After the Fire
When Bryan Fultz set himself on fire in an office accident, his girlfriend helped put out the flames. After that, it was up to the Johns Hopkins Burn Center staff not just to save his life but to give it back to him.
Pffffffffft. Whoosh. Boom.
A spark from the match ignited vapors wafting from the can. The can exploded. Flames shot up Fultz's legs and right side, then enveloped his chest. Burning alcohol pooled around his new Nike Zoom track shoes. His six-foot-two, 195-pound frame engulfed in fire, he ran toward the front office, searching for a patch of carpet where he could roll and extinguish the flames.
Melissa Kesner, Fultz's manager at the printing company and his girlfriend, heard the explosion from the office at the front of the building and ran toward the smoke-filled warehouse. As soon as she saw Fultz, she helped him tear off his burning shirt, then tackled and rolled over him. Mark Fisher, their co-worker, used a fire extinguisher to put out the fire that had flared up around them.
Firefighters and EMS technicians from Baltimore County arrived within minutes. Two of them tried to carry Fultz out of the burning building by his legs and armpits, but his ankles were so badly burned that when their hands touched him, he screamed to be put down. Fultz stumbled out of the burning warehouse and into the sunny, 90-degree day, leaving a trail of burned-off skin behind him. He sat down on the gurney outside the ambulance. "I remember the feeling of the sun hitting the burns on my bare chest," says Fultz. "It hurt like hell."
Within 40 minutes, Fultz's ambulance arrived at the Johns Hopkins Bayview Medical Center, site of Maryland's only regional burn center. His chest, right arm, and lower legs had all been badly injured, and his face had suffered superficial burns. He was admitted through the emergency room, where trauma specialists quickly took his history, monitored his heart rate and breathing, set up an IV to deliver fluids, and treated his pain with morphine. Fultz, who was slipping into shock, doesn't remember much about his first hours in the hospital. His family has told him that he gave the trauma team a hard time about the whereabouts of his belt and brand-new sneakers. Both melted in the fire and had been cut off.
Once transferred to the Burn Center on Bayview's third floor, Fultz was taken into the hydrotherapy room, where dead skin was washed from his wounds. It was only then that the extent of his burns could be assessed. Stephen Milner, director of the Burn Center and the attending physician that afternoon, and Leigh Ann Price, a plastic surgery resident, measured the surface area and depth of his injuries. Fultz had burns to 55 percent of his body, 42 percent of which were third degree. Milner's first priority was to stabilize Fultz to keep him alive. The first 48 hours would be critical to his survival.
A burn can be far more than just a wound on the surface of the skin. All burns are potentially serious, says Milner. "Particularly worrying are large burns and burns involving special areas such as the face and hands. Large burns can affect the physiology of all major organs, leading to shock, kidney failure, sepsis, and lung damage."
Founded in 1968, the Burn Center admits about 600 patients
annually and cares for an additional 1,600 outpatients. In
addition to attending physicians trained in general and
plastic and reconstructive surgery, the center's
interdisciplinary team has four intensivists specially
trained in critical care, an infectious disease specialist,
specialized burn nurses, a nutritionist, a social worker,
physical and occupational therapists, nurse practitioners,
|Stephen Milner presides over regular teaching rounds, which bring together the Burn Center's multidisciplinary team.||
"We treat some of the most seriously ill patients in the hospital," says Milner, a plastic surgeon who came to Hopkins in 2005 after eight years of directing the Regional Burn Center at Memorial Medical Center in Springfield, Illinois.
The nation's 125 specialized burn centers now save the lives of more people with big burns than ever before. Today about 2 percent of patients at Hopkins' Burn Center die from their injuries — a small number considering that at the end of World War II, a burn covering 40 percent of a person's body was fatal in half of all cases. Early excision of deep burns and skin grafting, which became an accepted treatment in the 1970s, are among the biggest changes in burn medicine in the last 50 years, says Milner, who is also a professor of plastic surgery at Hopkins' School of Medicine. "Before early excision and skin grafting became routine, the burned tissue was allowed to separate spontaneously," he says. "The problem was that patients would often die of infection waiting for this to happen."
