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Burn Unit: Saving Lives After the Flames
“A compelling blend of science, history and storytelling. Barbara Ravage has fashioned an enlightening, invaluable book.” —Stewart O'Nan, author of The Circus A True Story of an American TragedyThough each of us is just a spark away from being a burn victim, the public knows little and understands less about the world that patients inhabit. Pulling the curtains back on this private and sterile environment, Burn Unit is a riveting account of the frontline efforts—both modern-day and historical—to save lives devastated by fire. With unflinching urgency, Barbara Ravage follows an extraordinary team of healers at Massachusetts General Hospital, the cradle of modern burn treatment and the site of one of the best burn units in the world. From Boston's Cocoanut Grove fire of 1942 to the treatment of the victims of the Rhode Island nightclub fire in early 2003, we watch everyday heroes do their incredible but punishing work against the backdrop of history. Both a moving human drama and an engrossing scientific exploration of this little-known field of medicine, Burn Unit is an unforgettably powerful read.
326 pages, Kindle Edition
First published January 1, 2004
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February 28, 2012
About the Author: Barbara Ravage is a freelance science and health writer and editor living in Massachusetts. She is a graduate of Barnard College in New York City. She has also written biographies and books on nutrition.
Overview: Most of this book is about the burn unit at Massachusetts General Hospital in Boston. Starting in 2002, the author spent eighteen months there gathering information. She also describes some fires that lead to the burns, but I left the fires themselves out of my summary here.
Epidermis
• squamous epithelial cells
Dermis
• nerves
• capillaries
• lymph ducts
• immune cells
• hair follicles
• sweat glands
• oil ducts
Eschar: The dead tissue on the surface of a burn is called eschar. The word is pronounced ess-kar and comes from the Greek word for scab. Eschar may be red, white, brown or black. For deep burns, eschar must be removed for the wound to heal.
First Degree Burns
• superficial
• epidermis only
• painful
• get better on their own
• leaves no scars
• example: sunburn
Second Degree Burns
• penetrates dermis partially
• may heal on their own
• may required skin graft, depending on depth
Third Degree Burns
• penetrate dermis completely, to the layer of fat
• have eschar
• less painful than second-degree burns, because the nerves have been destroyed
• cannot heal on their own
• wIll form scars
Fourth Degree Burns
• go through layers of fat, fascia, muscle and perhaps even bone
• sometimes limb amputation is the only option
Rhabdomyolysis: Large amounts of dead muscle tissue may be more than the kidneys can handle. This is because protein contains lots of nitrogen, which the kidneys must excrete in the urine. This situation is called rhabdomyolysis. The burn patient must be kept well hydrated to help the kidneys clear the nitrogen waste. Nut-brown urine is a sign of rhabdomyolysis.
Infection: Infection is the main threat for the burn victim. Dead tissue is food for bacteria. Clostridium perfringens and MRSA (methicillin resistant staphylococcus aureus) are two serious pathogens that burn patients need to worry about. Vancomycin is often used for pathogens that are antibiotic-resistant, but it can cause tinnitus and hearing loss.
Bathing the Burn Patient: Pathogenic bacteria must be prevented from traveling (a) from one patient to another patient, and also (b) from one part of the patient’s body to another part of that same patient’s body. This latter concern has made nurses more reluctant to immerse a patient’s body in a bath tub full of water. Even if you thoroughly disinfect the bath tub between patients, the water can still transmit the infection from one region to another on same person.
Silver: Silver compounds have been found to be good at killing bacteria. For many years, newborn babies received silver nitrate solution in their eyes, to kill any gonorrhea bacteria they may have picked up from their mother. Silver nitrate and sulfadiazine are both common topical antimicrobial drugs used for burn patients. Gauze pads coated with silver particles are used in burn dressings.
Skin Grafts: If a skin graft is taken from one part of the body and used to replace skin elsewhere that has been destroyed by the burn, what happens to the region that the graft was taken from? Don’t we now have another region that has no skin? Well, the author explains that when the skin graft is removed, the dermis is sliced horizontally through the middle, so that the bottom half of the dermis remains at the original location. Nurses and doctors should ask the burn victim whether he or she has an identical twin. Skin taken from an identical twin will not be rejected by the immune system. Sometimes pig skin and cadaver skin are used as a temporary fix. Eventually, these alien tissues will be rejected.
