More Than Skin Deep
Burn unit nurse's passion for her work infuses her care of patients with life-altering injuries

By Heather Stringer
November 21, 2002

'I'm going to take your pillows away and we are going to give you a little bath." Fran Kitt, RN, raises her voice to grab the attention of a large, drowsy patient swathed in gauze.

He nods vaguely as Kitt and two other burn unit staffers gingerly begin peeling off layers of gauze to uncover the tender-or sometimes dead-skin below. The man starts flailing from the pain as a burn care technician daubs saline on his charred right knuckles. The sensitive, pink patches on his fingers actually bode well: a sign that parts of the skin are still alive.

But Kitt's gaze halts as she spots a pale, gray section on the man's back. After 20 years in the burn unit at Santa Clara Valley Medical Center in California, Kitt has seen the fate of bloodless areas like this.

This patient had been driving his car as usual during the early evening the day before when motorists started waving at him. He suddenly realized his car was smoking, but he pulled over only to discover his brakes had failed. The man, in his 20s, was trapped in the burning, smoking car as it rolled down an embankment. The flames destroyed 30 percent to 40 percent of his skin, leaving him at risk for infection, swelling and dangerously low blood pressure.

Although burns can be among the most devastating, life-altering injuries, Kitt said she is hooked working on a team that tries feverishly to give patients a chance to overcome the odds. "The people here are dedicated, crazy and fun," Kitt said. "You have to be a little crazy to do this job, but it's like a family here."

Kitt is one of a small number of nurses in the nation's 139 burn centers. These nurses must endure the often-grueling task of preserving the body's largest single organ-one that is vital for temperature regulation and protection against a plethora of germs. To catch a glimpse of how these nurses reverse the work of flames, scalding water, caustic chemicals and electricity, NURSEWEEK followed Kitt for a day.

Critical watch

Kitt leans toward one of the many machines monitoring the man's progress as she checks his urine output. She wrinkles her forehead. The burn team is racing against the body's natural response to leak fluid from damaged capillaries and other vessels. This leakage leaves precious little fluid for blood to flow to vital organs. To prevent organ failure, the burn team is pumping the man with a vast 13 liters of fluid-about 3½ gallons-during his first 24 hours in the hospital.

The test of their success is his urine output, and this man's urine flow is too close to the minimum of 30 cc's.

Kitt talks in a hushed voice with Andria Booth, a young new nurse she is training for the burn unit, while two of the patient's relatives sit quietly in the room. Kitt is concerned because the patient has refused to take any blood products because of his religious beliefs. If he were to take the plasma, it would reduce the swelling and retain fluid in his vessels, which would increase his urine output.

"It won't kill him [to refuse the blood product], but it will prolong his healing," Kitt said. The team takes another tack to bump up his urine flow: pump him with more IV fluids.

Kitt knows just how critical it is to keep watch over these details, even for patients who appear to be recovering smoothly.

Once, the unit received a pilot who'd crashed his plane and was burned over 80 percent of his body. She'd expected the man to survive, but after a few weeks he started to deteriorate and died from infections. Another time, she cared for a man who was burned nearly 100 percent after a heater exploded.

"You can't predict," she said. "The man who was burned 100 percent healed like a snake and never needed a graft. That never happens."

Although there are always anomalies, Kitt said a patient's attitude can be one of the best weapons in healing.

"More often than not, people who are positive, functioning and motivated pre-burn are more successful in healing," she said. "People who are more negative and less motivated often do worse."

The burn unit cares for about 150 patients a year, and about 90 percent eventually leave the unit alive. A patient's recovery can range from days to months, but usually hospital stays are about a day or day and a half multiplied by the percentage of burn. (An 80 percent burn victim would likely need about 80 to 120 days to recover.)

Flame and scald incidents are the most common causes of burning among adults, while the majority of toddlers arrive with scalds. Early in her career, Kitt discovered that these accidents can strike anyone, which is both a blessing and a curse for the people who work with the victims.

"Here, you get all walks of life, all ages," she said. "You also get a huge variety of acuity, and I like the variety. But the hardest thing is to see the kids, especially the abuse part of it. It's hard to remain detached."

Personal healing

Jill Sproul, RN, nurse manager of the burn center, is a walking example of a child burn survivor.

She was 7 years old when her older sister was struggling to light a fire on a family camping trip. Her sister decided to hunt for lighter fluid, but when she began pouring the fluid into the fire pit, the can ignited. The fluid turned out to be gasoline. Instead of dropping and rolling like her sister, Sproul started running. She was 60 percent burned from the accident and spent five months in the hospital.

Throughout those five months and the additional hospital visits during her childhood, Sproul remembers befriending the hospital staff. The experience prompted her to pursue a career in burn nursing to help others like herself.

Sproul peeks into the room where Kitt is finishing the daily dressing change.

"OK, we are going to turn you to your left," Kitt says loudly to the patient. After removing three layers of gauze from his back, she points to the grayish patches on his motley, burned skin. These sections may need to be replaced with living skin from other parts of the patient's body.

Even after any grafting is complete, a new battle begins to halt the natural hardening of the scar tissue in the grafted areas. The scars thicken and harden for a year after the procedure, so patients are sometimes forced to wear tight, elastic garments to keep scar growth to a minimum. Other times, the grafted skin areas fail to sweat, while healthy areas overcompensate by sweating profusely to regulate temperature. For some, this means staying indoors on hot days.

Other people on the burn unit focus on helping patients face the devastating disfigurement. Kitt has seen victims who lose their eyelids, noses, ears, not to mention the grafting that can leave faces distorted.

At the moment, though, Kitt is focused on fighting any infections that are vying to take the life of the car accident patient. She wipes a strong antibiotic on his ears, which are at greater risk of infection because the ears have less circulation than other parts of the body.

It's been nearly an hour since she, Booth and the burn care technician started re-dressing the man's wounds. Kitt admits that even simple dressing changes can be grueling at times because the skin contact often causes severe pain.

In the midst of the somewhat somber routine, a quick smile suddenly flashes across Kitt's face. She's looking at the urine machine. The patient has won the first of many small battles: His urine flow is up to 58 cc's.

It is cause for hope that this man who was burning in his car may be on the road to recovery, and it is victories like this that Kitt has learned to savor.

"Sometimes, I get overwhelmed with other people's tragedy, but when an 80 percent burn victim goes home, that'll make you cry."

Contact Heather Stringer at heathers@nurseweek.com