More burn patients are surviving their injuries, but
healing and closing wounds isn't the sole focus of the Burn
Center. Through counseling, rehabilitation, and
reconstructive surgery, the staff aims to give burn
patients their lives back. Robert Spence, A&S '69, Med '72,
a plastic surgeon who has worked at the Burn Center since
1985 and served for a time as its co-director and director,
specializes in reconstructive surgery. Spence might perform
a dozen operations on a single burn patient to help reduce
scarring and return the patient's appearance to more of
what it was before the injury. But he also recognizes that
until patients start living their lives as before, his work
hasn't been entirely successful. "I can make the most
beautiful reconstruction in the world, but if that patient
doesn't go out and start shopping at Giant again, it's a
hollow victory," says Spence, an associate professor of
plastic and reconstructive surgery at the School of
|A former Marine, Fultz is no wimp. And yet he describes the pain from his burns as savage and relentless.||
Milner was a surgeon in the British Army during the first
Gulf War and did residencies at top burn centers in Boston
and Galveston, Texas. He knew that Fultz, though critically
injured, had a good chance of surviving his accident.
"There are three main factors in determining the mortality
of a burn patient: the size of a burn, the age of a
patient, and the presence of smoke inhalation," says
Milner. Fultz's burn was big — any burn larger than
40 percent of a patient's body is considered a major burn
— but he was young and did not have a smoke
inhalation injury, which can cause airways to swell so
badly the patient suffocates. Unlike a high percentage of
the patients on the burn intensive care unit (ICU), Fultz
wouldn't need to be intubated and put on a ventilator to
keep him alive.
The biggest concern with him was the massive shift in fluid taking place in his body. Skin, the largest organ, controls body temperature and helps hold in fluids. When the body is seriously burned, there is a leak of plasma-like fluids from the capillaries. "If you don't replace that fluid, the patient will go into shock," Milner explains. "Then the patient can develop renal failure and die." To prevent Fultz from suffering hypovolemic shock, Milner began aggressive IV fluid resuscitation, ordering 14 liters of a solution called Ringer's Lactate over the next 24 hours, half to be pumped into Fultz during the first eight hours after his injury, the rest over the next 16. By monitoring his urine output, Fultz's doctors and nurses kept tabs on whether he was receiving enough fluid and adjusted it accordingly.
Fluid resuscitation is a delicate balance: Give a burn
patient too much, and you run the risk of flooding his
lungs. Give him too little, and he could become dehydrated
and go into shock. In addition to fluid shifts and
swelling, Fultz's body reacted to the burn in myriad ways.
The burns had temporarily suppressed his immune system,
making him more susceptible to deadly infections. So nurses
carefully monitored his body temperature, since an elevated
temperature could be a sign of infection. In addition, his
body became hypermetabolic, his metabolism racing at a rate
two times higher than normal. Because of his missing skin,
Fultz's body could not maintain a stable core temperature.
A heat shield in the ceiling helped bring his room up to
100-plus degrees, and nurses heated his IV fluids to help
keep him warm. The burn unit nutritionist introduced a
2,500-calorie high-protein diet to help his body keep up
with its increased nutritional demand. It might be nine
months before his metabolism returned to normal.
|Nearly a year after the accident, Milner assesses Bryan Fultz's progress.||
Fultz says he doesn't remember waking up in intensive care
until late in his first week on the unit. That's not
uncommon, says Craig Shoemaker, one of the nurses on the
burn ICU who took care of Fultz during his stay. Most badly
burned patients are heavily sedated for their first few
days, depending on the severity of their burns. "If they
don't remember the first part of their stay here, then we
have done our job," says Shoemaker, who has worked on the
unit since 1993.
Fultz is an athlete and former Marine. A self-described adrenaline junkie, he has earned more than his share of stitches, staples, and broken bones while skateboarding, mountain biking, and playing soccer and lacrosse. He is no wimp, and yet he describes the pain from his burns as savage and relentless. He hurt whether awake or asleep. The mere sensation of air hurt his burns. "I felt it every day, every minute," he says. Though he was on pain medication, with extra doses before dressing changes and physical therapy, Fultz says his pain never completely went away.
