| Saving the patient
10.27.03
By FELICE J. FREYER
Journal Medical Writer
Gina Gauvin went quickly into surgery.
More than 60 percent of her body had been burned in The Station nightclub fire, and all the dead skin had to come off within a week. Otherwise it would be food for bacteria -- and infection is a prime killer of burn patients.
On Monday, Feb. 24 -- four days after the fire -- the medical team at UMass Memorial Medical Center, in Worcester, removed most of the dead skin, cutting it off her scalp, back, arms, hands and fingers, in a procedure called debridement.
But a person needs her skin, and one who has been burned on more than half her body has limited healthy skin for grafting. And one who's on a ventilator, swollen and traumatized, can tolerate only so much time on the operating table.
"All the while the patient is bleeding, becoming cold and getting unstable," says Paul Savoie, the physician assistant who performed the procedure along with a resident and Dr. Gary Fudem, the leader of Gauvin's medical team. "You have to be able to work rapidly and precisely."
So it was a balancing act from the get-go, weighing one urgent need against another.
Working in saunalike heat to keep the patient as warm as possible -- 90 degrees and 90 percent humidity -- the medical team used an oscillating knife to shear off patches of skin from unhurt areas on her buttocks and right leg. This skin was passed through a mesher -- a pair of rollers with spikes that cut a pattern of small holes. It came out looking like a net. The skin could then be stretched to two to three times its original size. The holes also allow drainage of blood or other fluids.
The netlike rectangles of Gauvin's skin were stretched and stapled onto her left leg.
Skin can regenerate again and again. In patients burned virtually everywhere, doctors can, over time, graft enough skin from the soles of the feet or the scalp to cover the entire body.
To speed this process, Gauvin's doctors covered her back with a kind of "artificial skin" -- a collagen matrix derived from cadaver skin. With this matrix in place, doctors need apply only thin skin grafts, so the harvested areas heal more quickly and can be reharvested more frequently. Ideally, the matrix becomes permanently incorporated into the skin. But in Gauvin's case, much of the artificial skin became infected and had to be replaced.
At other times, when there was not enough skin to graft, the doctors used full-thickness frozen cadaver skin, which functioned like a dressing that could protect the burned areas for as long as two weeks. When she later heard about the cadaver skin, Gauvin chided her doctors for not at least getting her some with tattoos. But, in fact, the cadaver skin eventually was peeled off.
Denise felt she could always count on Gina
"GINA WILL be going in for another surgery," Denise Agin, her
41-year-old sister, wrote on the Web site, cricketfood.com.,
"tomorrow (Thursday) around 2:30 p.m. for more skin grafts on
her back. . . ."
It was Feb. 26 and Agin (known at the time as Denise Catallozzi; she changed her name when she married in June) was addressing an audience of lizard aficionados who knew her sister. For many years, Gauvin had kept and bred lizards, primarily bearded dragons. Gauvin found them as lovable as dogs and cats, but much easier on the furniture. She developed so much expertise that she became well known as an online source of advice on lizard care.
Cricketfood.com, an online seller of reptile food, had created a page and guestbook devoted to Gauvin, so her friends could follow her progress. The Web site also displayed some of Gauvin's artwork. As a hobby, she had painted colorful, detailed portraits of her pets.
Now the people who had consulted Gauvin about raising baby dragons were logging on to hear about her struggle to recover from burns. "As long as there are no signs of infection on her skin they will proceed. . . ," Agin's posting to the lizard community continued. "She is doing much better than the doctors anticipated but they also warn that it is still too soon to tell which way she will go. . . ."
Agin filed the medical reports to the lizard-loving world; she was also the one who gave the hospital permission for each procedure. She was amazed at how clearly and patiently Fudem and Savoie would explain what they planned to do. Sometimes she'd go to Worcester and read a book while the surgeons worked, often for four to six hours. In the early days, she felt she was living at the hospital.
Denise Agin was there to look out for her sister's well-being. But when they were children, Gina was Denise's protector, even though only a year and quarter separated them. In high school, when some girls threatened to "jump" Denise, she summoned her big sister, and one look from Gina was enough to quell them.
Gina was a fierce protector of animals, too. The family pet, a collie named Lad, had been rescued by Gina from a man who was beating it. Once a pit bull latched onto Lad's ear, and Gina used her bare hands to try to pry the attacker's jaws open. The only time Denise remembers seeing Gina cry was when Lad died.
