The state’s accident report is a sparse narrative, neatly packaged, the lines not yet colored in. A 49-year-old woman named Rana-Gee Lum, driving too fast on a country road near the Oklahoma border, loses control of her red Ford Explorer. The SUV flies off the east side of the two-lane road and strikes a tree, damaging a barbed wire fence. To complement this brisk description, there is a drawing of a car and an arrow and a black circle that represents the tree. The report notes that it took 18 minutes for first responders to arrive.
When they got there, they found Lum burning alive. She was tangled in the dashboard wiring, which dislodged after the front end met wood. The car had exploded when it hit that tree. Flames spread into the cab, melting the flesh on her left leg as she struggled to get free. Lum sucked in air and got smoke. The fire spread up her buttocks and settled into her back as it consumed the seat. She doesn’t remember much from there, but she remembers thinking of her daughter, and then she remembers fighting until she was out of the car.
A nearby homeowner saw the black smoke and dialed 911. Soon, Lum was in a helicopter, being flown to what was then known as Medical Center of Plano—one of two burn units in all of North Texas. Lum was one of 736 patients who required inpatient services at the burn center during its first year of existence, so many that the hospital had to hire a third surgeon. That Saturday, June 25, 2016, Dr. Salil Gulati, the burn program’s medical director and one of those surgeons, was called into work. A woman had just been flown in, and her leg was charred to the bone.
Cases like Lum’s are extreme, these deep thermal burns. When they cover more than 20 percent of the body, the injury becomes a cruel alarm; there’s a foreign invader laying waste to soft tissue and the organs respond by flushing the body with fluids. This causes pressure to build up under the skin, limiting circulation to the person’s limbs near the burns, requiring surgeons to quickly make incisions in the skin to relieve it. To treat an injury like Lum’s, who had 46 percent of her body covered in burns, a standard operating room will not suffice. And for decades, the only one that would was located at Parkland Memorial Hospital, 70 miles from the inferno in her Explorer.
The burn unit at Medical Center of Plano—since rebranded as Medical City Plano—has an emergency room with radiant heating panels above the bed, allowing surgeons to quickly adjust the temperature to prevent hypothermia. The unit has a machine to warm the fluids the patient receives, accurate to a single degree, so that once these fluids enter the body they are not so cold that the patient goes into shock. There is special irrigation and plumbing in the emergency room. Elsewhere in the unit, there are laser machines to aid in tissue reconstruction and hyperbaric chambers that expose the patient to high levels of oxygen to heal open wounds. It has a floor-to-ceiling cabinet filled with state-of-the-art dressings for patients like Lum. It is still also a trauma OR; many of the patients that surgeons see here will also have suffered blunt-force trauma.
“Many times, if there’s a motor vehicle collision and they have burns, then they have multiple injuries,” Gulati says. “Everything can be taken care of here.”
She pulls up her left pant leg to reveal her scars. They look like a patchwork quilt, as her mother told her. And she’s not embarrassed about them. “Anybody looking at them, they have no idea what I’ve been through.”
Upon her arrival, it wasn’t clear Lum would make it. Her father, Henry Lum, says the Texas Ranger who was trying to notify her sister accidentally called her 15-year-old daughter. He told her it was fatal. Two days in, Henry was asked to sign a do-not-resuscitate form. The ultimate prognosis wouldn’t be that bad, but Gulati thought the leg was going to have to go. The burns had left her kneecap exposed. They were so deep on her buttocks that Gulati was concerned about them healing.
The team began removing the dead skin. They’d do this again and again; her dressings were replaced sometimes two and three times a day. In place of the barbecued dermis, Gulati used what’s known as dermal regeneration templates—a two-layer membrane made of silicon and microscopic fibers that acts, essentially, as artificial skin. It helps lessen the scarring down the road. Three days later, Gulati and his team were able to graft her charred leg with artificial skin, cadaver skin, and portions of her right thigh. She had healthy tissue growth. She wouldn’t be losing her leg.
Gulati is not just a general surgeon. He trained in India, where surgeons who treat burns often learn plastic surgery. They incorporate both emergency and reconstructive surgery techniques in treating burn patients—it’s not just about saving someone’s life or limb, it’s also considerate of future scarring and mobility. American burn centers, Gulati says, do not always place such a priority on incorporating plastic surgery when a patient arrives by air or ground ambulance.
He’s a stocky man with thinning hair and brown-rimmed glasses. He smiles often, and though he seems shy at first, he’s personable, the type of guy who prefaces stories with “I don’t want to get my grandmother in trouble” and then tells you about the time she left a can of gasoline near an open fire when he was a boy. Gulati poured it onto the flames and suffered the consequences. “I was told I had blisters all over my body, but they obviously must’ve been superficial or I’d have scars,” he says.
He cares deeply for his patients, and he is the clinician architect of the program. He said it was exciting coming here from the University of South Alabama Medical Center’s Arnold Luterman Regional Burn Center, in Mobile. That program, one of the country’s most trafficked, was already established and often tied up in the political bureaucracy that accompanies funding at academic medical centers. Medical City Plano let him run wild and gave him the financial support to do it. And so the two other surgeons he has hired have backgrounds similar to his—general surgeons with a focus in reconstructive or plastic surgery. There are physical and occupational therapists on staff, as well as a therapist. When it is clear a patient will die, the hospital has a palliative care nurse that helps the family through the process.
