Shortly after 4 in the morning on Oct. 26, the doors of the UC San Diego Regional Burn Unit swung open, and the first of the San Diego wildfire victims was rolled into the intensive care unit. Flames had seared 60% of Rudy Reyes' skin, and the scalding, ash-filled air had smothered his lungs when he was caught in a firestorm while trying to flee his home.
Within minutes, a team of nurses and doctors began flooding the 26-year-old man's veins with dozens of liters of plasma and saline in a race to replace the vital fluids he had lost and hooked his damaged lungs to a ventilator. They intentionally paralyzed his muscles with drugs, sedated him and administered huge doses of pain medication.
"Burn survivors don't usually remember the ICU at all," said Ann Malo, the head nurse that Sunday morning. "Which is good. I wouldn't want to remember. It would be horrendous -- the pain."
In the two weeks since the Cedar and Paradise fires tore through San Diego County, killing 14 people and destroying about 2,400 homes, families and communities have begun the halting process of moving on.
For more than two dozen people, the journey back has begun at this university's nationally renowned burn center. Over the next few weeks, several will walk away with only slight physical reminders of what they endured. Others, however, face a much darker future.
Even for this elite burn unit at UC San Diego Medical Center, which treats more than 400 patients a year and trains for mass casualty events, the fires tested the center's limits. Nurses and doctors described a scene that grew increasingly frenetic that Sunday as patient after patient arrived.
Having exhausted the hospital's supply of new intravenous pumps, nurses at one point were forced to sterilize used pumps. Doctors had to use rooms elsewhere in the hospital when the eight ICU beds were filled.
The phones rang constantly with hundreds of people searching frantically for relatives.
"One girl called and said, 'My grandpa is 65 and has blue eyes. Is he there?' " recalled Laura Everett, an administrative assistant at the burn center.
To avoid being overwhelmed, Dr. Daniel Lozano, the center's director, made the early, tactical decision that only the most gravely injured -- those with burns over more than 30% of their bodies and lung injuries -- would be admitted. The scores of less serious cases would be treated at other hospitals. By that first Sunday afternoon, 14 people in critical condition had arrived at the hospital -- twice the number admitted on what had been the unit's worse day.
"I could best describe it as controlled chaos," Lozano said. "With the constant influx of patients, it was hectic."
By Tuesday, nearby hospitals had transferred nearly a dozen more badly injured patients in need of treatment in either the center's ICU or its other ward. Using cadaver skin, a synthetic material and unburned patches of the patient's own skin, Lozano and his staff painstakingly sewed quilt-like grafts over exposed wounds.
Such treatment does not come cheaply at what is one of the hospital's most expensive units. The total cost of care for those burned in the wildfires, Lozano estimated, would easily exceed $5 million, if not $10 million. In their first days at the center, patients in the ICU incurred expenses of roughly $10,000 each day. Lozano added that although insurance companies cover some of the costs, the hospital is often left to cover shortfalls.
By Saturday, 13 victims remained in the unit -- six of them in critical condition, not able to breathe on their own.
Reyes was one of them. He was still deeply sedated and covered from head to toe in white dressings. Family photographs of Reyes as a young boy and grown man adorned the wall at the foot of his bed. The plaster cast his brother made of his own face rested against a window.
"I still have my original face," Fernando Reyes said. "And we look pretty much the same. When the doctors work on my brother, maybe they can use it."
As they do with many patients, nurses and doctors had asked the family to bring in the pictures.
"The photos help us to get to know them," said Nancy Coplin, as she and three other nurses gently rolled Reyes onto his side to continue the delicate daily task of dressing changes. The nurses use the photos to make a personal connection with patients whose faces have been badly burned.
For several hours each day, Reyes' mother, Elena Lorte, has rocked gently in a chair beside her son's bed, watching his chest rise and fall with the uneven rhythm of the ventilator. Like the nurses and doctors who have told her that her son's heavily sedated mind can still hear voices, Lorte speaks to Reyes, sometimes reading to him. When she played his favorite Bob Marley song, Lorte said, her son's heart rate jumped up eight beats on the monitor.
But Lorte knows an increased heart rate is also a sign of the waves of intense pain washing over Reyes' body. Recalling that her son had been on the verge of beginning work as an archeologist before the fires, Lorte said she worries what the future holds for him now.
"I just want him to be OK," she said, her voice catching as tears slid down her cheeks. "I know he's not. I know he's in a lot of pain."
What happens next, Lozano said, depends greatly on each patient's ability to heal. Some will have to endure repeated surgeries, and many will still be in the hospital over the holidays.
And while those with burned hands and feet risk losing basic mobility, Lozano said, his goal is to ensure that all survivors can return to self-sufficient lives.
Dr. Mayer Tenenhaus, a UC San Diego reconstructive surgeon who has worked with some of the wildfire victims, echoed Lozano's hopes. He acknowledged, however, that his skilled hands can only do so much.
"There will be scarring, but the question is, how bad will the scarring be?" he said. "I can't make it like the burn never happened. That's the worst part."
Spirits have been considerably higher in the rooms outside the ICU, where eight patients with fewer burns and no lung damage continue to heal.
In room 513, Mara Snyder and Lori Bellante have become friends as they recovered. Snyder, an always positive and wisecracking 66-year-old, suffered third-degree burns on her right hand and legs. Bellante, a 51-year-old quiet mother of two, received deep burns on her arms while trying to lead her daughters toward safety in the midst of a swirling firestorm. Both said it helped having someone else who felt the intensity of the "furnace-like" heat and the fear that accompanied it.
Well enough to be discharged on Friday, Bellante shared a tearful goodbye with Snyder, the nurses and Lozano. One nurse told Bellante -- whose family lost everything -- that she had gathered clothes for her from friends. Another slipped her a card with her home phone number on it and told her to call if she needed anything. Faced with the prospect of reemerging into a life now empty of possessions and filled with questions, Bellante rested her still-bandaged arms against the wall and gave pause.
"All I've had to worry about is getting better in here," she said. "Now it is just so overwhelming, there's so much more to worry about."