A conversation with the author
How did you get the idea to write this book?
It was sparked by a news bulletin I heard on my kitchen radio while preparing dinner one night over a decade ago: another building fire and another firefighter trapped in the blaze and rushed to the nearest burn unit. I had heard such stories so many times, but for some reason, that time it snagged my attention and left me wondering: What is a burn unit? What goes on there? What do they do for a person injured in a fire? What kinds of burns and what kind of care make the difference between life and death?
As it happens, finding out the answers to those questions, and to many more questions that arose in my pursuit, began with someone I'd known for years, but never knew had anything to do with burns. It turned out he played a part in what is regarded as the watershed moment in modern burn care, the Cocoanut Grove fire in 1942.
Dr. Stanley Levenson was my father's roommate in medical school, so when I told my father I was curious about burns, he suggested I talk to Stanley. To my surprise, I learned that more than fifty years earlier he had been recruited to work on a government sponsored research project, part of a grant awarded to Harvard Medical School researchers after Pearl Harbor, to learn as much as possible about how to treat burns. The nation was in a war that was expected to result in many battlefield injuries involving burns and the government knew no one knew enough about burn treatment to deal with the looming crisis.
Stanley had been on the job for only five days when the Cocoanut Grove nightclub went up in flames, and scores of severely burned victims started arriving at the emergency room at Boston City Hospital, where he worked, and Mass General, which was also part of the burns research project.
Even though he was nearing ninety when he spoke to me, he remembered that night and the months that followed like it was yesterday, and he was able to tell me in vivid detail about treating the Cocoanut Grove patients and what was learned in the course of it. I was incredibly lucky to have him as the source of first-hand, eyewitness information about the fire: how it felt, what it smelled like that first night when badly burned bodies—some living, some dead—were brought to the hospital, and how intensely he and his colleagues worked over the months that followed.
The November 28, 1942, fire at the Cocoanut Grove, a swanky night club in Boston, eventually killed 492 people and injured hundreds of others. By luck and by chance, most of the fire victims were brought to two Boston hospitals that were engaged in that government-sponsored burn research project following the surprise attack on Pearl Harbor just one year before. Not only did the expertise of the doctor/researchers mean that many lives were saved, but the challenges they faced and the approaches they developed set the agenda for burn research for the next half century. Many of the most important treatment and prevention strategies that save lives today grew out of that fire.
In a nutshell: the Cocoanut Grove fire marked the beginning of the downward trend in both burn incidence (due to better public education and prevention) and mortality. Before World War II, a burn covering no more than half the total body surface area was fatal in half of all cases. Today, 95 percent of all burn patients can be saved, including some with burns over as much as 95 percent of their body.
The history of burn treatment is almost as old as burns themselves. The earliest known writings on the subject can be found in the Ebers Papyrus (1534 B.C.E.), which prescribes a combination of concoction and incantation to heal wounds inflicted by fire. It outlines a five-day regimen that begins with black mud, progresses through a yeasty dough made with calf dung, a porridge of barley and acacia resin, a paste of boiled beans and beeswax, and ends up with an ointment containing red ochre and copper. Another treatment features a poultice of ram's hair moistened with the milk of a woman who has recently given birth to a male child. The dressing is to be applied while the healer chants, "Water is in my mouth, a Nile is between my thighs, I have come to extinguish the fire."