Scar Formation: A scar is not made of normal skin, with all the complexity of the dermis described above, but rather of a simpler kind of tissue. In a hypertrophic scar, the collagen is not laid down in parallel but rather in a chaotic pattern. This produces thick, raised, tough knots of scar tissue. A keloid is an extreme type of hypertrophic scar that extends beyond the region of injury.
Inhalation Injuries: Inhalation injuries, that is, injuries to the lungs when smoke from a fire is inhaled, are a major problem for burn patients. Symptoms of inhalation injuries include crackly breathing, cough, and breathlessness. It is the toxic chemicals in the smoke, more than its heat, that damage the lungs. These chemicals damage the basement membranes of lung’s alveoli, causing the basement membranes to slough off their epithelial cells. These dead epithelial cells are food for bacteria, and pneumonia often results. So this debris in the lungs must be suctioned out with a bronchoscope (under anesthesia).
Hyperbaric Oxygen: In hyperbaric oxygen therapy, the patient is placed in a chamber full of pure oxygen under high pressure. The main use of hyperbaric oxygen therapy is to clear carbon monoxide from the lungs and bloodstream. It is hardly ever used for burn wound healing. Hyperbaric oxygen is also used for ocean divers suffering from the decompression sickness (also called caisson disease and the bends).
Itching: Itching is the worst long-term symptom of a burn injury. There is no good treatment for itching from burn scars.
Overview: Most of this book is about the burn unit at Massachusetts General Hospital in Boston. Starting in 2002, the author spent eighteen months there gathering information. She also describes some fires that lead to the burns, but I left the fires themselves out of my summary here.
Epidermis
• squamous epithelial cells
Dermis
• nerves
• capillaries
• lymph ducts
• immune cells
• hair follicles
• sweat glands
• oil ducts
Eschar: The dead tissue on the surface of a burn is called eschar. The word is pronounced ess-kar and comes from the Greek word for scab. Eschar may be red, white, brown or black. For deep burns, eschar must be removed for the wound to heal.
First Degree Burns
• superficial
• epidermis only
• painful
• get better on their own
• leaves no scars
• example: sunburn
Second Degree Burns
• penetrates dermis partially
• may heal on their own
• may required skin graft, depending on depth
Third Degree Burns
• penetrate dermis completely, to the layer of fat
• have eschar
• less painful than second-degree burns, because the nerves have been destroyed
• cannot heal on their own
• wIll form scars
Fourth Degree Burns
• go through layers of fat, fascia, muscle and perhaps even bone
• sometimes limb amputation is the only option
Rhabdomyolysis: Large amounts of dead muscle tissue may be more than the kidneys can handle. This is because protein contains lots of nitrogen, which the kidneys must excrete in the urine. This situation is called rhabdomyolysis. The burn patient must be kept well hydrated to help the kidneys clear the nitrogen waste. Nut-brown urine is a sign of rhabdomyolysis.
Infection: Infection is the main threat for the burn victim. Dead tissue is food for bacteria. Clostridium perfringens and MRSA (methicillin resistant staphylococcus aureus) are two serious pathogens that burn patients need to worry about. Vancomycin is often used for pathogens that are antibiotic-resistant, but it can cause tinnitus and hearing loss.
Bathing the Burn Patient: Pathogenic bacteria must be prevented from traveling (a) from one patient to another patient, and also (b) from one part of the patient’s body to another part of that same patient’s body. This latter concern has made nurses more reluctant to immerse a patient’s body in a bath tub full of water. Even if you thoroughly disinfect the bath tub between patients, the water can still transmit the infection from one region to another on same person.
Silver: Silver compounds have been found to be good at killing bacteria. For many years, newborn babies received silver nitrate solution in their eyes, to kill any gonorrhea bacteria they may have picked up from their mother. Silver nitrate and sulfadiazine are both common topical antimicrobial drugs used for burn patients. Gauze pads coated with silver particles are used in burn dressings.
