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Trial by fire
Orleans writer explores the history of burn treatment and explains why there's reason for hope


ORLEANS - As a scourge of mankind, fire has no equal. So says Orleans author Barbara Ravage in her new book "Burn Unit: Saving Lives After the Flames."

Author Barbara Ravage has turned a longtime interest in medicine and burn care into a readable look at how that care has changed over the past half-century.
(Staff photo by VINCENT DEWITT)

"Medical science may have conquered polio, may be on the way to eradicating malaria, and may in the near or distant future have the tools to stop cancer from taking human life," she writes in the introduction, "but fire and the injury it brings will always be with us."

The book, which tells the story of the evolution of burn treatment through a window into the intensive care burn unit at Massachusetts General Hospital in Boston, hit area bookstores Saturday.

An accomplished medical writer and editor, Ravage had incredible access to the unit over an 18-month period beginning in 2002. She tells the story of burn treatment by following the path of Mass. General surgeon Dr. John Schulz and two of his patients, Dan O'Shea (a pseudonym) of Boston, and Eastham summer resident Tom Parent.

O'Shea suffered severe and extensive burns when his apartment went up in flames, probably from a smoldering cigarette.

Parent was burned when the flames from an ignited cooking pot traveled up his hands and arms and flashed in his face as he tried to carry it outside.

Ravage's narrowing lens, from the history of burn care, to how it is rendered at Mass. General, to how it was handled in two individual cases, allows for a logical and easy-to-understand treatise on burns and how they are treated.

While the picture is not necessarily pretty, it is absolutely fascinating.

It is also all too common.

The statistics are chilling. More than one million Americans are burned every year. More than half are children. An estimated 45,000 are burned badly enough to require hospitalization and 4,500 die from their injuries.

More facts about burns

Burn injuries are second to motor vehicles as the cause of accidental death in the United States.

Burns are one of the most expensive injuries to treat. For example, a burn of 30 percent of total body area can cost up to $200,000 in initial hospitalization costs.

In the 1950s fewer than 10 hospitals in the United States specialized in burn care. Now, there are more than 200 special burn care centers across the U.S.

Source: Burn Survivor Resource Center, www.burnsurvivor.com

"They're way up there as part of the horrible killers," she said. "If there's a house fire, very often there are multiple members of a family affected or children are orphaned."

Burn injuries are "particularly cruel," she adds, "because of the often disfiguring scars."

"Sometimes they are so disabling that, in a way, you never get over it."

Those who are very old or very young are at highest risk of death from burns because they are less able to escape and their skin is thinner and organs smaller.

A shocking number of children are burned as a result of child abuse, Ravage found in her research.

Difficult but fascinating topic
While the work on her book spanned two catastrophes involving fire - the Sept. 11, 2001 terrorist attacks and the Feb. 20, 2003 Station nightclub fire in Rhode Island, neither was the impetus for writing it, she said.

Instead, "Burn Unit" was an outgrowth of a medical writer's intense curiosity, and the memory of ambulance sirens traveling to the Cornell Burn Center near her former home in New York City.

The discovery that her father's medical school roommate, Dr. Stanley Levenson, had gone on to become an important figure in the field of burn treatment, was also a turning point in her decision to write the book, especially since he had been involved in the care of victims of what she says was the pivotal moment in burn treatment protocol - the Coconut Grove fire.

The Nov. 28, 1942 fire in the Boston nightclub killed 492 people and injured hundreds of others. Up until that time, there was no standard method for treating burns. Most hospitals had developed their own method and were routinely using treatments almost 400 years old.

But the Coconut Grove fire, one of the worst civilian fire disasters in the nation's history, "marked a watershed in the medical understanding and treatment of burns," said Ravage.

Most victims were taken to two Boston hospitals, Boston City and Mass. General. The medical teams at both facilities tried different methods of treatment, both in the immediate hours after the fire and in the long-term recovery phase.

The methods the medical world learned at that crucial time, are still largely in use today, she said.

"More has been learned about burns in the past 60 years and more lives have been saved as a result, than in all the millennia since the big bang," Ravage writes in the book. "The key lies in the understanding that a burn is an evolving wound; the initial injury is only the beginning of an ongoing disease process that must be stopped or it will end in death."

Mass. General doctor, Dr. Oliver Cope, is credited with recognizing for the first time that the seepage of bodily fluid through the skin on burn victims "was a minor matter compared to the shift of fluid from the circulation to the tissues surrounding the burn and, mysteriously, in areas far distant from the wound," she said.

