AFTER THE BURN; One Man’s Struggle for Life: FIRST in a four-part SERIAL

In the hydrotherapy room, the burn center team removed the clean white sheet and examined their latest consignment. They checked for respiratory damage (none), and proper IV function and adequate pain control.

The 32-year-old man lay stunned and naked in the stainless steel trough, his pain often spiking through the maximum-prudent layer of comforting drugs. He had been scalded in the groin and on the thighs, trunk, back, arms and hands. Unlike flame burns, the scalds were clean and unassuming. No carbon soot or roasted crusts of flesh betrayed the enormity of their insult. Most of the man’s body was luminous pink.

When burn center nurse Elaine Blunt Shortall touched his arm, the skin slid off in her hand. Beneath was the garish white of cooked flesh, of third-degree burn.

After 18 years of treating badly burned patients, she had a first-sight sixth sense about which would survive and which wouldn’t. This one fell in a gray area. Whether he lived or died, he was in for an ordeal he could not have imagined. “He’s going to be a sick cookie,” she thought.

*

Lori Robinson was meeting with the telephone vendor, discussing details of moving phones among Remax/Beach Cities’ nine realty offices, when she received the call from her husband’s superintendent at the Jersey Maid dairy plant in the City of Commerce.

“Todd’s been in an accident,” the man said.

“How bad?” Lori demanded.

“Really bad. He’s been burned.”

“How bad?”

“Over 50% of his body.”

Lori, who at 31 was senior office administrator, prided herself on her command of detail. Yet she could not get her mind around the name and location of the hospital to which her husband had been taken. Her caller had to keep repeating, “Beverly Hospital . . . Montebello.”

She got there at 10:30 a.m., just in time to ride in the ambulance transferring her husband to the Grossman Burn Center at Sherman Oaks Hospital. Although morphined, he trembled and moaned. He entreated her to keep talking to him so he wouldn’t slip into unconsciousness or oblivion or whatever the darkness was that kept beckoning him.

*

State of California

Department of Industrial Relations

Division of Occupational Safety

and Health

Inspection No. 119790376

Narrative Summary

On Feb. 19, 1997, at approx. 9:30 a.m., Todd Robinson, a maintenance engineer for Jersey Maid Milk Co., answered a call to adjust a micro switch of a pump to make run on #3 pasteurizing unit. As the pump started (running) after adjustment, the cap came off the holding tube and the injured was showered with hot water. . . .

Water came on the injured in full force and he was knocked down on the concrete floor 7’ down and received severe burns on 70% of his body.

The pipes in question are 4” diam. 14 ga. stainless steel pipes suspended in the air and braced. . . . The water temp. was 165 F for forward flow with 60 to 70 lbs. P.S.I. . . .

The defective (poor) maintenance left the pipe joints weakened which give-away under pressure leading to this accident. A citation was issued on that basis.

*

Of all the misfortunes that can befall the human organism, few are as catastrophic as a severe burn. People sense this. An atavistic fear of burning smolders within them.

Skin is the body’s largest organ. It contains, defines and identifies a person. A severe burn is a trauma not only to the body, but to the psyche, and therefore to even the closest of human relationships.

When the skin’s integrity is destroyed, the body metabolically panics. It weeps fluids as though in grief. It thirsts and starves and begins to consume itself. It no longer can control its own internal temperature. It is open wide to the suddenly lethal microbes of the environment.

After a burn, the blood vessels rush fluid to the wounds to try to flush away contaminants. The walls of the capillaries leak plasma, the liquid component of blood, into surrounding tissues, causing swelling not only at the burned sites, but everywhere.

With the skin no longer a moisture barrier, the body may lose half a dozen liters of fluid to evaporation in 24 hours. The blood, having surrendered so much plasma, becomes concentrated, and sluggish in its delivery of oxygen to vital organs. Heart function begins to decline. The kidneys fall behind in the task of cleansing burn toxins from the blood.

Because of the swelling and disrupted supply of oxygen, tissue at the burned sites begins to die, sometimes to a depth several times the thickness of the original burn.

In response to all this, the body goes hypermetabolic, furiously expending energy. It burns 580 calories to evaporate each liter of escaping fluid. In its panic to replace burned tissue, it starts draining protein from the muscles so the liver can convert it into glucose, which fuels cell formation. Body mass is lost. A kind of starvation ensues.

Wasting its resources, the body is increasingly powerless to fight infection. This crippling of the immune system occurs just as bacteria are taking up residence en masse in the denatured protein of burned skin. In the history of burn medicine, infection has been a prolific killer.

A severe burn that is not immediately fatal puts a person on a torturous road with no shortcuts. Sometimes it ends quickly in death, typically within a couple of weeks. More often, it winds eventually to recovery, but not before passing through bitter landscapes. Then it heads into a future hung with uncertainties.

*

Todd and Lori Robinson started going together while students at Leuzinger High School in Lawndale. Their first date was skating at Olympic Ice Arena in Harbor City. It wasn’t long before it came to be understood that they’d marry, which they did, on New Year’s Eve 1988.

A year and a half later, they had a son, Cody. In November 1996 came a second son, Dylan; Lori stayed at her job at Remax/Beach Cities until noon the day he was born.

