A Valentine's Day bouquet of balloons and 165 get-well cards taped on the walls are among the brighter memories 9-year-old Lisa Wilder has of her stay in the burn center at Children's Hospital in the District. She prefers not to remember the excruciatingly painful daily baths in austere gray metal tubs, where the dead skin was scrubbed from the burns on her chest, and the repeated bandaging of her wounds.
But a stream of nurses, therapists and doctors kept Lisa, burned while playing with matches, from drowning in depression during those seven weeks in the hospital, and kept her mother, Barbara, sane.
The team of medical workers that runs the burn unit includes surgeons who removed thin layers of skin from Lisa's thighs to graft onto her chest, nurses who cared for her and watched TV with her, a dietitian who let her eat her favorite foods, a psychiatrist and a child life worker who talked to her about being sad, the physical therapist who helped her regain the use of her arms and the social worker who offered moral support and helped Lisa's mother make financial arrangements to pay the $27,000 hospital bill.
The 16-bed unit at Children's Hospital National Medical Center is the only children's burn treatment facility between Baltimore and Richmond.
It is perhaps the most heart-wrenching section of the hospital. There the daily challenge of the staff is to buoy the spirits of children who are in constant pain and who may be disfigured for life, to keep massive infection from invading their small bodies and to comfort frantic and guilt-ridden parents.
It is not an easy place to work. Frightened and hurting children often scream and cry. Sometimes they die. Sometimes only an old school snapshot taped on a patient's door gives a clue to what the child looked like before the accident.
Staff members, most of whom are under 35 years old, agree that it takes a special kind of fortitude to work in the burn unit. The hardest thing, says unit coordinating nurse Joan Holihan, is "recognizing these treatments are beneficial, but knowing that you are inflicting pain to get (the children) well."
This painful but most important aspect of burn treatment is continually removing the dead skin, a process called debriding, explained Chief Surgeon Judson Randolph. This is done by scrubbing, peeling or surgically removing the "burned leather" so healthy skin will grow over the wound, or so the wound is clean and smooth enough for a graft, or skin transplant, Randolph said.
With most burn patients, the immediate concern is the massive loss of fluids and possible shock, explained Randolph in his Texas drawl. The first task is to replace those important fluids, vitamins and minerals through nose tubes to the stomach and intravenous tubes into an arm vein.
Nurses say that when children are recovered enough to eat, persuading them to consume the large amount of calories they need to heal is a major challenge.
Across the country, burns cause 10 percent of all accidental deaths of children under 14, about 1,250 a year. Far more are burned and survive.
Between January and October of this year, 176 children were treated at the Children's burn center, staying in the hospital an average of 21 days.
In the winter when wood stoves, space heaters, fireplaces and flammable holiday decorations are in use, families must be especially watchful of curious children who run the risk of being burned.
According to the hospital staff, scalds are the most common types of burn, occurring when toddlers spill hot cups of coffee, turn over pots on the stove, or are burned by hot tap water in the sink or bathtub. Other common causes of burn accidents are small children's fascination with matches and tendencies to nibble on electrical cords. Teen-agers are most often burned while cooking. They also suffer a high proportion of chemical burns and are burned by electrocution, usually when playing near railroad tracks.
Randolph said that 10 percent of the burns seen at the hospital are not accidents, but the results of child abuse. Occasionally the unit has treated children who were innocent victims of adult vengeance and arson.
"We have more social problems here than anywhere else in the hospital," Randolph said.
Social worker Mary Berlin agrees. Although she said it is difficult to keep such records, Berlin said she feels that an unusually large number of the children hospitalized for burns are from families with single and often very young mothers, or whose parents have marital problems or abuse drugs or alcohol.
"The supervision is so poor; (parents) are preoccupied with their own problems so they aren't emotionally available (to watch their children )," Berlin said.
Holihan said parents sometimes punish young children by putting them in hot water, or leave them unattended, not realizing the severe damage that can be done to tender young skin by a few seconds' exposure.
"So often the family (said they) just had no idea," Holihan said. Hot water from the tap can cause the skin to peel immediately. Regardless of pigment, the skin turns white and angry red -- "like after you boil a lobster," she explained. A great many children at the unit have required grafts sutured on their feet, buttocks and backs of their thighs because of scalding. Often the scars are permanent.