Denise felt she could always count on Gina. "You need anything, you call her," she says. "She's always been there. It was like an unspoken thing."
Even so, in adulthood the family had not been especially close, Denise Agin says. The siblings -- Gina, Denise, Vincent and Renee -- kept in touch, but didn't talk or get together often. Probably the last time they'd all been together was at Christmas.
But disaster reeled them in and bound them together.
A slender woman with a tough but friendly demeanor, Agin is a shipfitter at Quonset Point. With a welding torch, she helps build barges. It's a physically demanding job, and also one with a great risk of burns. "I work with fire every day," she says. "I was terrified."
In the days after the fire, she'd go to the ladies' room at work and break down in tears. Worrying into the middle of the night, she would call the UMass nurses; even at 2 or 3 a.m., they were always happy to tell her how things were going and to chat for a while. The nurses amazed Agin. "They all care about her so very much," she wrote on the Web site. "They are all so very supporting."
HEATHER GAUVIN, at 18 the eldest of Gauvin's three children, also posted a message or two: "i saw my mother today," she wrote on Feb. 26. ". . . the doctors have woken her up and made her wiggle her toes and SHE DID!"
When Heather logged on to the computer, alone in her family's once-crowded apartment in Johnston, she found the last e-mail that her mother had sent. Would Gina ever write another e-mail? On the bed, Heather found some of her mother's clothes still laid out, left over from the last-minute what-to-wear decision before Gauvin went to the nightclub on Feb. 20.
Heather cried at every little thing, hardly ever slept. She had never imagined that it could be so hard to live without her mother.
When she couldn't stand it at home, she stayed with friends and relied on support from her boyfriend.
Heather's friends had always adored her mother; they loved her lizards, her attitude. She was a "cool mom." When Heather was little, she and Gina wore matching clothes. Her mother always had the prettiest outfits. Nowadays, Heather was wearing her mother's two rings, salvaged and returned by a kindly nurse at Kent Hospital, where Gina Gauvin had first been taken after the fire.
The biggest mother-daughter fights were about getting up for school. Gina once poured water over Heather to get her out of bed. But when Heather dropped out, Gina accepted her daughter's decision.
Now, rattled by crisis, Heather had dropped everything. She used to have two jobs, and was working on her general equivalency diploma, but all that was put aside. She spent her days running up phone bills and trying to find rides to Worcester, so she could visit her sleeping, wounded mother.
Heather would talk to her, tell her that everything was OK. When she talked about the family, when she mentioned Joseph and Shayna, the monitor showed her mother's heart rate going up.
Trying to ease the pain
WHEN NOT in the operating room, Gina Gauvin was wrapped from
head to toe in sterile bandages. Medication kept her deeply sedated.
Once a day nurses took her to the "spray table" -- a stainless-steel
table in a separate room of the burn unit. Hoses with spray nozzles
dangle from the ceiling.
Typically, the physician assistant, Paul Savoie, nurse Kathy Gaffney, and, if they were lucky, another nurse labored to unwrap the bandages, wash away the dead skin with special germ-fighting soaps, reapply the antibiotic ointment and replace the bandages.
To avoid infecting Gauvin, they all wore impervious gowns, caps, gloves and masks, and worked in a room heated to 85 or 90 degrees -- because burn victims lose their body heat easily. Each time, it took about an hour and a half, as they gently lifted and turned her to reach all the damaged skin.
This daily ordeal was exhausting for the medical staff -- and excruciating for the patient. Even when unconscious, burn patients often grimace during the procedure.
It's hard, says Savoie, for most people to imagine the pain of a severe burn. Savoie doesn't need to imagine it: he's experienced it. When he was a child, a charcoal grill fell on his back. He'll never forget losing a summer of his childhood to dressing changes; he'll never forget the sharp, searing, unremitting pain.
So Savoie strives to give patients enough medication to ease that pain, typically using morphine and Versed. He says it has taken him 10 years to develop the knowledge -- and the nerve -- to provide the right amount. Often, that means drugs in quantities that might stop an unburned person from breathing. Patients who are hurting badly have highly activated pain receptors that consume the morphine; they can tolerate much more medication than those who are well.
"Most people are too scared to give that degree of medication to the patient," he says. "It takes time to get there -- to feel confident that you're not going to kill the patient by giving them that much medication."