“We have a therapist that’s part of our multidisciplinary team. She is over here every day,” says Sue Vanek, the director of burn services, who left Parkland after 18 years for the program at Medical City Plano. “There are a lot of adjustments, if your appearance or function changes, or if it was a traumatic injury that caused PTSD. She supports them. That’s a really unique thing to have at a burn center.”
Burn centers spread throughout North America after World War II. At their peak, 175 U.S. hospitals reported having specialized burn beds. By 1992, according to the Journal of Burn Care & Research, 25 had closed. That decline continues to today. Only 129 remain operating, for a number of reasons. Cars and buildings are safer, bolstered by international building codes and technological advances. Successful burn centers upped their bed counts to account for the losses. Plus, it’s an expensive endeavor. Federal law mandates that emergency rooms provide care for any patient who arrives, regardless of their ability to pay. Supplies and inventory for the burn wards are substantial line items.
“You start to have an unhealthy payer mix and it can get upside down really, really quickly,” says Charles Gressle, Medical City Plano’s CEO.
But there’s also the matter of community need. Collin County has just about doubled in population since 2000, going from 491,000 then to 914,000 in 2015. The Dallas-Fort Worth-Arlington, TX Metropolitan Statistical Area passed the 7 million mark in 2015; that’s about 2 percent of all the people in the U.S. And yet Parkland Memorial Hospital’s Regional Burn Center remains the only accredited facility for burns in the region. (Medical City Plano needs to wait at least three years to apply for accreditation, to give it time to accumulate data; it plans to.) Gressle estimates that the hospital partners with something like 200 care sites in Collin County and beyond. Its burn purview extends into Oklahoma, Louisiana, Arkansas, and New Mexico.
“The origin for the center was increased demand and requests for these burn capabilities,” Gressle says. “We were having to fly patients down to Parkland, and sometimes Parkland was at capacity and they’d have to go to Galveston or San Antonio.”
As noted by Mark Gamber, the EMS medical director for the Plano, Frisco, and Murphy fire departments, the majority of cases being addressed by first responders aren’t the dramatic burns suffered by folks like Lum. They’re motorcycle spills on the Tollway. They’re chemical burns. They’re related to trauma, and they’re becoming more common as the population swells. And the severity of burns being treated in the operating room generally means the patient is, at least, facing multiday stays in the ICU. That often extends into weeks, and sometimes into months.
Lum was there from June 25 through September of last year. Recovery, at first, was slow. She’d been intubated upon arrival, her breathing managed by a machine through a tube that snaked down her throat. In addition to the smoke inhalation, her lung had collapsed. She didn’t recognize anyone until the Fourth of July, at which point the family had decorated her room with family photos. Lum still remembers the first words she uttered when she was able to speak again. “I love you, Mommy,” she recalls one afternoon in February, looking at her mother, Elaine M. Lum. “I told her I loved her.”
The physical therapy was rigorous. Lum says it felt like a Mack truck had hit her. The grafts meant that doctors would have to prop her up in odd positions to allow the areas where the skin was taken to heal. The therapists put special boots on her feet to keep them in a 90-degree position. She sat in her wheelchair and used a pedal machine. Eventually, she started getting off the bed, despite the pain. MK Roberts, a no-nonsense therapist, took the reins when Lum got a little difficult with the other providers. Roberts knew she wasn’t able to drink much water because of her recovery, meaning that Lum’s hydration came from rationed ice chips. Roberts used water as a goal. “I would fight for it,” Lum says. “I’ll walk those three steps and I’m gonna get that cup.”
Gulati’s motivator was doughnuts. Five steps with the walker got her a single glazed. Soon, she was racking up more than one doughnut. Henry Lum remembers a full dozen in his daughter’s room one day.
The wounds began to heal. August came and went, and then it was September. Her 15-year-old daughter, Shianne, made friends with a patient down the hall who’d had his arms and legs amputated. She read him the Bible. Later, the man’s parents would tell Henry Lum that these visits kept him fighting. They told him that their son was ready to die, and that the time spent with his granddaughter and the words she read from that Bible kept him alive, kept him positive.
There is a community in this burn unit. The providers who work here were not all trained to deal with complex burns before they came here. They engage in continued education to learn it. Vanek, the director, says she’s constantly surprised at how eager the nurses and other providers are to be in the unit. She notes that the patient is supported all the way through the injury to beyond the point that they’re ready to reenter society. Henry calls the people who work here “a family.” Everyone looks out for each other, and that includes the patients and their families. “They say that you don’t choose burn, that burn chooses you,” Vanek says. “There’s a lot of physically demanding specialties out there, but this includes an emotional component.”
Lum spent September through January at a nursing home and rehabilitation center called The Park in Plano, which accepted her despite never having taken on someone with such significant needs. They also provided the last few months of her rehabilitation as charity, when insurance refused to pay for it any longer. By the end of her time there, she’d learned to walk short distances with little assistance.
On an afternoon eight months after the fire that could have killed her, Lum sits with her father to her right and her mother to her left in an empty waiting room at Medical City Plano. She discusses her injury, acts out her therapies—stretches her arms at the elbow, extends her leg. She pulls up her left pant leg to reveal her scars. They look like a patchwork quilt, as her mother told her. And she’s not embarrassed about them. “Anybody looking at them, they have no idea what I’ve been through.”
“You’ve earned them,” her mother says.
When it’s time to go upstairs for lunch with her care team—she hasn’t seen many since her time here—she’s excited to show that she can walk. She trots the whole way on her own. And when she gets upstairs into the burn unit, before her therapists notice her, she balls her hands into fists and thrusts her arms high above her head.
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