He also learned that burns present a series of paradoxes for medical providers. Among them are that people who suffer thermal injuries are at high risk of hypothermia; that the deeper the burn the less painful the burn; and that people who are victims of fire often die without an outward sign of having been burned.

"People who are burned may literally drown as a tidal wave of fluid surges from the 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," Ravage says in the book.

It was only after the Coconut Grove fire, when doctors began looking beneath the skin "at the tempest raging within" that more lives began to be saved, she said.

Tough treatments
Ravage said she was given unprecedented access to the intensive care burn unit at Mass. General for her research.

"At Mass. General, I could stand right at the bedside because the beds are covered by plastic covering (to prevent infection). Any other places, I could not have seen the things I saw," she said. Most burn units do not have the individual tents around the beds, and even resident doctors doing rounds often stand at the door of the unit and get updates from nurses, she said.

"If you were asked to invent the perfect growth medium for bacteria," she writes in chapter nine, "you would be hard-pressed to come up with something better than a burn wound."

"A burn wound is essentially a puddle of protein and dead cells, a stagnant backwater devoid of immune defenses and bypassed by the river of oxygenated blood that is supposed to cleanse the area and carry away the debris. Simply put, it is a microbe's paradise.'

Ravage's access extended into the operating room with Dr. Schulz during his weekly surgical sessions when he was removing the burned area or doing skin grafts. Due to the risk of hypothermia and the need to keep the atmosphere bathed in moisture, the operating theater is kept at 98 degrees and 98 percent humidity throughout the operation, she said.

"I had a hard time standing up in the scrubs in that temperature for that amount of time," she admitted. "But (the surgical team members) are so focused."

Ravage raves about the medical personnel she got to know at Their commitment is shared by most in the field of burn care, a grueling and emotionally draining profession, she said.

"As soon as someone comes into their care, all the other stuff goes someplace else and this is a soul that needs to be healed," she said. "To me, it was the most amazing thing. It just felt like some state of grace that they were in."

But Ravage is clear to point out that there are many other burn units in the country doing equally good care.

"I'm not saying that Mass. General is better or the best. This is not a book about Mass. General. As with having to choose one doctor (Schulz), I had to choose one hospital," she said.

One's family's experience
Perhaps the most startling illustrations of Ravage's discoveries about burns and burn care are told through the experience of Tom Parent and his wife, Nancy. A pleasant Memorial Day weekend in Eastham turned into a nightmare for the couple and their daughter, Ashley, when a pot of cooking oil burst into flames on the stove.

"The way Nancy tells it, on May 26, 2001, they did everything wrong. But the truth is that what happened was a horrible accident, the kind that could befall anyone. It resulted from a series of miscalculations that added up to disaster," Ravage writes.

When Tom saw the flames licking towards the kitchen curtains, he grabbed the pot by the two handles and headed for the door. Nancy, writes Ravage, "heard Tom bellow, 'Fire!' and watched him head for the family room, which led to a screen porch and the backyard beyond."

In the book, Nancy describes what happened next.

"By the time he got to the doorway, I couldn't see him from the waist up. I couldn't see him at all. I could only see his legs." The rest of him "was engulfed in flames."

The family's ordeal over the next year or so is recounted in "Burn Unit," and through Tom's experience, the reader becomes intimately involved with the medical team at Mass. General. The account of his treatment and the accompanying suffering is, at times, difficult to read.

Serious burns must be soaked, covered with a solution called silver sulfadiazine, wrapped in moist bandages each day. Also part of the process is a procedure known as "debridement," which involves scraping off the dead skin each day. It is, by all accounts, and excruciating experience.

Parent told Ravage "he would never forget the agony of having his wounds scraped."

Burn scars are "the last great frontier," for burn care professionals, said Ravage.

"They have come a long way with grafting (the process of placing healthy skin harvested from another part of the body over burned areas), but the problem with scars persists as one of the great challenges."

"Burn Unit" will give the reader everything he or she wants to know about burns and their care in a very readable and well-organized format. Medical terms are clearly explained, and Ravage has a gift for handling the most sensitive topics in ways that readers will appreciate - graphically but always grounded in the humanity of the patients and the healers. These elements are part of Ravage's greater goal as a medical writer.

"I feel," she said "that it's particularly important with the current state of medical care in our country that people be very good consumers."

"Burn Unit" shows patients and their families as consumers of extraordinary medical knowledge and extraordinary compassion.

(Published: May 6, 2004)



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