After the Fire

They were wrapped like mummies to protect their burns, and respirators were breathing for them. Massive amounts of fluids were being pumped into their bodies to prevent deadly burn shock, and liquid nourishment was being fed into their stomachs through tubes. Early on, the boys had been slammed into morphine-induced comas to numb the deep, unrelenting pain of third-degree burns. Without the drugs, the pain would be unbearable.

It was almost 10 p.m., and Mansour wanted a shower and some sleep. He had to be back in the Saint Barnabas Medical Center burn unit seven hours later. Students Shawn Simons and Alvaro Llanos, both 18, had burns that were vast and deep, and their lungs were badly damaged by smoke. If they lived, they would be in the burn unit for a long, long time.

Burn recovery is erratic, fraught with fleeting highs and daunting lows. Mansour, director of the Saint Barnabas burn unit, told the Simons and Llanos families that the next few months would be "a roller coaster ride."If the boys did survive, they would lose months, maybe years to the healing process and even then many of their scars - physical and emotional - would be permanent.

For now, Mansour had done all he could for them.

They were wrapped like mummies to protect their burns, and respirators were breathing for them. Massive amounts of fluids were being pumped into their bodies to prevent deadly burn shock, and liquid nourishment was being fed into their stomachs through tubes.

Early on, the boys had been slammed into morphine-induced comas to numb the deep, unrelenting pain of third-degree burns. Without the drugs, the pain would be unbearable.

While it is often said that third-degree burns are the least painful because the nerve endings are gone, it is not true. Nerve endings on the surface may be gone, but deeper ones are not. And they transmit a hot, brutal pain that is difficult to fathom for someone who hasn't been burned.

The comas would last weeks, even months. Mansour told the families that the boys would not remember much about that time. But undoubtedly they would recall the misery of the burn treatment room where their raw, open wounds were scraped and scrubbed each day.

At least they were alive.

Burns were cunning, though. On the surface, everything could seem under control, while potentially fatal infections festered inside.

Opportunistic bacteria weren't Mansour's only worry, though. Burn patients get sick from the outside in. Wounds leak vital bodily fluids, triggering burn shock, which shuts down major organs.

Lung injuries pose the gravest danger to burn patients. Both Shawn and Alvaro were gasping for breath when they were brought to Saint Barnabas. It would be days before doctors could tell how badly their lungs were damaged. More patients die from complications resulting from smoke inhalation than from burns.

As soon as they were considered stable, both boys would undergo skin grafts. Shawn's hands were so badly burned that Mansour worried the teenager would lose his fingers. His face, particularly his forehead, probably would need surgery, too. Alvaro needed grafts for most of his upper body - his chest, back, arms, hands and neck.

Mansour could not say what the prognosis was for Shawn or for Alvaro. Either could die at any moment; Alvaro's condition was particularly precarious.

For their families, there was little to do but wait and watch the clock. Priests from Seton Hall were in and out of the burn unit waiting room. The Seton Hall president, Monsignor Robert Sheeran, prayed with the families. The Simonses and Llanoses were settling in for a long, uncertain ride.

Mansour liked Christine and Ken Simons right away. Both seemed bright and levelheaded. Mrs. Simons quickly won over the whole burn team. The doctors and nurses marveled at her composure. Her devotion to her son was powerful. She took an unpaid leave from her night job at Federal Express to sit at Shawn's bedside for hours at a time, having one-sided conversations as he lay there, oblivious to her presence. She wanted the best for her son and she was going to see that he got it. But she trusted the staff with the details.

Family support is critical to burn treatment. It often makes the difference in a successful recovery.

The Simonses presented a united front on behalf of their son. No one guessed they were divorced.

For three nights after the fire they set up house in the Saint Barnabas waiting room. They slept there - one on the couch, the other in a chair- they ate there and they prayed there.

On the third night, they fought there. It was 3 a.m. and Mr. Simons was getting restless. There wasn't much to do except watch the clock and wait. The chair in the waiting room was hard. The television was on, the sound off. It was hospital quiet.

Mr. Simons kept imagining his son's face the way it would look burned. He tried to blink the image away. It kept recurring. Shawn had been such a handsome kid. His friends called him "pretty boy." He was always checking himself out in the mirror. Mr. Simons used to say the boy primped more than a girl.