Doctors and nurses on the burn unit strive to manage their patients' pain, to remove as much of it as they possibly can. "It's a fine balance between managing pain and [minimizing] the side effects that go along with pain medication," Milner explains. Also at work is the fact that pain is subjective. The same dose of medication that might alleviate one patient's suffering may do little or nothing to help another's.
"All burns, no matter how deep they are, hurt," says Price, who spent a year on the burn unit as the center's fellow. "And even though we give burn patients a lot of pain medications, they can't take away 100 percent of the pain. I wish we had something that could."
The worst pain Fultz experienced, he says, was his daily
visit to hydrotherapy, or the tub room. When skin burns,
the damaged tissue left behind is initially sterile. But as
plasma seeps into the wound and a scab forms, the burn
oozes with protein and becomes a breeding ground for
infection. Wound infection can lead to sepsis, a blood
infection that can be fatal. To help prevent infection and
foster growth of healthy tissue, nurses and technicians
must debride the burns as part of twice-daily dressing
changes, carefully removing the dead tissue with
|In the beginning it took Fultz half an hour just to inch from his bed to the stretcher. The effort and the pain caused sweat to pour from his body and drench the sheets.||
As part of his daytime dressing change, Fultz was wheeled
to the tub room, where nurses and technicians removed his
dressings, debrided and cleaned his wounds with a water and
bleach solution to prevent infection, then dressed them
with antimicrobial agents, products like Silvadene cream
and Sulfamylon. Fultz dreaded the tub room and, using a bit
of gallows humor to deal with the stress, nicknamed it "The
Torture Chamber." In the beginning it took him half an hour
just to inch from his bed to the stretcher, even with help.
The effort and the pain caused sweat to pour from his body
and drench the sheets. He hated the smell of Xenoform, a
petroleum-soaked dressing covering some of his wounds. And
the debriding process — which lasted about an hour
— hurt worse than anything he had ever experienced.
"I remember looking down at the floor and seeing blood just
pouring out of me and flowing down the drain," he says. "I
was freaking out. I couldn't believe it was all mine."
"That's OK, baby," Sanovia Lee-Oden, a burn technician who for 31 years has worked in the tub room, would tell him. "That's OK, sugar. Just look at how good your circulation is."
The burn unit has 20 beds — 10 in the ICU, the rest in a step-down area. Nurses on the unit work three 12-hour shifts a week at jobs that are physically and emotionally demanding. Several times a day they must position and move patients who may be unable to move themselves. They work in swelteringly hot rooms dressed in plastic-coated gowns, masks, hats, and protective gloves. A single dressing change on a badly burned patient can take as long as four hours.
It takes a certain kind of person to be a nurse on the burn unit. Despite their best efforts to manage pain, nurses know their patients are often still hurting. "It's hard to see the patients in pain," says Rowena Orosco, a charge nurse on the burn unit who has worked there since 1992. "Sometimes I want to cry with them." Orosco talks to the patients and comforts them. She holds their hands when their families aren't there. "There aren't a whole lot of people who want to do this kind of nursing," she says. Sometimes new nurses on the unit quit during their first few weeks of orientation.
Some burns take weeks or even months to heal, and unlike other ICUs at the hospital, the burn unit cares for patients from the time they are admitted until they go home. As patients get better they move from the burn ICU to the step-down side of the unit. Even after discharge from the hospital, patients return to the burn unit for rehab and reconstructive surgery. Says Shoemaker, "You work your tail off saving this person's life. You work with them through their surgeries. You learn to read their wounds. You help make sure the wounds are healed enough so they can go home. Then we get to see them walk out."
Lying in his hospital bed wrapped in layer upon
layer of white sterile dressing, Fultz couldn't see his
burns or skin grafts except during dressing changes.