Meanwhile, Gauvin's metabolism had gone into overdrive from the stress and her body's effort to heal. As if she were running consecutive marathons, she was burning almost twice as many calories as normal. A slender tube through her nose delivered liquid nourishment to her small intestine, just below her stomach. This fuel was a carefully calibrated mixture of protein, carbohydrates and fats that were partially broken down.
Throughout March and much of April, Gauvin was wheeled into the operating room about twice a week for skin grafts and other procedures. Doctors removed what couldn't be saved: most of her burned left ear, her right pinky and the top two-thirds of the other fingers on her right hand. In all, she underwent 18 surgeries.
Gauvin's left arm was a particular challenge. She had been burned down to the bone around her elbow and on parts of her hand. Because bone has its own blood supply, skin can be grafted onto bone if the bone is sanded down until it bleeds. "It's not appealing; it's not ideal," Savoie says. "There's no padding. It's skin on bone. Sometimes you don't have a choice."
Unlike skin, muscle and fat do not regenerate. Individual muscle and fat cells get bigger or smaller, but adults can't grow new ones. The muscle and fat that had been burned off Gauvin's arm, and off parts of her flank, would never return. With enough exercise, the remaining muscle could grow to compensate somewhat, but Gauvin would never regain full function.
EVERY YEAR, according to the American Burn Association, some 45,000 people are hospitalized for burns, about half of them in one of the 125 centers that specialize in burn care.
But the average patient at a burn center has burns over only 14 percent of the body surface. Only 1 in 20 has burns over more than 60 percent of the body, as was the case with Gauvin and several other Station fire victims.
The five burn centers coping with The Station fire had their hands full, with an unprecedented number of severely burned patients. Rhode Island Hospital, in Providence, which treated the largest group of them, performed more than 40 skin-graft surgeries in two months -- about the number that the hospital would normally do in a year.
And not everyone made it through. Eight days after the fire, Linda Dee Suffoletto, 43, of Glocester, died at Massachusetts General Hospital, in Boston. Her husband had already perished in the fire. They left behind a son the same age as Heather. On March 1, Kelly L. Vieira, 40, of West Warwick, died at the Boston Shriners Hospital. On March 6, Mitchell C. Shubert, 39, of Florida, who had come to Rhode Island to visit a friend, succumbed to his injuries at Mass. General. The fire's toll had reached 99.
But at UMass, the four burn patients hung on. By mid-March, Gauvin was among 30 Station fire survivors in four hospitals (the last Shriners patient had been transferred to Mass. General). She was among 12 who were still listed in critical condition.
'Auntie, did Mommy cry'?
"AUNTIE, did Mommy cry?" 7-year-old Shayna wanted to know.
"Probably," Renee Walton replied. "But the doctors are giving her a lot of medicine so she won't feel bad."
Shayna did not visit her mother until near the end of her hospitalization at UMass. But Walton, Gauvin's younger sister and now Shayna's guardian, watched for openings to tell her -- bit by bit -- what had happened. The doctors had advised her not to volunteer information but to wait for questions -- and not to make any promises.
So Walton never said, "When Mommy comes home. . . ." It was always, "If Mommy comes home. . . ."
Walton says that Shayna Gauvin has always had a sunny disposition, and that, amazingly, her mother's calamity hasn't darkened it.
But Walton, a hairdresser, could rightly take some credit for that, for she was the one who took Shayna under her wing and prepared her for the new future. She told Shayna that if Mommy came home, the little girl would need to help around the house, and she gave Shayna responsibilities -- to feed the cat and dog, to fold the bedding from her temporary living-room bed.
On the night of the fire, Walton was awakened at home in Johnston by a frantic phone call from Heather, pleading into the answering machine, "Auntie, please, please pick up the phone!" Walton didn't panic. She figured her sister was down at the fire, talking to people, trying to help out. That would be just like Gina. Only when she heard that Gauvin had been airlifted to UMass did it begin to dawn on her that her sister was very badly hurt.
But Walton soon had another problem on her hands. As she was preparing to go to Worcester, her 15-year-old daughter, Jamie, had a seizure. So Walton detoured to Hasbro Children's Hospital, in Providence. As doctors were treating Jamie there, Walton was on the phone to UMass. All they would say was, "You need to get here now."
Walton brought Jamie home, and a neighbor came over to stay with her. (She had developed juvenile epilepsy.) With her boyfriend, Peter Morris, Walton picked up her mother, dropped Shayna with her Uncle Vinny and raced to Worcester. She kept thinking of the episode of E.R. in which the patient dies as soon as the family arrives.