How would his son handle being disfigured? Could Shawn deal with people staring at him? Could he? The noise in his head kept getting louder. Then Mrs. Simons woke up.

Christine and Ken Simons divorced when Shawn was 4. For their son's sake they had always made an effort to have a conciliatory relationship. Still, when they spent any time together, old tensions bubbled up.

This was one of those times.

"I'm worried about how Shawn is going to handle how he looks," Mr. Simons told his former wife. "When I was young I was handsome like him. I was God's gift to women. If he's anything like me he's going to be devastated by this."

Mrs. Simons was a stoic woman. But this was too much. Suddenly she was besieged by old resentments: the times her ex-husband had forgotten Shawn's birthday; the time he neglected to get his son a single Christmas gift; the time he told Shawn that his new family took priority over him. He's not like you, she wanted to say, but she didn't.

"We're waiting to see if God is going to spare our child, and you're thinking about Shawn's looks?" Mrs. Simons said, tears welling in her eyes.

It was the last night they would spend together in the hospital.

The Llanoses were loving parents, too. Mansour could see that. But they were harder to reach than the Simonses. Colombian immigrants who met and married in Paterson when they were in their early 20s, neither Daisy nor Alvaro Llanos spoke fluent English. Mansour wasn't sure whether their dazed expressions meant they didn't understand him or that they were bewildered by what was happening.

Alvaro was their only son. Their golden child. He would be the one to realize the American dream. He would be the first person in his family to graduate from college, to have a real career, to buy a house in the suburbs.

The family had just been through one catastrophic illness. Mr. Llanos, 46, had had a debilitating stroke two years earlier and was still recovering. He had left his job at the Marcal paper factory in Elmwood Park and he still

couldn't work, he couldn't drive and he couldn't walk without a cane. Mrs. Llanos was forced to quit her job at the Paterson post office to care for him.

Mansour wanted to comfort the parents more, but he couldn't say how long it would be before they would have their children back. He couldn't even tell them with certainty that they would ever be able to hold their boys again.

Wansour, 53, knew all about the torment of burns.

He was exposed to it for the first time while growing up in Lebanon. Mansour, not yet a teenager, was visiting his father in Beirut's military hospital when he heard a patient screaming in the next room.

The sound was like nothing he had ever heard. It seemed to start deep in the man's gut, then build slowly and deliberately until it finally spilled out into one long, tortured wail: the scream of a burn patient.

Why couldn't they help him? young Mansour had asked the nurses. There wasn't much they could do but wait for him to die, he was told.

"The pain, the way he was screaming, screaming in pain, that affected me - a lot," Mansour would recall, shaking his head as if he were trying to dislodge the memory from his brain.

Twenty years later, Mansour was a young doctor just beginning his career when he heard that scream again.

A resident in general surgery at St. George Greek Orthodox Hospital in Beirut, Mansour was assigned to care for a group of Syrian soldiers burned by napalm during the 1973 Middle East war. The burn field was so undeveloped and had so few practitioners that Mansour turned to books for guidance on how to treat his patients. During his research, he learned that the prognosis for the Syrian soldiers wasn't much better than it had been for the man he had encountered 20 years earlier.

Before 1970, major burns - covering one-third or more of the body's surface - were almost always fatal. The rare patient who managed to survive the initial burn shock usually died from massive infection.

Few doctors knew how to treat burns and fewer still wanted to.

Mansour did.

Where others saw hopelessness, he saw a challenge. He saw burns as his future.

Mansour was born Esber Hani Mansour in Beirut on July 19, 1947, one of five sons of Greek Orthodox parents. His mother Marie still lives in the house in Beirut where Mansour grew up. An older brother resides nearby. Mansour's father Nicolas, who died in 1986, was an engineer who owned a construction company.

The family wasn't wealthy, but they were educated, members of Beirut's intellectual class. Nicolas Mansour encouraged his boys to follow in his footsteps. Only Hani, the middle son, dared to study something different, and that was because his mother, whose father was a doctor, pushed him toward medicine.

