Battling Burns : Medicine: Advances in treatment have increased survival rates in serious cases. But soaring costs are forcing hospitals to close specialized wards.
The signs for Robert Martinez were not good when he arrived at the hospital four months ago. They rarely are when a body is stripped almost completely of the familiar insulating layer called skin.
With more than 80% of his body burned in a refinery steam explosion and his lungs horribly damaged by contaminants from the blast, Martinez could breathe only with the aid of a ventilator as he lay comatose in his specially equipped bed at Torrance Memorial Medical Center.
That he was covered nearly head to toe in bandages and splints provided dramatic evidence to only part of his plight. His body was so traumatized that all of his organs were failing. Infections were ravaging through his wounds. His eyelids were blistered shut. The fact that he already was severely deaf seemed almost trivial.
But Martinez went home recently, an achievement that stunned even the battle-weary crew at the hospital’s prestigious burn center. The fact that the 26-year-old construction worker is still alive is a testament to the strength of the human body and to the expertise of the specialists that assemble at the burn unit to care for people traumatized beyond recognition, and often, beyond hope.
But despite advances in burn care, critical-care centers such as Torrance’s have been disappearing in the last decade, victims of soaring health care costs that have led to the near collapse of trauma care networks nationwide.
Nowhere is that more true than in Los Angeles, where nearly a dozen hospitals have pulled out of the once-prestigious critical care network in recent years and the number of beds for acute burn victims has decreased by 50%.
Burn centers have been hit especially hard by rising medical costs. There are few traumatic injuries more expensive to treat than burns, largely because of the intensive, round-the-clock care and multiple surgeries required for those patients. A disproportionate share of burn patients are uninsured, according to medical experts, forcing hospitals to absorb the costs, which can easily exceed $500,000 per patient.
Brotman Medical Center in Culver City was forced to close its burn center five years ago, citing significant losses caused in part by a reduction in government reimbursements. The burn center received national attention for treating pop star Michael Jackson after the back of his head was burned during the filming of a Pepsi commercial.
Jackson later gave the burn center--which was named for him--a large endowment for research into burn treatment.
Torrance hospital officials placed their burn center on the critical list a few years back, citing the growing number of uninsured patients they were required to treat because county burn beds were filled. In 1989, the hospital wrote off as charity almost $1 million--the amount it cost the hospital to treat six burn patients.
Hospital officials later went public with their problem, saying that unless the county emergency network could figure out how to place more burn victims in county hospital beds, the medical center would shut down the unit because it could no longer afford to care for so many uninsured patients.
Hospital officials say the problem remains unsolved. If there is a major disaster in the area, they say, it could force the county’s three remaining burn centers back into intensive care.
“It’s a constant struggle,” said Ray Rahn, Torrance Memorial Medical Center’s chief operating officer. “It’s a big gamble for a medical institution. The exposure is always there and in a catastrophic case, where you would have dozens of burn victims, it could make the difference.”
County health officials say the problem is compounded by limited reimbursement to hospitals by the state. Health care officials estimate that an acute care patient costs the hospital $4,000 per day, while Medi-Cal reimburses at a rate of $1,600. Indeed, a single burn patient can easily use more than $100,000 worth of wound dressings during a typical stay.
“A patient with a 70% to 80% burn can be a tremendous financial burden,” said Dr. A. Richard Grossman, director of the Sherman Oaks Community Hospital burn center. “And now that we can save those patients that we couldn’t save years ago, it’s a much more costly process than ever before.”
David Langness, vice president of the Hospital Council of Southern California, said additional financial help is needed for hospitals that have agreed to stay in the burn-treatment business. “But that’s very tough to do because the money isn’t available,” he said.
About 50,000 people are hospitalized in the U.S. each year with burn injuries, said Baltimore physician Andrew Munster, secretary of the American Burn Assn. Yet the burn association estimates that only one in five patients is treated at a specialized burn facility because not enough beds are available.
“The problem has been that it is hard to place those individuals who most need to be referred to a specialized burn facility,” Munster said. “Some people just never make it, as a result.”
Los Angeles County, with more than 8 million residents, has 17 such intensive care beds, down from 35 in 1987. When the beds are occupied, victims must be flown to other counties or out of state.
And while the number of beds for burn patients has been dwindling, the need is increasing. The Office of Statewide Health Planning and Development predicts that by the year 2000, Los Angeles County will require a minimum of 40 acute care beds, when the population is estimated to exceed 9 million.
The availability of beds is further diminished by critical staffing problems that have plagued most burn centers. Health officials have estimated a 75% annual turnover of nurses at County-USC Medical Center. Burn specialists say the problem is compounded since it takes more than a year to train a qualified burn nurse.
But Todd Dimas was lucky. When the refinery blast occurred at Chevron’s El Segundo plant Jan. 23, beds were available at the burn centers in Torrance, at Sherman Oaks Community Hospital and at County-USC Medical Center. After he was stabilized at a local clinic, Dimas and Martinez, his nephew, were taken to Torrance.
They were standing on scaffolding about six feet above the ground when a sudden rush of steam filled a small silo where they were working. Dimas suffered burns over 40% of his body and serious lung problems after inhaling large amounts of black coke, one of the refinery’s byproducts. After undergoing three skin grafts during two months of hospitalization, he recently began the painful rehabilitation process to regain full use of his arms, hands and legs. Martinez’s injuries were much more severe and his rehabilitation is expected to take two years.
Medical experts say burn centers and neonatal intensive care units are among the most labor-intensive areas in health care, requiring teams of highly skilled personnel. Victims may require hospitalization of six months or more and years of rehabilitation.
Major burns are considered “catastrophic” injuries in that they can affect most body organs. While physicians must battle the constant threat of infection, they must also battle the clock to graft as much skin as possible to cover the wounds. The larger the burn, the less skin there is to graft. If infection sets in, the problems are further compounded. Because lungs are often damaged by smoke or chemical fumes, they can lose their ability to oxygenate blood. When the pulmonary system shuts down, kidney or liver damage can result.
At critical junctures, the internal systems of a badly burned human collapse like dominoes. “So much energy is expended by the body to fight the trauma that the person just runs out of gas,” said Dr. Neal Koss, medical director of the Torrance burn center.
Dr. Bruce Zawocki, medical director of the burn unit at County-USC Medical Center, the county’s largest, said that in the event of a major disaster, the capacity of the units can all be expanded, but only for a limited time.
Ironically, advances in treatment have led to longer hospital stays, which mean increased costs. Three decades ago most severely burned patients would not have survived long enough to require extensive medical care.
According to Dr. Arthur Mason, chief of the laboratory division at the Brooke Army Medical Center in San Antonio, a 21-year-old man admitted with burns over 50% of his body stood a 50% chance of surviving 30 years ago. Now a person with the same injury has an 85% chance of surviving.
Breakthroughs in the “harvesting” of skin from the victim’s body have helped enormously. Rather than waiting long periods and risking infection, surgeons perform skin grafts to cover the burned areas within three weeks after the patient is admitted. The grafts prevent fluid loss and bacterial infections, which are leading causes of death in burn patients.