They got to UMass around 6 a.m. Walton, who faints at the sight of blood, knew she couldn't tolerate seeing her injured sister at this time. She sent messages via others to let Gauvin know that she was there but couldn't enter the room. (She wouldn't enter until weeks later.)
When the family returned to Rhode Island, Shayna asked where her mother was. "Mommy is in the hospital. She was in a fire," Walton told her, adding that Shayna would stay with her.
Every night, Shayna prayed for her mother. And every now and then, she'd ask a question. One of her first questions was about her mother's hair. Walton said it had gotten burned. Placing her hand just below her shoulder, Shayna asked, "Is it up to here?"
"No."
The little girl moved her hand to her neck. "Is it up to here?"
"No," the aunt said.
"Then what?"
"She looks like Peter," Walton said, referring to her bald boyfriend.
Shayna burst out laughing.
The doctor wished Gauvin could take part in the decision
ON MARCH 17, the UMass doctors performed a tracheostomy. The
breathing tube through Gauvin's mouth would pose a risk of infection
if it stayed there any longer. But she clearly would need it for
weeks to come. So they cut a hole in her neck, just below the
larynx, and passed the tube through there.
Her lungs continued to struggle. As in most fires, the materials that burned at The Station gave off toxic fumes that form corrosive acids when they come in contact with the lining of the lungs. In response, the air sacs deep within the lungs become inflamed and swollen, making it hard for oxygen to reach the blood vessels. The ventilator, through the breathing tube, provides both concentrated oxygen and pressure to force it into the swollen areas of the lungs.
But doctors still have no way to prevent the tender lining of the lungs from thickening and stiffening, in response to the smoke and other factors. If this process damages too many areas of the lungs, the patient can die from lack of oxygen.
At the same time, bacteria proliferate in the warm, moist spaces in the injured lung. Soon, Gauvin's difficulties included pneumonia.
Her lungs were not the only place where germs were having a field day. Everyone carries microbes on his or her skin, and as long as the bugs stay on the surface, they cause no problem. But when skin has been burned away, the microbes have a chance to invade, and inevitably they do -- running especially rampant in patients whose injuries have weakened their immune system.
Gauvin was heavily dosed with antibiotics to fight off bacterial infections, but the infection that most worried her doctors was a rare, deadly fungus known as mucor. Her doctors had never seen it before and still don't know where it came from. If mucor got into her internal organs, she would die. But the antifungal medications can damage the liver. Again, the medical team struggled for the right balance.
"We were diligent and scared," Savoie said. "We knew the potential lethal nature of this infection. We don't often win that one."
The fungus, along with the bacteria, took up residence in Gauvin's blackened left hand. Hands have little meat between skin and bone. Although the dead skin had been removed from her hand and new skin grafted on to it, there wasn't enough living tissue to sustain new growth, and adequate circulation never resumed. Denise Agin, when she visited her sister, saw flat, black fingers poking out of the bandages.
By the last weekend in March, the infections were making Gauvin dangerously sick. She was running a fever. Dr. Janice Lalikos, the plastic surgeon who had taken care of Gauvin in the emergency room, was on call. Unable to reach Fudem on his cell phone, she e-mailed him, telling him it looked like time to act. He gave the go-ahead.
Lalikos is an artist, literally. Before she became a doctor, she earned a bachelor of fine arts degree in medical illustration -- taking her anatomical-drawing class together with medical students studying anatomy.
After graduating, she found herself drawn back to the classroom -- as a medical student. And Lalikos says her choice of specialty proved a "no-brainer": within the first year of medical school, this illustrator of the human form knew she would become a restorer of the human form -- a plastic surgeon. She specializes in correcting injuries and birth defects in children. But as do all the plastic surgeons at UMass, she also treats burn patients.
Lalikos knew that Gauvin was an artist, too, a left-handed painter. That left hand was dead now, with no blood flowing into it to bring the medications to fight the infections. The hand became the reservoir for the infections, the home base for their attack. The hand was threatening the rest of the body, threatening her life.
Lalikos spoke with Agin, and she agreed to the surgery. But it bothered the doctor that she couldn't speak to Gauvin herself. Even though she had no choice, even though she knew it was the best thing to do, Lalikos wished Gauvin could participate in this life-changing decision. How can you remove a part of someone's body without asking her permission?
Lalikos scrubbed up, snapped on her gloves and walked into the operating room. With tears in her eyes, she cut off Gina Gauvin's hand.
Tomorrow:
The painful road to recovery.
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