Neither could his family. Instead, they relied on a chart
posted outside his room, an outline of the front and back
of the human body on which Price kept track of Fultz's
burns, where skin had been grafted, and from where on his
body healthy skin had been taken. As the days passed, the
series of crosshatched blue ballpoint pen lines told the
story of his recovery.
|Physical therapist Mary Bernard stretches scar tissue to help Fultz regain range of motion.||
The first time Fultz went to the operating room, four days after his accident, Milner and Price cut away burned tissue from his back and chest. Then they covered the area with skin from his thighs — a thin piece of skin they first ran through a meshing machine to punch tiny holes in it, so it would stretch like a net. Five days later, they excised burns on his right arm and grafted more skin from his thighs. Two days later, they covered excised skin from his legs and ankles with donor skin from his back. Every time Fultz went to surgery, Price made a new chart and taped it to the wall.
With a big burn, excision and grafting is done in stages — about 20 percent of the body at a time. Patients without enough unburned skin for use in grafting receive allografts, skin from cadaver tissue donors. This skin covers the wound for about two weeks before the body rejects it. By then, surgeons can take skin from the patient's newly healed donor sites, or use cultured epithelial cells, epidermis grown in a laboratory from a small sample of the patient's own skin cells.
Excising and grafting have reduced infection rates among burn patients and reduced the number of days they stay in the hospital. But the procedure has its risks, as well. "It's not only the burn you worry about, it's the donor site, too," says Price. Every time surgeons take healthy skin, they create a new wound, in effect a second-degree burn, that needs to be dressed and watched for possible infection. And skin grafts sometimes fail. New skin attaches when blood supply from the wounded area finds its way into capillaries in the donor skin. A collection of pus or blood under the graft can cause new skin not to attach, and simply bumping a new graft can shift it out of place.
For four days following each skin graft, Fultz remained in bed. When his dressings were removed for the first time after the graft, what staff on the unit call "take down," nurses and doctors looked for the grafted area to be pink and healthy, not white and dead. While waiting for his grafts to adhere, Fultz worked with a physical therapist in his room to regain lost strength and make sure that his body's response to his burns wouldn't leave him permanently debilitated.
Superficial burns heal by regeneration of the epidermis, the top layer of skin, explains Spence. But deeper burns heal more slowly and form scars. "Burn injury results in a loss of normal tissue," he says. "Cells called fibroblasts come into a wound and correct this loss in tissue by depositing collagen. This mass of new collagen is referred to as scar tissue," he says.
The longer the wound remains open, the more fibroblasts come into the wound and the more scarring occurs. "Placing a graft on a fresh wound and closing it early reduces the amount of scarring," he says.
Scar tissue tends to contract as it heals. If a scar develops over a joint, the joint's movement can be restricted by a tight scar band called a contracture. Physical therapy can minimize this tightness. "When physical therapy and maturation of scar tissue fails, surgery can be used to sever the tight band and place new skin in the resulting defect to help the patient regain full range of motion," Spence says.
Fultz's right arm, burned across the elbow, had been in a splint since the day he was admitted to Bayview, to keep the elbow extended and help prevent a contracture from forming. While bedridden for several weeks, he wore specially crafted boots to prevent his feet from becoming fixed in a pointed position. "It's harder to regain lost motion than to prevent it from being lost in the first place," explains Linda Ware, an occupational therapist on the burn unit.
Physical and occupational therapists work with patients daily, helping them exercise their muscles, regain movement and range of motion, and learn how to walk and eat and sign their names all over again. "Sometimes, a lot of times, rehabilitation is put on the back burner when a patient is very ill," says Ware, who has worked with burn patients for 17 years. "We're not saving their lives, we're helping them recover."
As soon as he could, Fultz went to the unit's rehabilitation gym daily. It wasn't easy. He recalls the pain that accompanied his exercise sessions with physical therapist Mary Bernard. Lying on a mat, he would raise his right arm over his head and she would pull and pull to stretch the scar tissue from his wrist to his trunk. "God that hurt," he says. Scar tissue on his chest pulled his shoulders down and caused him to stoop. "His posture was atrocious," says Bernard, who has worked on the unit for two years and helps run the burn patient support group. She'd remind him to stop slouching whenever she saw him. "You're uneven again," she'd tell him, and he'd do his best to push his shoulders back.
