WASHINGTON — The critically burned patients resemble mummies, wrapped in gauze and a foil-like bandage impregnated with germ-fighting silver.
Most can't speak with oxygen tubes down their throats. One has a serious infection, and a special rotating bed turns his body almost upside down to help force air through his lungs.
This is the burn unit at Washington Hospital Center, where six patients, burned over half their bodies when a hijacked plane slammed into the Pentagon on Sept. 11, remain in intensive care.
Seldom in medicine is recovery as grueling as that from a major burn. For the Pentagon patients — six in intensive care plus two less badly burned — and 22 people hospitalized in New York with major burns from the World Trade Center attack, months of operations and rehabilitation lie ahead.
Unlike with many other injuries and illnesses, it's hard for doctors to say when a person with a major burn is out of the woods. Infection is a constant threat, as are respiratory problems and blood clots.
``It's kind of like running a race with high hurdles. You run a little ways and you've got to jump a big one. Occasionally you trip over them and stumble down the track. And sometimes the patient gets up and sometimes they don't,' says Dr. Marion Jordan, director of Washington Hospital Center's burn unit.
He lost one patient, Antoinette Sherman, 35, who died last week, her lungs unable to overcome smoke inhalation.
But even patients burned over most of their body can recover, and Jordan is heartened that three of his most critical patients have begun walking painstakingly around the burn unit. Moving is crucial to healing.
You're not a burn victim but a burned patient, Jordan tells them, and the goal is to send ``them out as healed, normal people.' But, ``it can easily be a two- to three-year project to get back to the nearest best you can reach.'
Odds of recovering depend on the extent and depth of burns, and the person's age. The younger the better; those under 45 tend to fare best, said Lana Parsons, burn trauma coordinator at the Baltimore Regional Burn Center at Johns Hopkins Bayview Medical Center.
The severely injured in the terrorist attacks in New York and at the Pentagon have burns over 35 percent to 80 percent of their bodies.
They are second-degree burns — bright red, blistered and severely painful burns reaching into the skin's second layer, the dermis — and third-degree burns, which go even deeper, into fat underneath the dermis.
With the worst burns, the skin is leathery, either charred black or blanched white, areas that can have little feeling because nerve endings were destroyed. Super-deep burns also can destroy muscle, even cause limb loss as blood vessels are destroyed.
Some second-degree burns can heal with time, but deep ones and third-degree burns require skin grafts.
Working on about two hours of sleep a night, Jordan and fellow surgeon Dr. James Jeng have operated about five times on each critically injured Pentagon patient so far. They are hours-long procedures.
First, they scrape away seared skin and infected tissue.
They have used almost 40 square feet of skin donated from cadavers, plus skin from pigs and patches of artificial skin-like coverings called TransCyte and Integra, to cover the open wounds. Then they slather on antibiotic cream and apply those silver-impregnated bandages.
The skin coverings aren't permanent — the body rejects grafts from donated skin within two weeks. The idea is to block infection until patients can get a permanent graft of their own skin.
So far, Jordan has used unburned skin on three patients to perform grafts on their hands. It's too soon to tell if the grafts will take or need redoing. In 10 to 14 days, the unburned site will have healed and he can cull it again for more grafts.
The grafts will itch and hurt while healing. Rehabilitation therapy is crucial so scar tissue doesn't immobilize joints.
Advances in recent years have greatly diminished scarring — but it takes a year to know how bad scars will be. Some who start out greatly disfigured and discolored can turn out nearly normal just with time; others will need plastic surgery, Parsons said.
One key is wearing special pressure garments for up to a year to keep scar tissue flat; left alone it would form lumps. They are girdle-like body suits and, for facial burns like many of the Pentagon victims have, clear plastic face masks custom-made from facial molds.
For most of these patients, it's too soon to worry about scars. They're still fighting to live.
"I tell the families, just so they have a reality check every couple of days, that, yes, they're stable and, yes, this one's doing well," Jordan said. "But I shall not rest until I see them walk out the door."