TO HELL AND BACK

By LEON JAROFF

It happens in an instant, but the scars and psychological damage can last a lifetime. An inquisitive child pulls at the handle of a pot on the stove and is scalded by a cascade of boiling water. A smoker falls asleep with a lighted cigarette and is badly burned when the bedding catches fire. An eruption of caustic chemicals engulfs a worker, eating away skin and flesh. A blast of superheated air burns a fire fighter's face and damages his lungs.

Some 1.25 million Americans suffer burns every year. Most of them quickly recover, both physically and mentally, with permanent damage limited to a small scar or two. But more than 50,000 burn victims require hospitalization annually, and 5,000 die of their injuries.

For the more severely burned, life hangs in the balance as they fight to survive the loss of large portions of the skin's protective covering, which keeps body temperature normal and internal organs properly hydrated. Many of the survivors continue to suffer psychologically, not only from varying degrees of disfigurement but also from frightening and debilitating flashbacks of their ordeal.

To deal with the many consequences of severe burns, a growing number of major hospitals have established burn centers, staffed by the medical equivalent of police swat teams, that accommodate every need of critically injured burn victims. America's busiest burn unit is at Manhattan's New York Hospital-Cornell Medical Center and consists of some 100 doctors, nurses, therapists, social workers and dieticians who treat 1,300 patients a year in the unit's 46-bed facility. "The name of the game in burns is teamwork," says Dr. Roger Yurt, the unit's director since 1995.

Yurt, 52, began specializing in burn treatment while he was a doctor in the U.S. Army. Since he took over the burn unit, he has expanded the team to include highly specialized nurses and even a chaplain, who ministers not only to patients and their families but also to staff members, who are exposed daily to unnerving sights and suffering.

A few team members are particularly motivated by the fact that they too were once burn victims. Others, like Dr. Harvey Himel, a plastic surgeon on the team, are attracted by a long-term association with the patients. "It's the real partnership with the the patients that I treasure," Himel says. "I always feel that I'm connecting with them." That connection can last for years. Himel follows his patients from their most desperate moments immediately after a burn, through skin grafts, follow-up visits and sometimes through reconstructive and cosmetic surgery.

The New York burn specialists and their patients are benefiting from some remarkable recent advances in operating-room techniques and a more sophisticated understanding of how the body reacts to severe burns. "Patients who 20 or 30 years ago would have died now survive the injury," says Lisa Staiano-Coico, dean of research at Cornell University Medical College and the team's wound-healing specialist. "Now the issue becomes one of how do we ameliorate the burn wound, how do we improve the rate of healing with less scarring. Now it's gone beyond survival."

As recently as the 1970s, a middle-aged patient with 40% of his body burned had a 1-in-2 chance of survival if his respiratory system had escaped damage. Today someone who has as much as 70% of his body burned can expect the same odds. And the average hospital stay for a severely burned patient is considerably less than the old rule of thumb, which was one day for every 1% of the body burned.

First-degree burns, which are the least dangerous because they involve only the outer, epidermal, layer of the skin, usually do not require hospitalization. Thin as a sheet of paper, the epidermis consists of about five layers of cells. The cells in the deepest layers constantly reproduce, pushing older layers to the surface, where they slough off after two weeks or so. Thus while first-degree burns appear red and swollen and are painful to the touch, they usually heal on their own.

Second- and third-degree burns, the kind treated by the New York team, call for much more care and, often, extended hospital stays. Penetrating below the epidermis, second-degree burns reach into the upper layer of the dermis, a thin layer of cells 1 to 3 mm thick that contains blood vessels, nerves, hair follicles and sweat glands. This upper portion can slowly regenerate and heal if damaged. But if the burn is third degree and destroys the dermis down to fat and muscle, skin grafts are needed for effective healing.

When the skin suffers a deep third-degree burn, two major regulatory systems go awry. The body loses its ability to control its temperature, causing burn patients to shiver even in temperatures as high as 75[degrees]F. Consequently, burn-unit rooms are often kept around 90[degrees]F, and a burn team's first priority is to warm the patients with heated fluids or heat shields suspended above the patient's bed.

Another major concern is the loss of fluid. When deep burns cover a large area of the body and the skin no longer provides an effective barrier against infection, the immune system goes into overdrive to ward off invading germs. It floods the injured areas with blood and plasma carrying immune cells, which cause extensive inflammation and swelling. In some cases the swelling is severe enough to interfere with breathing, and the patient must be put on a ventilator.