Accidents happen even in the most careful families, however. A few weeks ago at her home in Silver Spring, 11-month-old Angela Douglas toddled unnoticed into the kitchen where her mother was preparing dinner. The child's mother, Andrea Douglas, said Angela apparently fell forward against the glass window of the oven and burned her lip and the palms of her hands. Randolph said glass oven door burns are becoming increasingly common.
"My first reaction was to put her hands in cold water," said Andrea Douglas, a graphic artist. She said she's thankful she remembered reading somewhere that cool water, not butter or Vaseline, should be applied to burns.
Angela will probably stay in the hospital two more weeks until the graft on her right hand heals. Physical therapist Nancy Garrett explained that splints are put on the baby's hands when she sleeps to keep them spread open so the skin will not contract and the tiny hands will not heal in a claw-like position.
In more severe cases, a child who is being discharged would be fitted with a Jobst garment. This beige, elastic-like outfit is worn under clothes and is very snug. It reduces the puffiness of scar tissue as it heals. The Jobst face mask is frightening -- it looks just like Spiderman.
Cynthia Moats, a child life worker, a new category of medical professional who combines the skills of social worker and child psychologist, is on hand to hold and play with Angela and to encourage her to use her burned hands. Moats also helps children understand why they must endure the painful baths by allowing them to play nurse and scrub injured dolls in miniature bathtubs. Moats has a special treat for the critically injured patients whose mobility is restricted: a brightly decorated playroom complete with a yellow, heated waterbed. Moats said a change from the patient's own hospital room helps morale.
The child life worker also arranges goodbye parties for children who have been on the unit so long that they don't want to go home. Moats and other staff members also visit schools to explain what to expect from returning classmates. Sensitivity training is especially important if the child is returning to school wearing a Jobst garment or has severe scars, Moats said.
Lisa Wilder had a serious mishap and came to know all the members of the burn team well. Last January, she was playing with matches in the bathroom of her grandparents' College Park home when a spark flew onto her clothing, which went up in flames and melted in a matter of seconds, leaving Lisa's chest and upper arms badly burned. Her family rushed her to Doctor's Hospital in Lanham, where she received emergency treatment before an ambulance whisked her to Children's.
"She was real depressed the first couple of weeks," recalled Lisa's mother. She said the child felt guilty and embarrassed about her accident because she knew she should not play with matches.
Lisa's treatment was typical of many of the children on "3-Green," as the burn unit is sometimes called. During the first several weeks, Lisa spent most of the time in bed, wrapped in bandages, a feeding tube down her nose and an intravenous tube in her arm. At night, her arms were bound to "angel wings," large wooden splints that stick out from the side of the bed to keep the skin on her arms and shoulders fully stretched.
Lisa's mother was allowed to stay in the hospital with her. Barbara Wilder says she was in a fog much of that time. "I remember I drank lots of coffee." Social worker Mary Berlin is on hand for moms like Wilder. "There were time when I was depressed and needed someone to talk to; she was usually there," Wilder said.
Lisa said she made many new friends among the patients and nurses during her stay on 3-Green. As she regained her strength, she often wheeled other patients down the green carpeted halls, past rooms with brightly colored orange, blue, yellow and green curtains.
But, she told a reporter as she gazed at the green knee socks gathered around her ankles, "I got sick of the color green." Asked if she remembers the painful peeling of bandages, the baths and the graft operations, she tossed her dark hair over her shoulder and said, "Ooh, don't remind me of that gross stuff."
With her mother acting as cheerleader, Lisa did daily exercises that were painful at first, and massages to keep the skin supple. The work has prevented the healing skin and muscles in Lisa's arms and shoulders from tightening, and now she can do almost anything she could before.
During the summer, Lisa went to camp and went swimming. She wore a T-shirt over her bathing suit to cover the discolored scars, which probably will not disappear. With the ordeal just about behind them, Barbara Wilder sighed, "I was really glad it (the burn unit) was available." The only thing she is still concerned about is that Lisa will be more self-conscious about her scars when she becomes a teen-ager.