Ancient Chinese, Greek, and Roman pharmaceutical texts dropped the magic spells but retained the use of animal, vegetable, and mineral substances, which they claimed promoted rapid healing and minimized scars. These recipes were kept alive in both the Middle East and Europe throughout the Byzantine and Medieval periods by the writings of the seventh-century Greek physician Paul of Aegina and the Aqrabadhin, or Medical Formulary, of Abu Yusuf Ya'qub ibn Ishaq al-Kindi, the ninth-century polymath from Baghdad. Like those the Egyptians used, most of the treatments were outlandish—bear fat rendered in red wine and rubbed on the skin with roasted angleworms, ashes of dormice, bull bile, rabbit and pigeon droppings, and scores of other ingredients from the catalogue of what has been termed "excremental alchemy." Some make a sort of crazy sense: clays, waxes, and fatty salves are soothing and protective; rubbing burns with lentil meal and honey undoubtedly hurt like hell, but it would remove dead skin, making the wound more likely to heal than if left to fester beneath burned flesh. Some prefigure treatments used well into the twentieth century, such as the astringent tannin-rich tinctures made from extracts of tea, walnut, and oak leaves. As for the cutting edge, the active ingredient in some of the most effective antimicrobial agents in use today is silver, the antiseptic properties of which were first recognized in ancient Persia and its powers in wound healing mentioned in texts attributed to a fifteenth-century monk and alchemist named Basilius Valentinus.
Most of the advances in the understanding of burns and burn treatment coincide with times of war. Long before Pearl Harbor, the battlefield was the crucible out of which burn treatments emerged. Ambroise Paré, the sixteenth-century French barber-surgeon who is considered the father of modern surgery, was among the first to accurately describe burn depths and understand their significance, as well as to observe the systemic changes that result from burns. As an army surgeon in the service of the French king Francis I, Paré had ample opportunity to study battlefield wounds, including the very common but devastating gunpowder burns, during the Siege of Turin in 1536. His observations are stunningly consistent with what we now know. It is in this account that Paré wrote the oft-quoted "I dressed him, and God healed him."
The techniques of skin grafting were refined by surgeons repairing and replacing noses lost in battle or duels. The instrument that has made "harvesting" of skin grafts a routine procedure was developed by an army surgeon treating the survivors of the Bataan death march in World War II, and one of the most effective antibacterial ointments was developed from a recipe taken as war booty from Nazi medical research files. And of course, the victims of the Cocoanut Grove fire benefited from two government-sponsored research projects that had been set up in the immediate aftermath of Pearl Harbor. Yet, shortly after the attacks of September 11, 2001, the renowned burn research institute at Brooke Army Medical Center at Fort Sam Houston, Texas, was shut down. It is difficult to understand the shortsightedness involved in that decision, but we shall surely come to regret it.
No. I found it as fascinating as the history, if not more so. From the start, I was driven by my curiosity about what happens to people who are severely burned. Most people understand basic things about other serious and deadly medical conditions: infectious diseases, cancer, heart attacks, strokes. But I had no idea what actually happens to people who are burned, and I figured not many other people did either. What do people die of when they die of burns? What can be done to save them from dying?
The answer is intriguing: Heat inflicts a wound with far-reaching effects, some of them paradoxical, others bizarre, many of them not yet fully understood by those who study and treat burns. For example:
People who suffer thermal injury are at high risk for hypothermia —abnormally low body temperature. The deeper the burn, the less painful it is. Early on, burns excite the immune cells and bring about a violent inflammatory response; over time, an exhausted immune system leaves burn victims prey to deadly infections from within and without. People who are in fires often die without any outward sign of having been burned; instead, they suffer respiratory collapse as their airways narrow and close. People who are burned may literally drown as a tidal wave of fluid surges from within blood vessels to flood their lungs. Their hearts may stop, their kidneys shut down, their gastrointestinal tracts become paralyzed. They may swell grotesquely; they may become emaciated. And they may starve to death as the wound causes the metabolism to accelerate wildly, turning the body into a raging machine bent on consuming itself. In the course of my research, I found out that although burns start with a traumatic injury, they are actually an extremely complex progressive systemic disease. They set off a cascade of events as the entire body reacts to the violent assault. Because every system in the body is affected, treating a severely burned person requires a broad range of interventions drawing on the expertise of many medical specialties: from surgery to cardiology, pulmonology, infectious disease, ophthalmology, psychiatry, pharmacology, oooo anesthesiology, plastic and reconstructive surgery, and more, as well as intensive nursing care. Recovery requires participation of psychosocial services, rehabilitation therapy, speech pathology, nutritional support, as well as ongoing care and support on many other physical and psychological fronts.