The massive immune response can also cause fluid to leak from blood vessels throughout the body. This leads not only to dehydration and deterioration of vital organs but also to a dangerous drop in blood pressure, which can result in shock. Indeed, many patients admitted to burn units are already in shock and unable to feel the pain that would be overwhelming if they were conscious.

Even when a patient is conscious, though, the burn team must focus first not on painkillers but on stabilizing the blood pressure. The New York team accomplishes this by pumping as much as 8 gal. of a salt fluid into his veins in the first 24 hours of treatment, a process that can cause the patient temporarily to gain as much as 60 lbs.

"There is clearly a period at least early on where patients are not getting any type of pain relief," explains director Yurt. "It's too risky. You don't want to give them too much morphine. Otherwise they'll drop their blood pressure." Once the blood pressure stabilizes, however, doctors can begin dripping morphine directly into the veins, gradually increasing the dosage if the pain persists. Still, Yurt admits, "we can never relieve the pain completely."

The need to balance these concerns when both time and care are critical was evident to TIME reporter Alice Park, who observed members of the New York Hospital-Cornell burn team as they attended a 26-year-old woman who had been terribly burned on her face and upper torso by acid thrown on her by her male companion's former girlfriend:

7:47 a.m. After the nurses gently unwind the temporary loose gauze twined around her head, neck and chest, the woman is anesthetized, a breathing tube is placed in her mouth, and her temperature and blood pressure are monitored. While surgeon Alain Polynice finds her blood pressure to be within normal bounds, he notes that her temperature is slightly lower than desired, calls engineering to ask that the room temperature be raised. Then he places a bubbled heat blanket between her legs.

8:10 a.m. The surgical assistant begins washing the woman's left leg with a soapy solution, sterilizing it so that swatches of it can later be peeled away to graft onto her chest and neck.

8:14 a.m. Himel snaps some pictures of the patient's chest and the right side of her face. He is especially concerned about the patient's nose and right ear. "It's likely that she will lose that ear and have to have another one constructed for her next spring," he says.

8:25 a.m. Using an instrument resembling a vegetable peeler, Himel begins peeling back the hardened, white, dead skin on the woman's burned chest. "I know I've reached healthy skin if there's bleeding," he says. After a few thin layers have been removed, blood begins to ooze. While Polynice mops it up, Himel continues to peel away at dead skin until he reaches the fat and muscle layer underneath.

8:43 a.m. "The skin has been so damaged by the acid that it's liquefied," says Himel. It begins to stick to the razor-sharp peeler, which he wipes repeatedly to keep it clean.

8:50 a.m. Himel has moved his attention from the woman's chest to her neck and discovers that the acid has burned all the way through the dermis on the right side. He carefully slices away the damaged tissue.

9:40 a.m. Having removed all the dead skin from the chest and neck, Himel holds the patient's left thigh taut while the surgical assistant uses an electric-powered device to peel away two foot-long strips of the epidermis and the upper part of the dermis from the woman's left leg.

9:50 a.m. As the surgical assistant uses a razor to make tiny pinpricks along the entire length of each skin strip, Himel explains, "Pinpricks will allow the fluids and blood to seep out and any bacterial growth to leave the wound bed."

9:53 a.m. Displaying jigsaw-puzzle finesse, Himel and Polynice arrange and rearrange the strips over the patient's neck and chest, trying for a placement that will leave as few visible seams as possible. Finally they decide on two strips laid lengthwise, beginning under her chin and ending at the base of her neck.

9:57 a.m. Polynice begins stapling the grafts to the adjoining healthy skin. In tricky areas, he resorts to tiny steel clips that he squeezes closed with surgical forceps.

10:10 a.m. Himel decides he wants to graft two separate pieces of skin onto the woman's chest so that they meet in a seam between the breasts. He is concerned that a single band of skin might contract when it heals. Needing more skin, he measures for it by placing a piece of gauze over the remaining uncovered area.

10:30 a.m. Using skin sections taken from the patient's inner thigh, Himel deftly sutures the pieces together on her chest.

10:35 a.m. The surgical assistant places wound dressings over the donor sites on the thigh, which should heal enough in two weeks to provide additional donor skin if needed.