Mansour was accepted to the American University and St. Joseph's University, both in Beirut. He chose to attend St. Joseph's for his undergraduate work and medical school.

Mansour almost left medical school after the first day. His microbiology professor lectured about "echinococcus that multiply by schizogony" as if the students knew what that meant. Mansour didn't have a clue.

He went home dejected and cried to his mother that he wasn't going back. She insisted he try again.

Mansour did, and quickly he decided that he wanted to become a surgeon. He wasn't sure what type of medicine he wanted to specialize in, but his residency at St. George Greek Orthodox Hospital, where he treated the burned Syrian soldiers, took care of that.

In 1974, Mansour immigrated to the United States to take a residency in general surgery at the Union Memorial Medical Center in Baltimore. There he met his wife Claudette, who was working part time as a nurse. Inspired by a trip to France, Claudette, who grew up in Connecticut, was studying French. When she heard Mansour speaking French at the hospital, she struck up a conversation with him. He asked her out for pizza. They married in 1978.

A year later, Mansour was studying burn care under the pre-eminent burn surgeon Basil Pruitt at the U.S. Army Institute for Surgical Research in Fort Sam Houston, Texas. In short order, Pruitt promoted Mansour to chief of burn study.

While Mansour polished his skills in Texas, specialized burn centers were springing up around the United States. By 1980, there were 114 - nearly triple the number a decade earlier - and survival rates for burn patients had doubled since Mansour's boyhood.

In 1981, Saint Barnabas in Livingston called Pruitt looking for someone to head up its nascent burn program.

Saint Barnabas, now a 620-bed medical complex with 1,500 physicians in 68 medical and surgical specialties and 4,000 employees, had opened a burn center four years earlier. It was directed by a surgeon whose specialty wasn't burns. Saint Barnabas wanted an expert.

Pruitt suggested Mansour.

When Mansour arrived at Saint Barnabas he found a 10-bed burn center tucked away in a corner of the hospital basement.

Mansour was 34 at the time. His dream was to start a burn unit in Lebanon, but he agreed to come to New Jersey for a year before returning home.

In Texas, he and Claudette lived 15 miles and one traffic light from the hospital where he worked. As far as Mansour was concerned, that was too far. When the couple came to New Jersey they bought a map and drew a five-mile circle around Saint Barnabas. Any house they bought would have to be inside that ring, they told the real estate agent. Indeed, Mansour set his sights on a house right across the street from the hospital. He would be able to see Saint Barnabas from the living room window. But Claudette put her foot down, and they bought a house two miles away.

There was much to do. He had to teach the nurses, the technicians - even the plastic surgeons - how to treat burns.

In 1983, he needed help, so he hired someone who knew almost as much as he did. Sylvia Petrone was a New Jersey native who at the time was a fellow in burns at Cornell University Medical Center in New York City.

Like Mansour, Petrone made Saint Barnabas her life. A Morristown native and the daughter of a builder, she was single and lived within minutes of Saint Barnabas.

Petrone was the emotional antithesis of Mansour. He tended to wear his feelings on his sleeve. He was accessible and down to earth - as polite to the cleaning staff as he was to the hospital

president.

Petrone, now 47, was formal where Mansour was casual, reserved where he was familiar with the staff. Petrone hid her feelings well, but when someone on the burn staff was in need, she was often the first one to help. When Chris Ruhren, the nursing director, required minor surgery, Petrone showed up in the operating room and held her hand until the anesthesia took hold.

And Petrone was an artist when it came to skin grafting.

With Petrone assisting, Mansour expanded the burn team and upgraded its profile, moving the unit from the windowless basement to a sunny location on the second floor. In 1993, they recruited a third burn surgeon. Michael Marano was studying burns on the same fellowship as Petrone had at Cornell University Medical Center. Marano, who is married and the father of two children, grew up in Newark and graduated from Seton Hall and the University of Medicine and Dentistry of New Jersey.

He, too, had his distinctive personality. Most would define him as a gentleman.

Over the years, Mansour became known as impish and a little eccentric. Before he knew it, one year had turned to 19.

Staffers went out of their way to accommodate him. When the 5-foot-4 doctor decided to go on the Atkins diet the nurses hid birthday cakes from him. Mansour pouted and complained that he seemed to be gaining weight, not losing it. (He eventually dropped 44 pounds.)