I conducted on-the-scene research at the Sumner Redstone Burn Center at Massachusetts General Hospital over the course of about a year, spending days at a time, and sometimes nights, in the ICU and the OR, talking with the nurses, doctors, rehabilitation therapists, administrators, residents, aides, and watching them at their work. I wore scrubs and stood by the bedside as nurses did dressing changes, as residents changed intravenous lines and did bronchoscopies (using a fiberoptic instrument to examine the patient's respiratory tract), as respiratory therapists monitored their breathing, as physical therapists worked to restore their mobility.
I feel very fortunate that everyone was willing to take the time to explain and answer questions and keep up a running narrative while they worked. I guess the truth is, people love to talk about their work. More than one of the burn-care professionals I met told me that no one—not their families, not their friends—wants to know about what they do all day, so they were thrilled that someone was interested.
I spent hours in the tropical heat of the burn OR, standing just outside the sterile field, peering over the surgeons' shoulders and watching them do burn surgery, skin harvesting and grafting, as well as an amputation, installation of a gastric feeding tube, and other surgical procedures that are not specific to burns but that burn patients often need.
The burn OR is a hot, humid, and bloody place, but despite the seriousness of what goes on there, the party atmosphere is lively, even raucous. Somehow, expert and intricate surgery can and is performed to the tune of dance music issuing from a boombox and nonstop banter and scalpel-sharp repartee.
Don't ask me why, but I had no trouble watching the blood and gore, the flayed flesh and oozing wounds and the viscera displayed on a screen above the operating table as the endoscope journeyed down into the patient's stomach and beyond. To the squeamish, it would have been unwatchable, but to me it was fascinating. Much of it evoked food analogies: the tools used for skin grafting look like giant cheese cutters and pasta machines; the electrocautery wand that zapped bleeding capillaries filled the air with the aroma of grilled hamburger; the surgeon and one of his residents shaped the bloody stump after an amputation as though they were tying a rolled roast. Sometimes it seemed like a video game: the resident wielding the endoscope and driving it down the long red-walled tunnel of the gastrointestinal tract was like a kid working a joystick while watching a video screen, steering his craft down a narrow passage like Luke Skywalker navigating the entrance to the Death Star at the end of the first Star Wars movie.
Mass General is considered one of the finest specialized burn treatment centers in the country, but there are nearly 150 of them and all give great care. I had to choose one to focus on, but my book is called Burn Unit for a reason: this particular one stands for all the others; each nurse and doctor and respiratory and occupational therapist stands for the many others working there and at burn centers throughout the country. I chose Mass General because of its historical significance as the place where modern burn treatment began, where the Cocoanut Grove patients were treated; but also because of the extraordinary access they gave me. I was able to see things that I could not have seen at other burn units because of the unique way the burn unit is set up.
As the nurse manager of another burn unit told me, it is a busy busy place—all burn units are. No one is sitting around waiting for patients to ring for the nurse. Like most burn units, Bigelow 13, which is the informal name of the burn unit at Mass General, has an acute care, or ICU, where patients are on respirators, get heavy duty monitoring, and one-on-one care around the clock. There is also a stepdown area—what they call "floor patients"—for patients who were either less severely burned to begin with or those who have graduated from intensive care and are on the way to recovery. But everyone is very sick, and most patients are in for a very long stay—weeks at least, but sometimes months.
In just about every burn unit in the country, patients whose wounds are still open— which means they are extremely vulnerable to life-threatening infections—are kept in strict isolation, in single rooms that no one enters unless fully gowned, gloved, masked, covered in sterile garments from head to toe. But here's where the uniqueness of the Mass General burn unit comes in and the lucky break I got that made it possible for me to do this book:
At Mass General, the ICU is a large room with four acute care beds, each of which is inside a clear plastic tent called a bacteria controlled nursing unit, or BCNU. They were specially designed by John F. Burke, MD, the founder of the burn unit, to protect patients from bacterial exposure. The plastic barrier prevents bacteria and other microbes from traveling to and from other people; the flow of air within the tent carries any microscopic organism downward and out through special filters. The climate inside the tents is also controlled to benefit the burn patient: it is very hot and very humid—it feels like a tropical rain forest—which is what someone who has lost skin and may have respiratory damage needs.
