugar is fine. Her lactate is high but not nearly as high as you'd expect. Her blood gas results are also surprisingly fine. Her PaO2 is totally normal. Her CO2 is still somewhat high and her blood pH is low but not that far out of range.

Huh. Well, she's continuing to compensate shockingly well for the sheer extent of the damage, and who knows how long that's going to last but at least it buys them time. There's a bed available in the ICU, they should probably relocate her there ASAP. 

The trauma surgeon agrees that taking her to the OR so they can remove the armor and debride the burns at the same time is a better plan than just ripping it all off now. They can plan on it in an hour or two, maybe, if she's still stable then. 

Marian is on shift today and she's getting an admission! Apparently it's weird! She's looking forward to taking report, she likes weird cases. 

...Uhhhhhh. She likes it less after the report. It mostly sounds like it's going to be incredibly tragic, and also what the actual fuck. Reno sees a lot of weird shit in the ICU but usually it's more...mundane...weird shit. 'Patient in medieval-re-enactor armor' and 'patient appears to have picked up third-degree-or-worse steam burns beside the highway somehow' are both baffling. Also apparently the patient is STILL in the armor and they're going to literally take her to the OR to remove it, aaaaaaah. 

She's ready, though. She heads over to the ER to help collect the patient and transfer her over. 

The patient looks horrifying because of how much of her flesh has been boiled off (nearly all of it). She is, in addition to the armor, wearing a leather headband, three different amulets all on the same thin chain around her neck, a ring on one finger of the exposed hand, and a cloak neatly embroidered with heraldry. 

She's still deeply unconscious. They've suctioned up a horrifying amount of lung tissue and she's intubated but her oxygen levels now seem completely fine. All the wounds are still oozing.