Everyone on the burn staff knew when a child had been admitted because Mansour would become glum. Yet whenever the stress in the unit grew nearly unbearable, it was Mansour who broke it by telling a corny joke, laughing the hardest of all. His body would jiggle and his face would turn scarlet.

One day, Mansour came to work wearing a black shoe and a brown shoe. As he stood in the burn unit talking to the family of a new patient, Ruhren, the nursing director, followed the eyes of the relatives down to the doctor's feet. Ruhren could hardly keep from laughing.

"I don't want you to worry just because he can't tell the difference between a brown and a black shoe," she told the family when Mansour walked away. "He really does know what he's doing." They all laughed.

By the winter of 2000, Saint Barnabas and Hani Mansour were ready to handle a disaster of the scope of the Seton Hall fire.

With 30 beds and a staff of 90 burn specialists that included social workers and respiratory, physical and occupational therapists, as well as the doctors and nurses, Saint Barnabas was one of the leading burn centers in the nation.

Since Mansour's arrival, the number of patients had quadrupled to 425 a year. They came from all over the state. Many, like Alvaro, would have their care paid by Medicaid; others, like Shawn, were covered by private insurance. Because the cost of treatment often mounted to millions of dollars, the hospital set up a burn foundation to help.

Within the hospital, the burn unit was called "the golden child" and the "premier service." The staff was considered elite. To be a member of the burn team was something to boast about - though some still wondered who would choose such a grueling specialty.

Mansour liked to say the members of his team could have worked anywhere in the hospital. They were the cream of the crop. The best of the best. Always at the top of their game.

The game had gotten more complex, however. Burn care had advanced light-years since Mansour treated those Syrian soldiers in Beirut.

Mansour would say that burn treatment was part science, part art. In its earliest days, it was neither.

In 1500 B.C. the Egyptians were treating burns with mud and cow dung. Seventh-century practitioners advised using a salve consisting in part of the fat of old, wild hogs and bears, and a chunk of genuine mummy.

In succeeding centuries the remedies became slightly less exotic: purging and bleeding in the 16th century; turpentine and maggots in the 17th century.

As Mansour learned during the 1973 Mideast conflict, modern warfare forced learning in the science of treating those burned in battle.

During World War I, burns were treated with sterilized wax. World War II brought huge advances in anesthesia, skin-grafting techniques and the use of antibiotics.

By the 1960s, doctors were infusing burn patients with liquid formulas to replace the huge amounts of plasma leaking through their pores. Advances in topical antibiotics to fight septicemia, a massive infection from burns that poisons the blood, further reduced the death rate - though the prognosis for burn victims still was poor.

Eventually, burn specialists learned to feed burn victims early and to feed them often. Burns, more than any other injury, cause the metabolism to race. It is as if the comatose victim were jogging 24 hours a day, seven days a week, constantly expending calories. Without enough nutrients to nourish itself, the body would begin to eat away at its own muscle mass.

To make up for the lost calories, protein-enriched formulas are pushed through tubes into patients' stomachs within hours of their injury. Once they are able to eat on their own, they are encouraged to consume high-calorie foods - milkshakes, cheeseburgers, pizza. A 5,000-calorie diet is not uncommon for a burn patient.

In the 1980s, burn surgeons realized that early removal of burned skin and immediate skin grafting provided the best wound cover and protection against infection. But where to acquire the skin?

Cutting a patient's own healthy skin is the most efficient way to graft. Using a stainless-steel instrument that looks like a cheese cutter, surgeons slice strips of healthy skin from unburned sections of the victim's body. The strip is passed through a machine where tiny metal teeth puncture it, creating a mesh that can cover a larger area. The fine mesh strips are then stapled to the burned areas. The metal staples are removed later.

In the past few years, doctors have learned the use of cultured skin, where a tiny patch of the patient's healthy skin is sent to a laboratory and grown in petri dishes. After 18 days enough skin has been produced to cover an entire torso. But the skin has the consistency of wet tissue paper. It is difficult to work with, and the cost is exorbitant: $80,000 to $100,000 to cover a chest.

