The signs for Robert Martinez were not good when he arrived at the hospital four months ago. They rarely are when a body is stripped almost completely of the familiar insulating layer called skin.
With more than 80% of his body burned in a refinery steam explosion, his lungs horribly damaged by contaminants from the blast, Martinez could breathe only with the aid of a ventilator as he lay comatose in his specially equipped bed at Torrance Memorial Medical Center.
That he was covered nearly head to toe in bandages and splints provided dramatic visual evidence to only part of his plight. His body was so traumatized that all of his organs were failing. Infections were ravaging through his wounds. His eyelids were blistered shut. The fact that he was already severely deaf seemed almost trivial.
"Just think of the horror of the situation where he couldn't hear, he couldn't talk and he couldn't see, and all he could feel was indescribable pain," said his primary physician, Dr. William Davies. "It was the ultimate in bad trips."
But it wasn't Martinez's final trip. Last week, he went home, an achievement that stunned even the battle-weary crew that work at the hospital's prestigious burn center. That the 26-year-old construction worker is still alive is a testament to the strength of the human body and to the expertise of the specialized group that assembles at the burn unit to care for people traumatized beyond recognition, and often, beyond hope.
Despite recent advances in burn care, critical-care centers such as Torrance's have been disappearing in the past decade at an alarming rate, victims of soaring health-care costs that have led to the near-collapse of trauma care networks throughout the nation.
Nowhere is that more true than in Los Angeles, where nearly a dozen hospitals have pulled out of the once-prestigious critical-care network in recent years and the number of beds for acute burn victims has decreased by nearly 50%.
Burn centers have been hit especially hard by rising medical costs. There are few traumatic injuries more expensive to treat than burns, largely due to the intensive, round-the-clock care and multiple surgeries required for those patients. And a disproportionate share of burn patients are uninsured, according to medical experts, forcing hospitals to absorb the costs, which can easily exceed more than $500,000 for a single patient.
Brotman Medical Center in Culver City was forced to close its burn center five years ago, citing significant losses, due in part to a reduction in government reimbursements. The burn center received national attention after pop star Michael Jackson was treated there after the back of his head was burned during the filming of a Pepsi commercial.
Jackson later gave the hospital a large endowment for research into burn treatment and the singer reportedly was extremely angry when the center--which bore his name--shut its door with little notice.
Torrance hospital officials placed their burn center on the critical list a few years back, citing the growing number of uninsured patients that they were required to treat because the county burn beds were filled. In 1989, the hospital wrote off as charity almost $1 million--the amount it cost the hospital to treat six burn patients.
Hospital officials later went public with their problem, saying that unless the county emergency network could figure out how to place more burn victims in county hospital beds, the medical center would have to shut down the unit because it could no longer afford to care for so many uninsured patients.
So far that has not happened, but hospital officials say the problem remains unresolved. If there is a major disaster in the area, they say, it could force the county's three remaining burn centers back into intensive care.
"It's a constant struggle," said Ray Rahn, chief operating officer of Torrance Memorial Medical Center. "It's a big gamble for a medical institution. The exposure is always there and in a catastrophic case, where you would have dozens of burn victims, it could make the difference."
County health officials say the problem is compounded by limited reimbursement provided to the hospitals by the state. Health care officials estimate that an acute care patient costs the hospital $4,000 per day, which Medi-Cal reimburses at a rate of $1,600. Indeed, a single burn patient can easily use more than $100,000 worth of wound dressings during a typical stay.
"A patient with a 70% to 80% burn can be a tremendous financial burden," said Dr. A. Richard Grossman, director of the Sherman Oaks Community Hospital burn center. "And now that we can save those patients that we couldn't save years ago, it's a much more costly process than ever before. But who can put a dollar value on a child's life? When they come in, we just do what we do."
David Langness, vice president of the Hospital Council of Southern California, said that "there has to be additional financial help for those hospitals that have agreed to stay in the burn treatment business, but that's very tough to do because the money isn't available.
"Burns fall very low on the priority list except when there happens to be a high-profile victim or accident. But in anything like a huge fire, the system would be overloaded and we would lose a lot of people in the process."
About 50,000 people are hospitalized each year with burn injuries, according to Baltimore physician Andrew Munster, secretary of the American Burn Assn. Yet despite the severity of some of the injuries, the ABA estimates that only one in five patients is treated at a specialized burn facility because not enough beds are available.
"The problem has been that it is hard to place those individuals who most need to be referred to a specialized burn facility," Munster said. "Some people just never make it, as a result."
Los Angeles County, with more than 8 million residents, has a total of only 12 intensive-care beds, down from 35 in 1987. When the beds are occupied, local burn victims must be flown to other counties or even out of state.
And while the number of burn beds has been dwindling, the need is increasing. The Office of Statewide Health Planning and Development predicts that by the year 2000, Los Angeles County will require a minimum of 40 acute care beds, when the estimated population tops 9 million.
The availability of beds is further diminished by critical staffing problems that have plagued most burn centers. Health officials have estimated a 75% annual turnover of nurses at County-USC Medical Center. Burn specialists say the problem is compounded since it takes more than a year to train a qualified burn nurse.
But Todd Dimas was lucky. When the refinery blast occurred at Chevron's El Segundo plant on Jan. 23, beds were available at the burn centers in Torrance, at Sherman Oaks Community Hospital and at County-USC Medical Center. After being stabilized at a local emergency clinic, Dimas, one of 10 construction workers injured in a severe steam blast, was taken to Torrance.
