Burn victims' recovery a delicate balancing act

Dr. Fred Mullins had a newly unboxed cell phone on his desk last week, but he wasn't using it yet.

"They gave me a phone but didn't give me a phone number," he said with a laugh.

The medical director of the Joseph M. Still Burn Center at Doctors Hospital will be wearing out that phone in the coming weeks and months. The phone will be dedicated strictly to the families of 14 patients from the Feb. 7 Imperial Sugar Co. refinery explosion who will be recovering at the center. Twelve are still listed as being in critical condition; two are listed as serious.

They face a daunting journey that goes beyond taking off the dead skin, applying a temporary covering and regrafting new skin. Large third-degree burns throw off every system in the body, affecting every organ, and doctors must work a delicate balancing act that is sometimes more art than science, said Richard Cartie, a pediatric intensivist who works at the burn center.

"Burns are the ultimate trauma," Mullins said.

"It just wreaks havoc on the body. It confuses the body, so sometimes it doesn't know which way to go."

Because of the nature of the explosion, some of the refinery patients had broken bones as well, he said.

"We found out that a lot of them were in two explosions, basically," Mullins said. "I saw one guy, when the second explosion occurred, it threw him up where he hit the ceiling and came down. Another guy said he was thrown through a wall."

In addition to getting a good airway and circulation going in the patient, the doctors have to take those other injuries into account, he said.

Fluids are an example of the contradiction severely burned patients can present. A large burn removes the protective barrier of the skin and causes immediate swelling, "sort of like a bruise," Mullins said.

That inflammation is part of the body's attempt to heal itself, but it can cause problems of its own by collapsing veins in the extremities.

"When that closes, it backs blood up, so the arteries can't pump anymore," Mullins said. "It causes it to clot and it can kill you."

Vicious circle

The burn also causes pores to open in the vessels and proteins to leak out, taking fluid with them.

"They go out, and take the fluid, so you have to give them more fluid," Mullins said. "In turn, that makes the fluids go out more. It's just a vicious cycle."

That also adds to the swelling problem severe burn patients face.

When Mullins went down to Savannah on the night of the fire, he ended up cutting slits on the sides of patients' burned chests and arms just so they could breathe easier and to restore blood flow.

The fluid leaking out of the vessels also drops the blood pressure, and if not enough blood and oxygen reach the kidneys, they will shut down, he said.

Large burns also cause the body's metabolism to increase two to three times its normal rate, Cartie said.

"It's just like turning the thermostat up," he said. But without the skin to trap the heat, the body uses up huge stores of energy, like a furnace in a house with all of the doors and windows open, Cartie said.

Once it has used up the easily available energy, the body begins to feed on itself, on its lean muscle mass, a process called catabolism, he said.

"The body very quickly, in a situation like that, switches over to using its own proteins to supply energy," he said.

A real struggle

The staff has to battle this by supplying more protein and more nutritional supplements and vitamins, but it is a struggle for some patients to get enough to keep up, Cartie said.

"And the proteins can be bad for the kidneys," Mullins said.

The biggest limiting factors for getting the skin off and getting new skin on are temperature and blood loss.

The operating rooms at the burn centers are kept at 80 to 100 degrees during surgery to try to combat that, Mullins said.

"We're all used to it," he said.

There also is a need for speed at the beginning.

"It's been proven that the quicker you remove the dead tissue, the better off they will be," Mullins said.

All of the patients had their dead tissue removed by Sunday evening. Biopsies of healthy skin from each patient already had been mailed off by then to Epicel in Cambridge, Mass., where they will be used to grow cultured skin.

In the meantime, the patients got either cadaver skin or pig skin as a temporary covering.

"Cadaver skin is a little better" because some of it will incorporate into the wound bed, Mullins said, "but when you're battling temperature and it starts dropping, then you need the skin as quick as you can."

Pig skin is a little easier to apply, and it will eventually slough off.

Battle against infection

Bacterial infection becomes a concern within a few days, and the staff uses gowns and masks in the room and changes the bandages twice a day, Mullins said. The burn center uses antimicrobial dressing, some impregnated with silver, to try to stave off infection, he said.

If they are on mechanical ventilation, they are kept in a medically induced coma, which also helps with pain control.

The new skin grafts will probably be applied in about two weeks, using either the Epicel skin or grafts taken from healthy sites on the patient's body.

Using a process called meshing, making tiny slits in the graft, the skin can be stretched out two to six times its normal size, Mullins said.

"They may need two, possibly three procedures if they are huge burns to get everything wrapped," he said.

The patients are bundled up in bandages for about 10 days after each procedure, although the surgeons try to go as fast as they can, Mullins said. Each operation is a setback, and the staff works hard to build the patient back up, Cartie said.

"We try to get them to the point where they can tolerate the next step," he said. "There's the science of this and then there's the art. There's a lot of art in this."

Extended process

After the last permanent skin goes on, the earliest the patients might be considered for discharge is 10 to 14 days, Mullins said. But those patients "are usually so weak that they end up going to an inpatient rehab center," he said.

Months of physical and occupational therapy can follow, and many of the patients will have spent three to six months at the center before they leave.

Justin Scurry, 21, spent 108 days at the center last year after he was burned over 25 percent of his body in a traffic accident. He doesn't remember the coma but does remember the shock of hydrotherapy.

He was burned on his face and legs and lost his right hand and part of his right leg. He went from 168 pounds to less than 130 but has built himself back up by working out three days a week.

The day after he left the center, "I was out on the river in a boat," he said. He also went hunting last year.

"I climbed a couple of deer stands, which the doctors weren't happy about," he said from his home in Cayce, S.C. "I do everything I used to do. I'm just a little bit slower."

Scurry said it is important to leave the accident and the fire behind.

"Put it in the back of your mind," he said. "It's all up to them. You'll find out you can still do things."

In fact, Mullins is optimistic for the refinery workers.

"I expect the majority to go back to work," he said. "It may not be the same thing they were doing, but it may be something similar. It just depends on them. With determination, you can do anything."