Skin Grafts: If a skin graft is taken from one part of the body and used to replace skin elsewhere that has been destroyed by the burn, what happens to the region that the graft was taken from? Don’t we now have another region that has no skin? Well, the author explains that when the skin graft is removed, the dermis is sliced horizontally through the middle, so that the bottom half of the dermis remains at the original location. Nurses and doctors should ask the burn victim whether he or she has an identical twin. Skin taken from an identical twin will not be rejected by the immune system. Sometimes pig skin and cadaver skin are used as a temporary fix. Eventually, these alien tissues will be rejected.
Scar Formation: A scar is not made of normal skin, with all the complexity of the dermis described above, but rather of a simpler kind of tissue. In a hypertrophic scar, the collagen is not laid down in parallel but rather in a chaotic pattern. This produces thick, raised, tough knots of scar tissue. A keloid is an extreme type of hypertrophic scar that extends beyond the region of injury.
Inhalation Injuries: Inhalation injuries, that is, injuries to the lungs when smoke from a fire is inhaled, are a major problem for burn patients. Symptoms of inhalation injuries include crackly breathing, cough, and breathlessness. It is the toxic chemicals in the smoke, more than its heat, that damage the lungs. These chemicals damage the basement membranes of lung’s alveoli, causing the basement membranes to slough off their epithelial cells. These dead epithelial cells are food for bacteria, and pneumonia often results. So this debris in the lungs must be suctioned out with a bronchoscope (under anesthesia).
Hyperbaric Oxygen: In hyperbaric oxygen therapy, the patient is placed in a chamber full of pure oxygen under high pressure. The main use of hyperbaric oxygen therapy is to clear carbon monoxide from the lungs and bloodstream. It is hardly ever used for burn wound healing. Hyperbaric oxygen is also used for ocean divers suffering from the decompression sickness (also called caisson disease and the bends).
Itching: Itching is the worst long-term symptom of a burn injury. There is no good treatment for itching from burn scars.
March 31, 2023
Very well written. I would not, however, recommend this book to those not in the medical field or not deeply interested in the same.
November 20, 2008
I acquired this book after reading Daniel J. Brown's Under a Flaming Sky: The Gredat Hinckley Firestorm of 1894 (also reviewed on this site), because he referred to Burn Unit in his discussion of the way fire wounds and kills. (My literary co-conspirators and I are working on a science-fiction novel about the Great Los Angeles Firestorm of 2022, and Under a Flaming Sky, Firestorm at Peshtigo, and Burn Unit are three of the resources we've been mining for ideas for our novel.) At any rate, Burn Unit discusses numerous issues related to burn wounds and deaths; written in a very accessible style, with great compassion for both burn victims and those who tend to them, it is a valuable resource for professionals directly concerned with rescue and treatment of burn victims as well as a unique human-interest document giving insight into the suffering caused by burns and the drama of burn-unit experience. It also covers the history of burn treatment from the primitive remedies that were the only ones available up until the 1940s, and rapid advances in burn therapies since then, which took off as a result of Boston's horrific Coconut Grove nightclub fire of 1942, in which a number of military personnel were injured or killed by the fire. It goes into the daily experiences and careers of those who work with burn patients in burn units. That thankless job isn't for everyone; most medical personnel who work in burn units are happy to rotate out of them or simply resign after a year or even a few months. Burns are the worst injuries the body can sustain; inevitably they become worse before they get better -- if they ever do -- and entail real illness, as well. Burn patients aren't just injured, but sickened by their burns, and the worse the burns are, the sicker the patient becomes, the longer it takes to heal, with decreasing success, and the more likely death as a result of his or her burns. The smell of rotting tissue pervades burn units, one of the things that deters most medical personnel from having anything to do with treatment of burns, a complaint that goes back into the mists of history and the first use of fire as a weapon of war, when men burned in battle were housed in hospitals that were little more than charnel houses for the dying. Those medical personnel -- nurses, doctors, technicians -- who do elect to take up permanent careers in the field of burn treatments tend to be extremely compassionate people with a will of iron and nerves of steel. If that seems oxymoronic, consider what it takes to work all day at relieving the agonizing pain of burns, keep immobilized, often deeply unconscious patients clean and fed, comfort the families of burn patients and those who have died of their burns, keep their gorges down in the face of that ever-present effluvium of rot, and smile for the benefit of patients and families alike, all the while knowing full well that between one day's shift and that of the next, a patient may be wheeled out of the room feet-first, on his or her way to the morgue. Knowing that there are people that good-hearted gives me hope for my benighted species. This book is a fascinating introduction to the medical technology, history, biology, and human-interest aspects of burns and burn therapy. Meticulously researched, drawn in great part on interviews conducted with burn-unit professionals at Massachusetts General Hospital and other area hospitals, where modern burn therapy began, this is an outstanding introduction to the subject.
