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Medicine: The Sickest Patients You’ll See’

8 minute read

> Charlie, 40, has had many close calls in his ten years as a helicopter pilot in the Alaskan bush, but his luck ran out when a sudden gust of wind caught his chopper near Juneau, causing it to crash in flames. Nearly three-quarters of his body surface was charred, and doctors at Seattle’s Harborview Hospital burn center had serious doubts that he would survive. Yet, after 30 long months of treatment, including ten operations just to reconstruct his burned hands, Charlie is back in Alaska piloting helicopters.

> Debbie, a pretty, blonde two-year-old from New Jersey, was playing with matches when her clothing suddenly caught fire. More than 90% of her body was burned, but doctors at Boston’s Shriners Institute, a special burn center for youngsters, refused to give up on her. She underwent eight major operations, received 270 pints (128 liters) of blood and spent a total of 114 days at the hospital. Debbie still bears the scars of the accident, but she is beginning nursery school and resuming a normal life.

> Bruce, 14, and his two friends were so eager to set up a CB antenna atop his home near Chicago that they failed to notice a nearby power line. When the antenna brushed against the high-voltage wire, Bruce’s two friends were electrocuted, and he was burned so severely that doctors at the burn unit of Chicago’s Cook County Hospital had to amputate his legs and an arm. But their treatment saved Bruce’s life, and now, fitted with prosthetic devices, he is taking golf lessons.

More than 2 million Americans are burned seriously enough each year to need medical attention; some 70,000 require hospitalization, some 10,000 die. Yet in spite of the increasing incidence of fires and other accidents, the number of deaths from burns has remained surprisingly constant. More heartening, even victims of the most severe burns, like Charlie, Debbie and Bruce, not only survive but are being rehabilitated enough to resume normal lives.

Dr. P. William Curreri, director of the new 24-bed burn facility at New York Hospital-Cornell Medical Center, points out that only a generation ago the chances of survival were minuscule for anyone with burns over as much as a third of his body. Says he: “Today, 30% is considered a readily treatable burn in skilled hands. Even if a young, healthy person has burns over three-quarters of the body, his chances of survival are about 50%.” A major reason for this remarkable improvement is the emergence of a whole new branch of medicine. A few years ago, only a handful of the nation’s 6,000 hospitals had the special staff and facilities for treating critically burned patients. The number of burn units has now risen to 174. About a dozen with research labs qualify as major burn centers.

Few injuries are more traumatic or difficult to tend. When a victim surfers a major burn—one in which at least 20% of the skin is lost—damage may extend far beyond the burn site. Vital fluids ooze out, upsetting blood chemistry and metabolism. Temperature often rises as the body desperately tries to fight infection. Functioning of the kidneys, heart and other vital organs may be seriously impaired—even halted entirely. If much smoke has been inhaled, the lungs may be so seriously damaged that they are no longer able to take in enough oxygen, and the patient must be put on a respirator. Often, especially in electrical burns, nerves and muscles are damaged along with the skin. If that happens, a limb may have to be amputated to prevent gangrenous infection. Says Curreri: “These are among the sickest patients you’ll ever see in your life.”

Preventing Shock. The first few hours are critical. If the patient has lost too much body fluid and protein, doctors must quickly administer large amounts of intravenous (IV) fluids and blood plasma to prevent shock. This treatment was pioneered by the Brooke Army Medical Center in San Antonio, Texas, which has cared for thousands of badly burned GIs and civilians. A patient weighing 68 kilograms (150 lbs.) who has lost 70% of his skin may need 19 liters (20 quarts) of IV fluid on his very first day.

Soon thereafter, patients are placed in superclean tubs of warm water at roughly body temperature, 38° Celsius (100° F.). The baths not only help doctors assess the injuries, but also wash off dead skin, a potential breeding ground for bacteria. To ensure complete skin removal, careful scraping by a surgeon’s scalpel may later be required. Some centers are experimenting with carbon-dioxide lasers to cut through the dead tissue and seal off severed capillaries, thereby halting bleeding.

Infection is the gravest risk for burn victims. But standard antibiotics usually do little good; the capillaries that might carry them to the burn site have been destroyed. Thus, doctors have developed new creams containing silver sulfadiazine and other sulfa compounds that are applied directly to the wound. These have sharply reduced infection from pseudomonas bacteria, which once killed nearly a third of all burn victims.

Still, the wounds must be bathed at least once a day and constantly tended, which makes it critically important for burn units to maintain aseptic conditions. Visitors must don gowns and face masks. A large share of the building cost of New York Hospital’s new center went into a ventilating system that maintains a higher air pressure inside the facility, thereby preventing all but germ-free filtered air from seeping in.

In the most serious, third-degree burns, involving loss of all the layers, skin will not regenerate. To prevent loss of body heat and fluids until the patient is ready for grafts, the wound needs temporary biological dressings; overhead heat shields are also used. Doctors apply either pigskin (which closely resembles human skin) or skin from cadavers. Artificial skins have not yet proved successful, and doctors are only beginning to take matching skin from siblings and parents. But M.I.T.’s Ioannis V. Yannas, together with Shriners’ Dr. John F. Burke, may soon try a promising material made of polysaccharides and the connective protein collagen on patients.

Still, the best covering for a burn is the patient’s own skin. Taken from uninjured areas, in sheets as thin as 0.025 centimeters (0.010 inches), it is sometimes perforated and stretched, and then applied as a mesh over the burn. It thus can cover an area three to six times as large as that from which it was taken and acts as a scaffolding for growth of new skin.

Healing is slow and agonizing. Patients are barely able to eat; yet their high metabolism rate means they must consume as many as 6,000 calories a day. Lest the limbs become stiff, exercises must be started almost immediately, despite the fact that any movement can be extremely painful. Though hospital stays have been shortened, many burn victims remain from 30 to 60 days and some are kept a year or more, not only because they are undergoing extensive skin grafts but because portions of the body may have to be entirely reconstructed. In fact, says Brooke’s Colonel Basil A. Pruitt, the army’s top burn expert, the plastic surgery in some cases is sheer artistry.

God’s Angels. Because burn patients require constant attention, the centers must have large staffs. Nurses must be at bedside 24 hours a day, and at least one physician must always be near by, to say nothing of a host of aides, ranging from cleaners to technicians who prepare the IV fluids. In some hospitals, because of the horrible nature of the injuries, few staff members remain in burn units for more than six months at a time. Those who stay on win the admiration of their colleagues. Says Spokesman Kenneth Dale of the Crozer-Chester Medical Center, a major burn facility near Philadelphia: “Our nurses have been called God’s angels on earth.”

Though prompt application of new flexible splints and pressure bandages lessens scars and skin contractures, burn victims are often left with disfiguring features that even the best plastic surgeons cannot eliminate. Says In-Service Education Director Carol Fulton of Boston Shriners: “They don’t go home like Cinderella and live happily ever after.” To prepare patients for re-entry into the outside world, many burn centers have added psychiatrists, psychologists and other therapists to their staffs.

Expensive equipment and large staff-to-patient ratios (10 or 15 to 1) make burn care extremely expensive. Daily costs run from $350 to $750. Also, occupancy rates in burn units may be low for long stretches. For these reasons, some officials would like burn treatment kept part of the regular acute-care facilities of hospitals. Burn specialists disagree. They argue that burn centers not only provide patients with a level of treatment unavailable anywhere else but also make economic sense. Insists Dr. John Converse, head of reconstructive plastic surgery at N.Y.U. Medical Center: “Good burn centers eventually save money.” Why? Because, he says, “you may have a functioning, working taxpayer instead of a cripple.”

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