Lying painfully in his hospital bed with tubes in his body, firefighter Christopher Barth tells in a whisper how the wind suddenly shifted, how he was covered with flames, how he waited for death.
"I moaned that I thought I was going to die," said the 25-year-old Seal Beach man.
Somehow, Barth survived the fast-moving wildfire in Altadena Canyon on Aug. 20 that killed two other fire crew members and badly burned another.
But survival is one thing. Physical and emotional recovery are another.
He has had five surgeries to treat the deep, third-degree burns on about 25% of his body, including his face, knees, elbows, buttocks and backs of his legs. He has trouble talking because smoke inhalation has injured his vocal cords.
"It is a trip through hell," said Dr. Clinton Tempereau, chief of psychiatric services in the burn unit at Sherman Oaks Hospital and Health Center.
For Barth, hell has two forms.
Besides the physical pain, doctors say Barth's mental recovery is complicated because the fire trauma has triggered frightening flashbacks of his combat experience as an Army artilleryman in Operation Desert Storm during the Persian Gulf War.
At least with fire, Barth said, "you can see it coming."
Except for the flashbacks, the war against Iraq and the brush fire are over and he is trying to put them behind him. The battle to go on living has just begun.
"Today I am getting well," Barth said with determination as one of his doctors held his wrist sympathetically and nodded encouragement.
At Sherman Oaks Hospital, where his care costs $5,000 a day, Barth is surrounded by a highly specialized medical team that includes a psychiatrist, pulmonary specialist, plastic surgeons, internist, nutritionist and infectious disease specialist.
They are summoning an arsenal of medical technology and knowledge to help him.
He has endured skin grafts and dressing changes and has been continuously fed nutritional supplements through intravenous and nasogastric tubes to replace the thousands of calories his body is consuming daily as it eliminates toxins and strives to heal.
Twice daily he is placed in a hyperbaric oxygen chamber where pressurized oxygen is forced into his bloodstream to fight infection and promote new tissue growth.
Although he can self-administer morphine by punching a button, drugs only do so much to help, and pain is still his constant companion.
Doctors say Barth can expect many months of physical therapy and possibly more reconstructive surgery following his release from the hospital in three more weeks. For a year, he will wear specially designed, snug-fitting clothing to reduce swelling and scarring.
"It becomes a one-day-at-a-time thing," Tempereau said. "There is the feeling there is no end to it. And along with that, it is a very depleting, exhausting experience."
Dr. A. Richard Grossman, founding director of the burn center, stressed the importance of the patient's attitude.
"I as a surgeon can do my job, but if a patient loses his will to survive, I can't do enough for him," Grossman said.
Barth and 19-year-old Hector (Gabe) Larios, another fire suppression aide with the Los Angeles County Fire Department who was severely burned in the brush fire, receive moral support from nurses who attend to them around the clock.
Fire Department volunteers hover at the bedsides of their injured comrades and maintain a 24-hour vigil at the hospital to answer telephone calls from family, well-wishers and potential blood donors.
Hundreds of people have offered to donate blood, fire officials say.
Barth is expected to require 50 to 60 pints of donated blood before he goes home, said his attending surgeon, Dr. Michel Brones. Much of the blood is needed to replace what is shed during surgeries.
Only as many layers of burned skin are removed as necessary during surgery so that disfigurement will be minimized, Grossman said. The first skin removal performed on Barth was not deep enough, he said, so surgeons had to go back and cut more.
A decade ago, surgeons began using skin from cadavers to cover open wounds. The procedure replaced the use of skin from pigs, which the human body quickly rejects.
Cadaver skin "acts like a biological dressing," Grossman said. "It promotes a warm, nurturing environment for skin growth and the wound starts to heal. . . . Wherever we put the skin, the pain stops."
Only a temporary dressing, the cadaver skin later has to be surgically removed and replaced with grafts of healthy skin taken from the burn victim or from plastic surgery patients who donate skin left over from face lifts, tummy tucks and breast reductions.
Surgeons removed healthy skin from Barth's scalp to graft to his face, while other burned areas were covered with skin taken from unharmed parts of his legs and chest.
Facial reconstruction is the most important to the burn victim and his family, Grossman said.
"I don't care if it is a child or a 70-year-old person, everyone is worried about their face," he said.
Families of the two injured firefighters have placed their pictures, taken before the fire, on the windows of their hospital rooms. But Grossman admits that he will not be able to exactly duplicate nature, try as he will.
"I can't give them their faces back," he said.
However, he promises to bring the patients back when improved surgical techniques become available. "You don't let them walk away without hope," he said.
It is not an empty promise, Grossman said, noting the advances in surgical techniques, antibiotics, nutrition and materials used for grafting.
If Larios and Barth had come to him 15 years ago, he said, "I wouldn't expect Gabriel to live and I would expect Chris to survive but to have terrible scars."
Over those years, doctors have learned to widely use cadaver skin as well as laboratory-grown skin cultivated from skin cells of the living. Although the laboratory-grown skin is too thin to cover third-degree burns, it can give a much smoother result when grafted onto faces, he said.
In addition, Dr. Bruce Achauer, director of the UCI Medical Center burn unit in Orange, 10 years ago devised a way to save the lives of severely burned patients who do not have healthy flesh for grafts: with the permanent use of cadaver skin and an anti-rejection drug, cyclosporin.
The skin-grafting process, which Barth is undergoing, is a critical point for the surgeons, Brones said, because a sudden infection under the skin could cause the grafts to be rejected. "We cross our fingers and we wait," Brones said.
Grossman was dismayed to find infections in Barth's knees and elbows, which had been deeply burned when he fell on fiery embers. After that discovery, Barth was put on high doses of intravenous antibiotics. "He is not out of the woods yet," Grossman said.
Last week, he surgically attached Barth's left elbow to his stomach wall so the soft tissue and muscle of the stomach will protect the elbow's exposed joint and enable it to heal without becoming arthritic.
The elbow will remain attached to the stomach for three weeks before it is surgically separated, Grossman said.
Tempereau said burn patients can use their long physical recovery to deal with psychological trauma. He encourages the patients to talk about what happened to prevent terrifying and uncontrolled flashbacks in the future.
His goal is to help patients such as Barth turn a tragedy to their advantage, Tempereau said.
"When you face death like this and then lay in a hospital for weeks on end," he said, "you get in touch with values and priorities and get to think about what is important in life."
Despite what he has suffered, Barth said he still wants to be a firefighter.
"It is the only thing I have any desire to do," he said. "Some people are just born to it."
Recovering from Burns
Rehabilitating burn victims is a complicated process:
1. Fluid restoration: In the first 48 hours, fluids lost through the injury are restored.
2. Painkillers: Patient is put on self-administered painkillers, available in minute doses.
3. Hydrotherapy: Patient undergoes hydrotherapy; loose skin is removed during treatment.
4. Hyperbaric oxygen therapy: Patient is immersed in pressurized, pure oxygen to speed the healing.
5. Biological dressing: Dead skin is removed; skin from a cadaver is applied as a biological dressing.
6. Counseling: Psychological counseling is provided.
7. Therapy: Occupational therapy begins.
8. Skin replacement: Cadaver skin dressing is removed and replaced with thin sections of patient's own healthy skin.
9. Special clothing: Patient is fitted for pressure garments, special gloves, T-shirts and leotards, which minimize swelling and scarring, for a year.
10. Going home: Patient is sent home and therapy continues for a year, after which any reconstructive surgery is performed.
Source: Dr. A. Richard Grossman, medical director, Sherman Oaks Burn Center; Researched by LESLIE BERKMAN / Los Angeles Times