Fultz remembers how scared he was the first time he walked after the accident. He was in his hospital room and had been in bed for nearly three weeks. The skin grafts to his legs had taken, and his legs and ankles were tightly wrapped in elastic bandages for support. "Even though his blood supply had grown into the skin graft, his venous system needed support from the bandages on his legs to help return the blood to his heart," Bernard explains. Fultz swung his legs over the side of the bed, moved toward the edge, and stopped. He was nervous. It felt like blood was pooling in his legs. "What if the skin doesn't hold and blood and fluid just come rushing out?" he worried. "What if my legs can't hold me?"
He gripped the walker and pushed up. He stood there for a moment and took his first step. Physical therapist Annie Welty held him steady from the back of his waist and cheered him on. He took five steps. Within a few days he was walking on his own.
As the ability to save people with massive burns
has increased in recent years, so too has the recognition
that some burn patients need additional psychological and
social support. "It used to be that if adults got burned
over 80 to 85 percent of their bodies, they were likely to
die," says James Fauerbach, the Burn Center's chief
psychologist and an associate professor at the School of
Medicine. "Now it's quite possible to have patients with 90
or 95 percent burns walk out of the hospital. That's great,
but it's also a challenge because of psychological and
social problems related to the scarring and the trauma that
these patients have experienced."
|"What happened to me was a mistake, an accident. Other people have made the same mistakes. It was reassuring to talk to them and know I wasn't alone."||
Fauerbach is nationally recognized as a leader in
psychological research and clinical care of patients with
burn injuries, including secondary complications such as
post-traumatic stress disorder, depression, and body image
dissatisfaction. "There is much work being done by basic
scientists, surgeons, and wound-care specialists to improve
cosmetic outcome; however, severe burn injuries result in
patients leaving the unit looking quite different than
before their injury," he says. In addition, physical
challenges such as pain, limited strength and endurance,
and poor tolerance for heat or cold, plus psychosocial
challenges from altered appearance or traumatization, make
it difficult for many to return to work or participate
fully in the community. For example, about one-third of
burn patients suffer from nightmares, depression, or an
inability to relax or sleep. "These problems with sleep
disturbance and severe depression can be part of
post-traumatic stress disorder but also constitute
significant problems on their own," he says.
Fauerbach and his team meet with patients on the burn ICU as soon as the patients can talk. As part of a multi-faceted approach, they see patients throughout their stay and use cognitive behavioral therapy and other methods to help patients adjust to the trauma and to changes in their appearance and function. Sometimes patients with depression and extreme anxiety may be treated with medication. Other methods, such as exposure therapy, encourage resilience and positive coping so that burn patients recognize they can return to the place where they were burned and learn to deal with the stares and comments of others. "Trauma stops us in our tracks," he says. "Like a deer in the headlights, it makes us stop, look, and listen. This is a useful thing to do after a life-threatening event. However, after that, it is important to find healthy ways to get back into life."
Fultz didn't have major psychological issues as the result
of his accident. His girlfriend, his family, and his
friends were a huge source of support. But he did struggle
|Burn nurses perform twice-daily dressing changes dressed in plastic-coated gowns, hats, masks, and protective gloves.||
Fultz didn't see any mirrors in his hospital room. He had been in the hospital for about three weeks when he started agitating for one. He had shielded his face with his arm when the can of rubbing alcohol exploded, so the damage there was superficial. Still, he could feel the burns on his face and right ear, and he was curious. He asked for a mirror again and again until he eventually cajoled someone into giving him one. The sight of his face with its raw, red scabby surface stopped him cold. "Is it permanent?" he asked.
It was too early to know, and the experience triggered a bout of depression, in which Fultz wouldn't talk and wouldn't eat. He just lay in bed, and his healing stopped. Finally, after three days, he had enough of his own wallowing. "Screw this," he said to himself. He had never been negative or anything other than self-sufficient, and he wasn't about to start. So he ate. He did his exercises. And during his last weeks on the unit, he started visiting other burn patients, asking them about their injuries. He'd wander in and say, "Hey, what happened to you? Do you want to talk?" Usually they did.