10:50 a.m. Winding down the procedure, Himel injects a saline solution under the skin grafts to irrigate the wounds before nurses cover them with an antibiotic and a gauze dressing. He takes his final photos of the grafted areas, which are now neatly covered with skin lined by shiny staples.

10:52 a.m. Himel wants no head movement that could retard healing, so two physical therapists arrive, dip a large, heat-sensitive plastic sheet into a warm fluid to make it flexible, place it on the woman's chest and begin to cut and mold it to her chin.

11:07 a.m. The therapists wrap the woman's chest, first in gauze, then in an Ace bandage.

11:20 a.m. Removing the breathing tube, the anesthesiologist awakens the woman, who clenches her fists, moans and begins to shiver. The nurses cover her with a prewarmed blanket while Himel makes a note to the intensive-care staff, stressing that he does not want her blood pressure to exceed 130 systolic. If it did, she might bleed through her sutures.

11:27 a.m. More than 3 1/2 hours after entering the operating room, the woman is wheeled out to the intensive-care unit to begin what will likely be more than a year of recovery and additional surgery.

Because the patient's acid burns, while severe, were confined to her face, neck and chest, skin taken from elsewhere on her body could be used for grafts. "Most people still get their own skin grafts because it's what your body accepts most readily," says Himel. But for many patients with more widespread damage, the healthy skin that remains is insufficient to cover their wounds. For those patients, New York Hospital maintains a skin bank, which provides its burn team with a large store of frozen cadaver skin. Unlike the patient's own skin, cadaver skin is soon rejected by the immune system, which recognizes it as foreign. But it survives long enough to protect the wound from bacteria and viruses while stimulating the patient's own skin to grow.

The skin bank owes its success to hospitals throughout New York State that call the New York Hospital-Cornell burn team whenever they receive consent to release a newly deceased cadaver. Nancy Gallo, director of the bank, immediately dispatches a pair of assistants to the calling hospital and books an operating room, where the assistants take blood from the body for later tests for infectious diseases, then peel away skin from the back, chest and legs of the cadaver. Keeping the skin iced and in a sterile jar, they race it back to New York Hospital where, frozen in liquid nitrogen, it can keep for as long as five years. But before it can be judged suitable and released for grafting, two months of testing are required.

Still, skin banks are sometimes depleted, and the New York burn team, like other burn units, is turning more and more to substitutes for cadaver skin. Cornell's Staiano-Coico was part of the first research team to report success with grafts grown in culture from bits of cadaver skin, and describes them as "biological Band-Aids to provide growth factors to the wound to help increase the healing process." Other groups have used skin taken from raised blisters on unrelated, live donors and cultured into sheets in the laboratory. In both procedures, only the patient's cells remain in the healed wound after about two weeks.

Commercial skin substitutes for both the epidermis and dermis are also becoming widely available. One epidermal substitute is made of silicone, whereas the dermal varieties can consist of nylon or of collagen taken from cows, pigs or cadavers. Explains Staiano-Coico: "A lot of the dermal substitutes are like scaffolds, so the body can come in and use that matrix to rebuild its own dermis." Eventually, as healing takes place, the artificial structures are absorbed or surgically removed.

The New York burn team abounds with other specialists. Within a day after surgery, a physical therapist visits a burn patient to see whether the injury has affected the fingers, knees, ankles or other joints. If it has, the therapist begins guiding the patient through some simple daily exercises that involve working the joints to prevent natural shrinkage and the resulting loss of flexibility that can occur as the body heals.

Another team member, Joyce Scheimberg, is one of the few social workers to be found in any hospital trauma unit. Yet her presence makes good sense. Since house fires are the most common cause of burns in the U.S., many victims have lost their homes and most of their belongings. Other family members may also have been injured in the blaze. "Everyone who comes in here is an emergency situation," says Scheimberg, who acts as the liaison between the patient and his family, the hospital staff, insurance companies, lawyers, emergency community services and other pertinent agencies. In her role, Scheimberg is all too aware that the burn victim may not recover--or at least may not recover enough to return to the job. "You don't know what the future will bring," she says, "but we at the burn unit are all eternal optimists."

That optimism pervades the New York Hospital-Cornell Medical Center burn unit, and more often than not, it is justified by the sight of recovered burn patients ready once more to lead normal lives.

--Reported by Alice Park/New York

With reporting by Alice Park/New York