When flames shot up over his head from the engine he was repairing, Wardell Guyton thought he was going to die. With his clothes afire, he ran screaming from the burning Volkswagen into his Northeast home. His wife smothered the flames with an overcoat.

Guyton, 31, a doctoral student in physics, was more fortunate than many severe burn victims. He talked about his accident and the painful ordeal of treatment for his seared limbs recently at the Washington Hospital Center's burn unit - a medical facility unlike any other in the Washington area.

It is a place where most patients are in pain around the clock. The treatment is often more agonizing than the injury. Enormous efforts, costing five times that of average hospital care, are spent on persons whose deaths are almost certain from the time they enter.

Nurses and acute care technicians who work the nine-bed unit say they are constantly drained by the intense emotional and physical demands. Lifting, exercising and perpetual handling of patients are routine. Patient stays are measured in months, and the attachments they develop with staff are difficult to break. And, above all, there is the ordeal of hurting people in order to help them, staff members said.

"They scream, curse, yell and sometimes kick you, but if you stop to think about it you know it's the pain they're mad at," said Barbara Ecklund, head nurse of the unit.

"I just block everything out and get by living from minute to minute. I can't look forward to anything," Guyton said. "Just deal with the pain."

With burns covering his body from the waist down, Guyron, still in the hospital after five weeks, said he "sometimes got disturbed when they (nursing staff) were pressuring me and I was walking and exercising, trying to do the best I could."

Former head nurse in the unit, Glennda Harrison, said she and other staff members have to use a great deal of diplomacy and sensitivity in applying the painful treatment. "I can't just saunter into a room and tell somebody 'I have to rip your body apart because it will help you.'" At the same time, Harrison said, nurses cannot shrink from their duties because "you know that if you don't (treat them) the person is going to die."

Dressings that stick in the open, draining woulds have to be stripped off and replaced every eight hours. Patients endure daily scraping and cutting away of the scorched skin, in a process called debridement, to prevent infection.

Frequently the demerol, laudanum or other pain reducing rejections "don't even put a dent in the pain" of these treatments, assistant head nurse Arlene Carosella said.

In addition victim of severe burns have their bodies invaded by tubes, needles and catheters necessary to monitor vital organs that are made extremely vulnerable by the destruction of the skin.

"A severe burn puts a lot of strain on all the systems of the body," Dr. Carlos Silva, acting director of the burn unit said.

If the burn is deep enough, the body automatically covers it with eschar, a leathery drawn "pseudo scar" that can be deadly if not removed, the unit's staff said. The material protects bacteria that can cause fatal infection, it can cut off blood circulation or suffocate a patient with chest burns, they said.

"And then there's Curling's ulcer, the internal sore that mysteriously accompanies burns," Ecklund said. Researchers have not isolated its cause, and the ulcer shows no signs until it break, often fatally, she said.

"I have to really get myself psyched up for it," Guyton said, as he sat with bandaged legs raised, and wait for the daily "tanking", a soaking, exercising and debridement hour in the large stainless steel Hubbard tank.

After the critical organs and body functions have been stabilized, it is Silva's job to "add insult to injury" as he described it, by shaving off as much healthy skin as the burns have destroyed, for the purpose of grafting the wound.

"Anybody that has a full thickness burn, where the skin is killed by the injury, has to have a skin graft done," Silva said. "So the problem is doubled for about 10 days until the graft takes."

Fatal burn victims are unusually those who do not have enough healthy skin left to graft. Medical science has not yet developed successful skin transplants, although the skin of a cadaver or young pig is sometimes used as a "physiological dressing" until the patient's own skin begins to heal, Silva said.

"A person with a 90 per cent burn has only 10 per cent left. Anything beyond 65 per cent or so, especially in an older patient," is usually fatal, Silva said. "The best I have on the street is an older man who was about 65 per cent burned, after six or seven years" in burn treatment, he said.

Like Guyton, who had third degree burns over 30 per cent of his body, many of the unit's patients are accident victims, injured on the job, or in repairing machinery at home. Staff members said they occasionally get self-immolation cases, or patients deliberately set afire by others.

The single most frequent cause of severe burns however, is careless smoking in bed, Silva said.

Only adult burn patients are brought to the Hospital Center, while those 14 or younger go to a similar unit at Children's Hospital. Staff members in the adult unit said they believe the treatment they give is more complex because of the psychological effects on grown-ups of burn injuries.

Dr. James Collins, a consulting psychologist to the burn unit, said he sees no great difference between the mental hardships of burn patients and those of any other severely injured or ill person. Members of the unit's staff disagreed.

"When somebody breaks a leg or has surgery, the body image is threatened (temporarily), but these people are going to have an altered body image forever," said Glennda Harrison.

The burn unit is seen as a special place by those who work there, both for its difficulties and its rewards, they said.

Patients are generally grateful for their care, and return to visit after they are discharged. For some, however, the resulting scars explode their hopes that they will heal back to their original appearance. "They leave hating us," nurse Carosella said. And even more depressing, about 30 per cent of the patients die, workers said.

"The intensity with which the staff gets involved in people's care is a lot higher here," said Harrison. "We're really kind of responsible for that person's life.

"You learn to isolate the patient from the wound," Ecklund said. "Until you see the look on their faces when they realize its part of them, a definite body image destruction."

It takes a great deal of humor to work in the unit said Carosella. Other hospital workers "look on us as a colony of lepers," and burn unit workers do not associate much with other staff members, she said. Burn unit workers have to wear grey surgical gowns, paper shoe covers and caps at all times to prevent infection. They rarely leave the ward for lunch, and work four 10 hour days to modify the strain.

"There is so much suffering that it would be hard to take, but then you realize that you are treating the injury for the good of the whole patient," Silva said. "It makes me feel good."