Read
September 3, 2025"resuscitation is a job for experts, not because it is an exact science but because it is not. ...any formula is just a starting point and then as Bob Droste puts it, "you adjust for reality."
^ so true ^ cooking is like emergency medical is like driving is like cooking is like life.
nurses being the people that have been there forever is like senior staff. they may not be in charge but they may have the real lowdown.
"Well, it's sixteen years later and I'm still here. So I think that says a lot. I'm a firm believer that if it works you should keep doing it, and when it stops working, you try something else; it still works for me" is Lula still working for me?
"...the junior attitude doesn't fly around here. The work's too heavy. So people will come over and help you out. And you don't have to go and ask, to beg. ... We wear pajamas to work; they're ill-fitting, and we don't care! We don't have a mice clean job. We're doing nasty things. And so we're all in the same boat together and we all have to help each other because you can't do it yourself."
this book rocked. Mary roach and malcolm gladwell have been super seeded by far. I want to have this in paper back, though I suppose I could just borrow it again from the library.
^ so true ^ cooking is like emergency medical is like driving is like cooking is like life.
nurses being the people that have been there forever is like senior staff. they may not be in charge but they may have the real lowdown.
"Well, it's sixteen years later and I'm still here. So I think that says a lot. I'm a firm believer that if it works you should keep doing it, and when it stops working, you try something else; it still works for me" is Lula still working for me?
"...the junior attitude doesn't fly around here. The work's too heavy. So people will come over and help you out. And you don't have to go and ask, to beg. ... We wear pajamas to work; they're ill-fitting, and we don't care! We don't have a mice clean job. We're doing nasty things. And so we're all in the same boat together and we all have to help each other because you can't do it yourself."
this book rocked. Mary roach and malcolm gladwell have been super seeded by far. I want to have this in paper back, though I suppose I could just borrow it again from the library.
May 23, 2019
As a burn survivor (though not from fire, but from a rare reaction to sulfa), this was a fascinating book. I don't know if it would be as interesting to someone who has not spent time on a burn unit ... Even though much of what happened to me was slightly different, this book filled in information about what happened that I was missing. And, in the acknowledgments, a thank you to one of the docs at Harborview, Nicole Gibran, who was on my team. The people who work in these units are amazing - so glad that someone wrote about this. Thank you to Barbara Ravage!
June 7, 2020
A superb example of medical writing, combining solid scientific explanations with emotive storytelling and personal recollections of burn survivors. A fascinating foray into the world of burn care; there’s so much more to it than I could ever imagine, and I will remember what I’ve learned from this book going forward.
March 25, 2021
Reading this made clear that what I thought I knew about burns barely scratches the surface. From the medical facts to the personal stories, everything about this book was engrossing, and I know so much more now.
Did Not Finish
June 11, 2018Did not finish.
April 30, 2023
This was nothing like I imagined it to be but it was a pretty interesting read nonetheless.
December 14, 2010
Really informative. Its an aspect of medicine that I was not familiar with, so it was interesting to learn the day in day out routine of a burn unit. It definitely made me more interested in exploring that field of medicine.
My only gripe is that the author has a hard time choosing an audience to write to. At some points she over-simplifies things for a lay-reader but then others she gets into really intricate technical topics. For example, she goes into detail about the different types of artificial skin, down to specifics between brand names but then writes out the phonetic spelling of the word "trach" (anyone interested in the brands of artificial skin probably knows what trach is). At other points she goes into technical detail about starling properties of extra cellular fluid and plasma... something i'm pretty sure I wouldn't have understood if I hadn't just taked medical physiology...but would then return to oversimplifying other concepts.