But the great thing, for me, was that I was able to stand outside the tents, next to the nurses and other caregivers, see them work, see the patients, see the burns and the way they were cared for, talk to members of the burn team, ask them what they were doing. I was given fly on the wall status that I would not have gotten anywhere else.
When will we ever learn? When The Station, a down-at-the-heels music club in the former mill town of West Warwick, Rhode Island, erupted in flames on the night of February 20, 2003, it was like a B-movie version of the Cocoanut Grove fire. An overcrowded night spot and alleged criminal negligence on the part of the management were once again a combustible and deadly combination. As at the Cocoanut Grove, many died at the scene. The eighty-one who escaped death but were badly burned were distributed among eleven hospitals in Rhode Island and Massachusetts in accordance with state and regional disaster plans instituted in response to the terrorist attacks of September 11, 2001. Nineteen victims were sent to Boston, which has three specialized burn units: at Massachusetts General and Brigham and Women's hospitals, and the Shriners Burns Hospital, which treats children only, but in this emergency situation took four adults. Thirteen came through the emergency department of Mass General just hours after the fire, two more were transferred later. A little over a week after the fire, two of the hospitalized victims died, and a week later a third death was reported, bringing the toll to ninety-nine. Ten weeks after the fire, the hundredth victim died. All had been in critical condition at Mass General, which took the most severely burned patients. The doctors, nurses, and other members of the burn team—many of them the people readers will meet in Burn Unit: Saving Lives After the Flames—fought valiantly to save these lives, but big burns compounded by seared lungs, virulent infection, and organ failure won out in the end. Those who survived faced months of hospitalization, with numerous surgeries, intensive nursing, and arduous courses of rehabilitation. Those who were able to return home will be scarred both physically and emotionally, their lives saved but forever altered.
Classification of burns is really a combination of the degree—first, second, third are the familiar terms—and size—what burn professionals call percentage TBSA, which stands for total body surface area. The worst burns are both big and deep.
A first degree burn—a sunburn is the most common example—affects only the thin outermost layer of the skin, the epidermis. It hurts a lot, but it is not life threatening and does not require hospital care. Burns start getting serious when they are second degree, going through the epidermis and into the dermis. Third degree burns penetrate the entire dermis and extend into the fat layer beneath. But burns can go all the way through the muscle layer and even into the bones.
Whether it is second or third degree, anything bigger than 10 percent TBSA is considered a severe burn that should be treated in a specialized burn center. Even smaller burns need specialized care if they are on the hands or feet, the face, or the genitals, if they extend across a joint or wrap completely around a body part, if there is even a suspicion that smoke has been inhaled, and especially if the victim is a child, over 60, or has another illness or injury.
There is a saying in the burn-treatment world that "Normal people don't get burned," and it is only partially gallows humor. Statistically, the people who fill the nation's burn units are our poorest and least visible citizens: the homeless, the mentally ill, the would-be suicides, the addicted, the aged, and the abused.
A chapter in my book is called "The Very Young, the Very Old, the Drunk, and the Stupid." That's what a burn doctor told me was the group that is typically burned. It sounds really harsh, but as another doctor said: "All of us can be stupid sometimes, and that's when we get burned."
Agewise, the peak ages for getting burned are 5 to 20 and 30 to 40. In terms of gender, men are burned at more than twice the rate of women. Lots of children get burned, and burns are particularly threatening to them. Tragically, many are the result of abuse.
