A Valentine's Day bouquet of balloons and 165 get-well cards taped on the walls are among the brighter memories nine-year-old Lisa Wilder has of her stay in the burn center of the District's Children's Hospital. She prefers not to recall the excruciatingly painful daily baths in austere gray metal tubs where the dead skin had to be scrubbed from the burns on her chest, or the repeated bandaging of her wounds.
But a seemingly endless parade of nurses, therapists and doctors worked to help make Lisa well and kept her from drowning in depression during those seven weeks in the hospital after she was burned while playing with matches.
The multidisciplinary team that runs the burn unit includes surgeons who removed thin layers of skin from Lisa's thighs to graft on her chest; nurses who watched TV with her and monitored her progress daily; a dietitian who let her eat her favorite foods; a psychiatrist and a child-life worker who talked to her about being depressed; 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 hospital's 16-bed burn unit is the only children's burn treatment facility between Baltimore and Richmond. It is perhaps, the most heart-wrenching section of Children's Hospital. There, the daily challenge of the staff is to buoy the spirits of youngsters who are in constant pain and who may be disfigured for life, to keep massive infection from taking over their small bodies, and sometimes to assuage the consciences of 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 the patients' doors give a clue to what the children looked like before their accidents.
The occupancy rate of the burn unit has been high over the past several years and so has the level of tension because nurses usually bear the brunt of the responsibility for the children.
Hospital spokesman Harold Kranz said there was recently a "knock-down, drag-out meeting" where problems in the department were discussed. The hospital administration is currently considering hiring more doctors and nurses for the unit. "Everyone is concerned that the service has grown faster than the staffing patterns," Kranz said.
The staff members, most of whom are under 35 years old, agree that it takes a special kind of nerve and tolerance to work in the burn unit. The hardest thing, says Joan Holihan, the unit's coordinating nurse, is "recognizing these treatments are beneficial, but knowing that you are inflicting pain to get them well."
The painful but most important aspect of burn treatment is continual removal of the dead skin, a process called debriding, explains the hospital's 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 to for a graft, or skin transplant, Randolph said.
Nationwide, burns cause 10 percent of all accidental deaths of children under 14, causing about 1,250 deaths a year. Far more than that are burned and survive. Between January and October of this year, 176 children were treated at the hospital's burn center. These youngsters stay an average of 21 days.
According to the staff, scalds are the most common type of burn, particularly to toddlers who manage to pull over a hot cup of coffee, a pot on the stove, or who are burned by hot tap water in the sink or bathtub. Other common burn accidents are caused by children's fascination with matches and by nibbling on electrical cords. Teen-agers are particularly susceptible to burns while cooking, chemical burns and burns from electrocution -- especially from playing with cables along railroad tracks.
Randolph says that 10 percent of the burns seen at the hospital are not accidents, however, but cases of child abuse. Occassionally the unit has even 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.
Mary Berlin, a hospital social worker, agrees. She says the burn unit sees an unusually large number of children from families with single and often very young mothers, or children 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.
The punishment and negligence burns from putting children in hot water or leaving them unattended in the tub are often the most disconcerting because they can be prevented, Holihan said. The damage that can be done to tender young skin by a few seconds' exposure is widely underestimated.
"So often the family [said they] just had no idea," Holihan says. 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 explains. A great many children at the unit have had to undergo grafts sutured onto their feet, the backs of their thighs and their buttocks because of scalding. Often the scars are permanent.
Accidents happen even in the most careful families, however. Last April, when her mother wasn't looking, 18-month-old Elizabeth Posniak hoisted herself up to the edge of the dining room table and spilled her mother's cup of hot tea over her chest and shoulder. "I got there within the first 10 seconds," said Jane Posniak, "pulled off her clothes and she was already bright red."
The Friendship Heights mother took her child to Sibley Hospital and on to Children's. "I was expecting a bandage, some cream and go home." But because a toddler's skin is so fragile, what Posniak first considered a rather common household accident became a 17-day hospital stay for Elizabeth.
Several weeks ago in Silver Spring, 11-month-old Angela Douglas waddled unnoticed into the kitchen where her mother was preparing dinner. Andrea Douglas said her daughter apparently fell forward against the oven's hot glass window and burned her lip and the palms of her hands. According to burn specialists, burns from glass oven doors are becoming an increasingly common injury.
"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.
Because of her mishap, Lisa Wilder came to know all the members of the burn unit team well. Lisa was playing with matches in the bathroom of her grandparents' College Park home last January when a spark ignited her clothing, melting it in a matter of seconds and left Lisa's chest and upper arms badly burned. An ambulance took her to Children's.
"She was real depressed the first couple of weeks," Lisa's mother recalls. She said the child felt guilty and embarrassed about her accident because she knew better than to play with matches.
Lisa's treatment was typical of many of the children of "3-Green" as the burn unit is affectionately called. The first several weeks Lisa spent a great deal of time in bed wrapped in bandages, a feeding tube down her nose and an intravenous line in her arm.
Her mother says that although the daily exercises were painful at first, massages have prevented the healing skin and muscles in Lisa's arms and shoulders from tightening, and now she can do most anything.
But the scars on Lisa's chest and shoulders are not going to go away. Barbara Wilder is now concerned that Lisa will become more self-conscious about her appearance when she becomes a teen-ager.