I feel like this was the case of an expert trying to write something for the layperson and getting overwhelmed as to whats common knowledge and where the level of "expertise" lies...a problem that I assume occurs in any field where a complicated topic is simplified. In addition, while being a medical/science writer, the author admits to not being a doctor and knew little to nothing on burns prior to the onset of her research for the book. It is possible that in many cases she found something interesting that she felt was important, but wasn't knowledgeable enough in the topic (i.e. starling principle) so included them practically verbatim from the source without attempting to simplify or modify so as not to risk making an error.
Overall it was a great book, highly recommended for anyone interested in medicine or nursing.
My only gripe is that the author has a hard time choosing an audience to write to. At some points she over-simplifies things for a lay-reader but then others she gets into really intricate technical topics. For example, she goes into detail about the different types of artificial skin, down to specifics between brand names but then writes out the phonetic spelling of the word "trach" (anyone interested in the brands of artificial skin probably knows what trach is). At other points she goes into technical detail about starling properties of extra cellular fluid and plasma... something i'm pretty sure I wouldn't have understood if I hadn't just taked medical physiology...but would then return to oversimplifying other concepts.
I feel like this was the case of an expert trying to write something for the layperson and getting overwhelmed as to whats common knowledge and where the level of "expertise" lies...a problem that I assume occurs in any field where a complicated topic is simplified. In addition, while being a medical/science writer, the author admits to not being a doctor and knew little to nothing on burns prior to the onset of her research for the book. It is possible that in many cases she found something interesting that she felt was important, but wasn't knowledgeable enough in the topic (i.e. starling principle) so included them practically verbatim from the source without attempting to simplify or modify so as not to risk making an error.
Overall it was a great book, highly recommended for anyone interested in medicine or nursing.
June 3, 2014
The treatment of burn victims and their caretakers holds a unique place in medicine and surgery. It is a subspecialty that few chose to pursue but for those who do, it is a tight-knit community that draws strength from each other while caring for some of the most horrific of injuries. Author Ravage does an amazing job of discussing the history of burn care while interweaving the stories of two patients and their individual treatments and recoveries. The world of burns is not well known by the lay public and whether that is due to fear, disinterest or disgust or some combination thereof is anyone's guess. Ravage's book presents this area of medicine within its rightful context as a demanding subset of medicine that has a long history of treatment modalities and how several large-scale civilian fires in the first half of the 1900's pushed forward the knowledge base on how to best treat these patients. I doubt many people other than those who either have known a burn victim or have worked within a burn unit are aware of much of what Ravage discusses so in that respect this can be enlightening for the interested reader who wishes to expand their knowledge base. Portions of text that review the biochemistry of wound healing may be a little dry but these comprise only a small percentage of the novel. Other sections are quite graphic but in a respectful way but readers with a sensitive stomach may need to be forewarned. An enlightening and accurate account of a much-misunderstood field of medicine.
May 11, 2015
Ever since Prometheus ignited the first flame, fire has had the power to both help and harm humankind as no other force can do.
The burn unit strikes fear and revulsion in people, with good reason. We are taught to fear fire and its fatal and disfiguring effects from a young age. Barbara Ravage spent time in a burn unit following the brave men and women recovering from burns, their families, and the dedicated medical staff that care for those that have been burned. She shows the full scope of the damage burns do and the long road to recovery, while also shedding light on new research and medical treatments that are helping to ease the recovery.
This is one of those medical books that do it pretty well. Ravage mixes together the right blend of science, while also bringing the human story to the forefront. I like that she tells patients' and their families' stories with compassion, while also explaining the science behind what happened to them. So many books about medical topics get so caught up in the science and the research that they forget that this happened to real people. The medical staff is also featured heavily in the book, which gives a great insight into the burn unit and the job it is to help people recover from burns.
I recommend this book to those who like medical nonfiction and like the human stories, as well as the scientific understanding. It is a very informative and eye-opening read.