Old people get burned because they are less mobile and less alert, less able to escape. And when they get burned, it is more serious because they have other health problems that exacerbate their burn injuries.
And of course a lot of battlefield injuries involve burns. We have seen that in every war in history and are seeing that again in Iraq and Afghanistan.
But the truth is, every burn victim is an individual, a life to be saved or mourned. Burn patients are not statistics; they are people. They are not them; they are us.
In Burn Unit: Saving Lives After the Flames, I consider the case of Tom Parent, the archetypal "normal guy"—solid citizen, homeowner, weekend sailor, loving husband and father. On Memorial Day weekend the Parent family was at their vacation home on Cape Cod. Tom had just come in from working on his boat; his wife Nancy was preparing dinner. A pot full of cooking oil on the stove burst into flames, starting a chain reaction that landed Tom in the Mass General burn unit and changed his family's life forever. What happened that Saturday afternoon was a simple, though horrible, accident, the kind that could befall any one of us. It resulted from a series of miscalculations that added up to disaster.
Tom spent two weeks in the hospital, and two years as an outpatient, enduring the physical and emotional rigors of healing. But what happened to Tom happened to Nancy as well. She has not been able to let go of the conviction that it was all her fault; she is scarred by guilt every bit as immutably as Tom is scarred by his burns. Although she insists they identify themselves as burn survivors rather than burn victims, she also acknowledges that "a burn is forever" and nothing afterwards is ever the same.
What really revolutionized burn treatment was the realization that the problem was not the surface, but the wound itself, which was causing a progressive systemic disease. I call it "a riot in the body," a deranged state that involves everything from the immune system to the metabolism and that can threaten organ systems and parts of the body far removed from the area that was burned. In the 1960s, doctors started to figure out that the thing to do, as Dr. John Burke told me, is to "cut off the dead"—surgically remove the entire burn, all the dead skin, anything that could not be expected to heal on its own within three weeks. Sometimes it is tricky to know in advance which those are, but in general it is wounds that are big and wounds that are deep.
So now doctors remove burns surgically and cover them with skin grafts. That strategy alone has saved lives that would have been lost fifty, even thirty years ago.
But the best graft—really the only one that can permanently close a wound—comes from the patient's own body. Anything else—skin from another person or an animal or some manufactured material—will be rejected sooner or later. The lucky thing is that people with severe burns have suppressed immune systems; that's what makes them so vulnerable to infection, but also allows some time before the immune system recognizes the foreigner and rejects it.
The problem is that with a big burn, there may not be enough healthy skin available to replace all the skin destroyed by fire. Burn wounds are grafted in stages, with time between for new skin to grow where it was harvested. That is where artificial skin comes in. But it's far from perfect. It doesn't replace the patient's own skin; it merely acts as a placeholder until enough skin grows back for reharvest.
I am pretty cynical about the so-called artificial skins, a cynicism I share with a lot of burn surgeons. The "Wow" factor is huge, but the truth is that science is still a long way from giving nature a run for the money. A lot of heavy breathing accompanies the introduction of every a new product that its manufacturer claims will be a viable substitute for human skin. The excitement, thus far, has not been justified by the result. Some "artificial skins" are useful in a narrow sense—as temporary place-holders until the body regrows its own. Others are based on interesting science but impractical for actual use. A few suggest a promising new approach while others may, with refinements, someday fill the need. Those are a lot of maybes and not yets. The fact is, tissue science is still far from finding the holy grail: a ready and abundant supply of new skin to replace what has been destroyed by heat and flame.
A message of hope: about science, about medicine, and about the human spirit.
Each of us is just a spark away from being a burn victim, but most of us know nothing about the world burn patients inhabit and what burn care professionals do to save their lives. Burn Unit: Saving Lives After the Flames is part mystery, part adventure yarn, and part love story. It is about the right people being in the right place at the right time, about a team of passionate and selfless healers for whom nothing is more important than saving lives, about patients whose courage is matched only by the devotion of their families, and in the end, about modern medicine at its very best.