Dimas was standing on scaffolding about six feet above the ground when a sudden rush of steam filled a small silo where he was working. The 28-year-old Downey resident suffered burns over 40% of his body and serious lung problems after inhaling large amounts of black coke, one of the refinery's byproducts. After undergoing three skin grafts during two months of hospitalization, he recently began the painful rehabilitation process to regain full use of his arms, hands and legs.
As bad as his injuries are, however, Dimas said he feels fortunate.
"When the steam hit I thought I was going to die because I couldn't breathe," Dimas said. "It was super, super hot but at the time I didn't feel the burns. It all happened so fast that I don't think anyone realized how bad we were burned."
Dimas was unconscious by the time he got to the hospital and lapsed in and out of consciousness for several days. Since then, besides his family and the hospital's medical staff, pain has been his most constant companion.
He shudders when he recalls the whirlpool baths in which much of the dead tissue on burn victims is removed in a process called debridement.
Burn victims have likened it to being skinned alive, and many patients have said that going through the process was the worst pain they have ever experienced. But burn experts said the immediate removal of the tissue was one of the breakthroughs in the past two decades that has greatly improved the survival rates for severe burn patients.
"There's really no way to describe the pain, other than it's beyond your imagination," Dimas said. "Imagine somebody scrubbing these burns with a Brillo pad. It's a nightmare."
Martinez, who is Dimas' nephew, said he knows he faces a long, painful road back. But that he has any future at all has amazed burn specialists who have seen some of the worst injuries a human body can sustain.
"I'm stubborn," Martinez said. "I just never asked myself (why this happened). My main worry was that I was never going to be able to go home. That's what kept me going."
Medical experts say burn centers and neonatal intensive-care units are among the most labor-intensive areas in health care, requiring teams of highly skilled personnel. Victims with serious burns may require hospitalization of six months or more, followed by years of rehabilitation.
Major burns such as those suffered by Martinez are considered "catastrophic" injuries, in that they can affect most of the body organs. While physicians must battle the constant threat of infection, they must also battle the clock to graft as much skin as possible to cover the wounds. The larger the burn, the less skin there is to graft. If infection sets in, the problems are further compounded. Since lungs are often damaged in fires due to smoke or chemical fumes, they can lose their ability to oxygenate blood. When the pulmonary system shuts down, it can lead to renal or liver damage.
In essence, at numerous critical junctures, the internal systems of a badly burned human collapse like dominoes. "So much energy is expended by the body to fight the trauma that the person just runs out of gas," said Dr. Neal Koss, medical director of the Torrance burn center. "All the other systems suffer."
For the past 16 years, Pam Hunt has seen every type of burn imaginable at the Torrance ward--from infants to octogenarians, from those who had no chance to survive and did, to those who somehow slipped away despite a favorable prognosis. Hunt is an emergency care nurse who runs the ward.
"What's amazing to me is that each year we seem to operate it at a thinner and thinner margin," she said. "But if we get five big burns, it may take up all of our staffing. I shudder to think what will happen if there were a big airplane crash or another major disaster.
"Last year, like the year before that, we took in more patients than we could reasonably handle," she said. "What you find out quickly about burns is that the peaks are very high and the valleys are seldom seen."
Dr. Bruce Zawocki, medical director of the burn unit at County-USC Medical Center, the county's largest, said that in the event of a major disaster, the capacity of the units can all be expanded, but only for a limited time.
"We can handle a pretty large number of burns maybe twice a year," he said. "But we can't do it for prolonged period of time. If that's required we'd have to begin transferring them."
Ironically, advances in burn treatment have led to longer hospital stays, which have resulted in increased costs. Most severely burned patients would not have survived long enough to require extensive medical care 30 years ago.
According to Dr. Arthur Mason, chief of the laboratory division at the prestigious Brooke Army Medical Center in San Antonio, Tex., a 21-year-old male admitted with burns over 50% of his body stood about a 50% chance of surviving then. Now, a person with the same injury has an 85% chance of surviving, and a young adult with an 85% burn probably has a 50% survival rate.
In the past, doctors waited weeks before entirely removing burned tissue and artificial dressing, a process that involved pain, demanded immobility and often led to infection.
But breakthroughs in the "harvesting" of skin taken from the victim's own body have helped enormously. Rather than waiting for long periods at great risk of infection, surgeons now perform skin grafts to cover the burned areas within three weeks after the patient is admitted. The grafts prevent fluid loss and bacterial infections, which are leading causes of death in burn patients.
To treat burn victims, doctors remove all the dead tissue destroyed by the burn and then cover the wounds with newly harvested skin. Although cadaver skin has been readily available for years, surgeons preferred not to use it because it is rejected as a foreign tissue by the body's immune system.
Rosario Chavez is living proof of the advances in burn treatment. The 33-year-old Santa Maria woman was critically injured in a house fire last Christmas Eve and had to be airlifted along with three of her children to burn centers in Los Angeles after the conflagration. She suffered burns over 80% of her body. Chavez and one of her sons ended up at Torrance, while her two other children were flown to Sherman Oaks.
Chavez defied the odds, moving from the critical-injury list to a rehabilitation hospital after nearly three months of intensive care and multiple surgeries at the burn center. As severe as her injuries were--most of the burn center's staff gave her little chance of survival--the toughest part came weeks after the fire, when she learned that two of her children subsequently died.
When Chavez left the hospital last month to go to a special rehabilitation center, she left the hospital with a $500,000 medical bill. Like many burn patients, she was uninsured.
"In that kind of catastrophic case, the (health-care) system doesn't operate very well," said Rahn, Torrance's chief operating officer. "If you end up with too many cases like that, then you have to decide whether you can continue to operate. The sad thing is, in burns, you're dealing with an extremely skilled and compassionate group of people. And it would be a real tragedy to lose any part of that."