One man had poured gasoline into a hot lawn mower and the engine exploded; he was burned over 55 percent of his body. Another patient, a landscaper, had burned more than 93 percent of his body in an accident at work and had been on the burn unit for 15 months. And then there was the man burned by the jet engine fuel he had used to start his barbecue grill. Talking to them made Fultz feel lucky that he had survived.
"What happened to me was a mistake, an accident," says Fultz. "Other people have made the same mistakes. It was reassuring to talk to them and hear their stories and know I wasn't alone."
Fultz endured his first 48 hours on the burn unit, the three surgeries, the pain of daily dressing changes and debriding, and the fears of what his life might be like after he was discharged. He survived his injuries and got to go home to a life that looked a lot like the one he had before. That's happening more and more at the Hopkins Burn Center, where mortality and infection rates are at an all-time low and the average length of stay for patients has been steadily dropping over the past five years.
Also of note is the emphasis placed on clinical research in the last two years. The Burn Center focuses on research it can use to treat patients and improve care. Currently, there are some two dozen research projects in progress on the unit, covering everything from new therapies and wound healing to rehabilitation.
Doctors told Fultz he'd be lucky to be home by Halloween or
Thanksgiving. But he healed faster than they predicted. He
was discharged from Bayview on September 23, 2006 —
31 days after the accident. That morning, before the
discharge, he was so overwhelmed by thoughts of everything
he wouldn't be able to do like he used to — lacrosse,
mountain biking, going outside without sunscreen —
and by worries of how he and Melissa would keep up with the
dressing changes and rehabilitation, that he passed out in
the tub room shower.
|Sanovia Lee-Oden and Fultz embrace during his recent visit to the unit.||
When Fultz returned to his room, Shoemaker sat him down for a talk. "Don't let this get to you," he said. "You've got to beat it. Go outside. Find ways to do what you love. Just don't stay inside and let it get to you."
Once he was home in Catonsville and his open wounds had healed, he had to wear a special compression suit day and night for a year, to help flatten out the topographical map of bumpy purple scars enveloping his arm and chest and legs. Unable to go up stairs when he first came home, he lived in the basement.
He now does rehabilitation exercises several hours a day, including throwing a baseball against a pitch-back for 60 minutes. The scars itch like crazy, and the pain hasn't gone away yet. Perhaps it never will. He hasn't had nightmares from his accident, but Kesner has. "I have the physical effects of the accident; Melissa has the mental ones," he says.
The first time he hit the ignition on his gas grill, he was startled by the sound of the gas and the flame meeting: Pffffffffft. Whoosh. He dropped to the ground.
"My heart nearly stopped when I heard that," he says.
As soon as he could, Fultz returned to work and played lacrosse and football with his co-workers on his lunch hour. He took camping trips with his friends and beach vacations with Kesner and her two children. When the sun was too hot for him, he came out at night instead. "I've become nocturnal," he jokes. And after 11 years of friendship and a little more than a year of dating, he has proposed to Kesner. They plan to get married in May.
Sometime this year, Fultz will likely have Milner do more surgery, to release a contracture in his elbow. First he must wait until his scars have fully matured. He could also choose to have reconstructive surgery to help minimize the appearance of his scars. But at this point he's not looking to go back to the Burn Center anytime soon. Not as a patient anyway.
When he was at Bayview surrounded by people dedicated to helping him recover, and talking with other patients about their burns, Fultz started thinking about changing his career. With Shoemaker's urging, he decided to become a burn nurse, and he'd like to work at the Johns Hopkins Burn Center. After all, he wasn't bothered by seeing people's wounds. He liked talking to burn patients. And he was impressed by how hard the nurses worked and how compassionate they were. Fultz started nursing school at Catonsville Community College earlier this year and will graduate in 2009.
"All the nurses who took care of me, they're all great, but none of them has gone through the experience of being a patient on the burn unit like I have," he says. He hopes to volunteer on the unit with Kesner. He imagines how it would be to talk with patients in the tub room, people who know tremendous pain and fear it. Fultz, more than anyone on the unit, knows how it feels to be not just a burn patient but a burn survivor.
"I've done it," he will tell them. "You can do it, too."
Maria Blackburn is a senior writer for Johns Hopkins Magazine.
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