At home, as at work, Lori was the organizer and the keeper of standards. She could not abide dirty dishes, and, as watchdog of family finances, was known to snarl when money was foolishly spent.

Todd was genial and hard to rattle, “a go-with-the-flow guy,” Lori liked to say. He saw no particular unwisdom in spending money to enjoy life. A lean 6-footer, he especially loved water-skiing, and skied at a high amateur level. Nearly every Thursday, he and his friends pooled money to rent a small private lake near Bakersfield and skied all day.

The couple bought a small house in Gardena, and Todd, who was good with his hands, set about expanding it. Working alone afternoons and evenings after returning from his job, he added a dining room, two children’s bedrooms, a master bedroom and a master bath. Then he remodeled the original structure.

The house grew from 800 square feet to 1,700. It took three years.

He had just begun the final phase of the project, tiling the new master bath, when the pipe at Jersey Maid burst.

*

At 5:30 a.m. on Friday, Feb. 21, a quartet of surgeons assembled at the Grossman Burn Center. Gowned and masked, they congregated over an anesthetized and unconscious Todd Robinson. Since his admission two days before, doctors had been waiting for his burns to demarcate themselves more clearly.

Now he lay on the operating table with arms flung wide, legs spread, heels elevated. His swollen face was a picture of unworried repose.

His body, however, was a map of insult. Large, irregular areas of white and glowing pink defined the territory of his burns, most of which were third-degree. These contrasted with the scarce unburned regions--primarily the face (a great blessing) and the lower legs--which were yellowish beneath the surgical lamps.

Since his arrival, Todd had been irrigated with intravenous fluids to replace those being squandered by his body. A feeding tube had been inserted into his stomach to allow massive delivery of calories--as many as 8,000 a day, if necessary--to counteract his body’s self-inflicted malnourishment.

The badly burned human body has no chance of surviving except by grace of the knife. Burned skin is an open sewer of microbes, and must be cut away as early and aggressively as possible, despite the patient’s depleted state.

The tolerances are fine. Skin is, on average, but an eighth of an inch thick. Yet what has been burned must be cut until the knife reaches unburned skin, or fat, or muscle, or even bone. The deeper the cutting, the more elaborate scarring is likely to be, and the less functional the healed area.

The surgical term is debridement (duh-breed-MAHN), a French word whose elegant sound belies its benevolent brutality. In an era of exquisite high technology, burn treatment is as low-tech as medicine gets--doctors with knives carving away bad flesh. “Civil War surgery,” burn center founder Dr. Richard Grossman calls it.

The surgeons commenced to cut.

Grossman switched on a dermabrader, a slender implement with a burred, revolving, gumdrop-shaped head. It whined like a dentist’s drill. The surgeon took it to the swollen genitals. With long, brisk strokes, he banished the top layers of dead tissue. Fine pink spatterings decorated the clear visor over his face.

Surgeon Matt Young removed the glove of dead skin from Todd’s right hand with a six-inch Weck knife, a kind of straight razor with a guide to regulate the thickness of the cut to 8 or 10 or 12 thousandths of an inch.

Surgeon Peter Grossman, Richard’s son, worked on Todd’s upper right arm with a Watson knife, a long, rectangular version of the Weck that left shallow, fan-shaped carving marks each time it passed. Surgeon Michel Brones used a Watson on Todd’s trunk.

For nearly an hour, they cut, flicking away paper-thin scraps of dead tissue, which lay gray and curled on the surgical sheeting. The surgeons moved from position to position, sitting or standing bent over the patient. They cut until pinpoints of blood blossomed and conjoined and flowed away, a sign they were near viable tissue.

Then they wrapped the cut areas in bandages soaked with a mild adrenaline solution to stop the bleeding, and dressed them in cadaver skin.

Cadaver skin, called homograft, comes in thin, pale, deep-frozen strips approximately 10 by 4 inches. An operating room technician thaws it in sterile solution, fixes strips on plastic carriers, and then puts each through a hand-cranked machine that punches a latticework into the skin to make it expandable to a surgeon’s requirements.

Todd required 13,104 square centimeters of homograft, about 14 square feet. After, the surgeons swaddled him chin to knees in sterile dressings, concealing their melancholy handiwork in tidy, padded whiteness.

Four days later, having shriveled and browned, the cadaver skin was stripped away in a second operation. Richard Grossman rolled Todd onto his side and held him in an awkward embrace. “Dermabrade his back--hard,” he instructed. Brones, whining implement in hand, bent to the task.

Every place that had been cut before, as expected, had to be cut again. Serious burns are deceptive; tissue death can continue long after the source of heat has been removed. Getting to true living tissue at all sites typically requires multiple surgeries.

Grossman had hoped that day to begin permanently covering a few of the key wounds with some of Todd’s scarce unburned skin. The burns, however, were deeper than anticipated.

“He’s no way near ready to graft,” Peter Grossman said.

The surgeons applied another 14 square feet of fresh cadaver skin, and re-dressed Todd. They would have to try again in a few days.

Time, however, was beginning to press. Todd was showing signs of going into a toxic crisis from the bacteria proliferating in his unhealed wounds.

*

MONDAY: The physical--and mental--battles continue.