The burn unit strikes fear and revulsion in people, with good reason. We are taught to fear fire and its fatal and disfiguring effects from a young age. Barbara Ravage spent time in a burn unit following the brave men and women recovering from burns, their families, and the dedicated medical staff that care for those that have been burned. She shows the full scope of the damage burns do and the long road to recovery, while also shedding light on new research and medical treatments that are helping to ease the recovery.
This is one of those medical books that do it pretty well. Ravage mixes together the right blend of science, while also bringing the human story to the forefront. I like that she tells patients' and their families' stories with compassion, while also explaining the science behind what happened to them. So many books about medical topics get so caught up in the science and the research that they forget that this happened to real people. The medical staff is also featured heavily in the book, which gives a great insight into the burn unit and the job it is to help people recover from burns.
I recommend this book to those who like medical nonfiction and like the human stories, as well as the scientific understanding. It is a very informative and eye-opening read.
January 30, 2009
When my nephew and his wife were badly burned in a plane crash in August, in the midst of tears and prayers, I found myself with far more questions than answers. Up to this point, I have known no one who was a major burn victim. And somehow I couldn't see pestering all the loved ones on the front line with my gazillions of questions, when they had far greater demands on their time and thoughts and hearts.
So I reverted to habit and sought out books on the topic. Burn Unit was by far the most readable and helpful of all the books I read. Barbara Ravage takes the reader into the burn unit of a major medical center/teaching hospital, and shows us the devastation wrought by burns on not only the affected area, but the whole body, the whole person, and the whole family.
Besides a unflinching stare at the physiological process of burn damage and healing, we see the committed personnel who work in a burn unit, the procedures, such as debridement and skin grafts, that are peculiar to burn treatment, and follow two victims through the entire process. Add a comprehensive history of burn treatment, and the last question I have is: how did she make it so compelling?
I don't know, but I am grateful. This is the book to read on major burns.
So I reverted to habit and sought out books on the topic. Burn Unit was by far the most readable and helpful of all the books I read. Barbara Ravage takes the reader into the burn unit of a major medical center/teaching hospital, and shows us the devastation wrought by burns on not only the affected area, but the whole body, the whole person, and the whole family.
Besides a unflinching stare at the physiological process of burn damage and healing, we see the committed personnel who work in a burn unit, the procedures, such as debridement and skin grafts, that are peculiar to burn treatment, and follow two victims through the entire process. Add a comprehensive history of burn treatment, and the last question I have is: how did she make it so compelling?
I don't know, but I am grateful. This is the book to read on major burns.
January 30, 2010
started 01/30/10. (oooh, they updated this so I can add it without have to type it here! Groovy!)
OK, so we've pretty much established I'll read books on any medical topic. I have friends who once worked in the Burn Unit at our hospital, so I thought this would be an interesting read.
I was right! I learned alot about the pathophysiology of burns and how they are treated.
OK, so we've pretty much established I'll read books on any medical topic. I have friends who once worked in the Burn Unit at our hospital, so I thought this would be an interesting read.
I was right! I learned alot about the pathophysiology of burns and how they are treated.
March 11, 2012
Read this book prior to interviewing for a job on this unit. While some the facts are skewed, it is a terrific insight into the workings of this unit, the patients and families they deal with and the staff. The book also showcases the history unique to this hospital and the Cocoanut Grove and Station nightclub fires, and the advances made in burn care between and since these two deadly fires.
October 18, 2015
This was a tough read. It took me a while to get through it but it was fascinating. I had just finished reading a bio of an acquaintance at my gym who is a burn survivor. Her perspective was from the patient's side and this book was from the medical side. I always knew the burn unit was one of the most difficult but special places to work in a hospital. Now it's clear why.
January 7, 2008
I read this book in hopes that it would help emotionally prepare me for my job. It pretty much just confirmed the terror I feel. If anyone wants a glimpse into what my life is going to be like for the next 2 years, read this book!
February 13, 2008
very technical and medically-oriented, not as much for the lay person as i thought but still very moving and with great stories
July 2, 2012
Very informative. I am in Nursing School and had to do a research paper on what kind of nursing I wanted to do. I would like to be a Burn Unit nurse and so I read this book as part of my research.
February 24, 2014
Entertaining, educational and a lesson in the simple power of well-written prose.
Displaying 1 - 20 of 20 reviews