Cadaver skin is frequently used as a temporary cover until a patient's own skin can be grown. The process is called a homograft. Cadaver skin is the best substitute for a patient's own skin, but it, too, is costly: several hundred dollars for a small strip from a skin bank. Saint Barnabas keeps it in a deep freeze in the operating room.

The most recent advance has been the development of artificial skin. When a patient is so severely burned that there is not enough of his own healthy skin to use for grafting, surgeons turn to artificial skin, though only as a last resort. It doesn't take well and it tends to become infected.

Petrone is unimpressed by any of it. "None of this stuff is the panacea they make it out to be," she said. "There is no panacea when it comes to healing burned skin."

Within a week of the fire, Shawn's hands were grafted using skin from his shins. The burn surgeons stripped Alvaro's thighs for his five skin grafts, all of which took place during the first three weeks of his hospitalization.

The doctors would have to wait to see whether either boy required further surgery. In the meantime, they'd start with a basic treatment plan, then customize it to each patient.

What worked for Shawn would not necessarily benefit Alvaro - but both would start out every day the same way: in the burn treatment room.

The staff calls it the tank room. Patients call it the torture chamber.

"It's something you don't wish on your worst enemy," said Ann Marie Majestic, who has worked as a nurse in the Saint Barnabas burn unit since the beginning. "You can't describe it. You take your most God-awful open wound and rub sandpaper or Brillo over it. That is the pain these patients go through every day."

The tank room is the heart of burn treatment. It is foul-smelling and muggy. The temperature is set at 90 degrees Fahrenheit to protect patients from chill, and hanging heavily in the air are the sickening odors of burned flesh and open wounds. Between the heat and the smell, medical students often faint.

Antiseptic, windowless and bright under fluorescent lights, the tank room looks like most other hospital treatment rooms.

It is not.

It is what burn patients tend to remember most about their hospital stay - even years later.

Lexine Skinner-Simon was burned in a propane tank explosion on June 10, 1989. When she returned to the Saint Barnabas burn unit to visit the nurses a month after the Seton Hall fire she teared up at the sight of the tank. "Do you know what it was like being in that tank room? The awful pain. The tears. Everyone scrubbing and you couldn't say anything because you had tubes down your throat? That was the dreaded thing - when they said you were going to the tank room and you knew everyone was going to hurt you in there and you didn't understand why. The tank room, well, hell couldn't be any worse than what went on in there."

Most patients, already heavily sedated, are injected with booster shots of morphine before they are brought in. They still feel the pain.

A tanking usually takes an hour or less. Alvaro's burns were so vast it took two - two dreadful hours for the patient and the staff.

At 5-foot-8 and 200 pounds, plus the 70 extra pounds of fluids he retained after the fire, Alvaro was the largest patient in the burn unit and the most seriously burned. Unconscious, he was dead weight and difficult to handle, even for the team of five that it usually took to wash him.

Paul Mellini, the chief tank room technician, tried to schedule Alvaro early. His tank time was draining for the staff both physically and emotionally.

On one typical morning, Mellini and veteran burn nurse Andy Horvath led a team of technicians into Room 4 where Alvaro slept. Two doors down a 2-month-old baby, scalded in a bathtub and admitted the night before, was screaming. An elderly woman burned in a cooking accident moaned in the room next door.

The mood inside Alvaro's room was tense. On a count of three, Mellini, Horvath and three others lifted Alvaro off his bed and onto a plastic-covered, stainless-steel shower trolley. They covered him with a blanket, then rolled the trolley 25 feet into the tank room under a trio of hoses suspended from the ceiling. The trolley was tipped slightly and a 2-inch-wide black hose was attached from the bottom of the gurney to a drain in the floor. The hose would accommodate the runoff of water, blood and dead flesh.

Mellini tried to keep the atmosphere light. He asked one of the burn technicians to save him some cake from a lunchroom celebration, then launched into a spirited conversation about the late cartoonist Charles Schulz. "Livin' La Vida Loca" played on a boom box in the room.

The team began to cut away the gauze covering every inch of Alvaro's body except his feet, his nostrils and his lips. Horvath gave Alvaro some more morphine as they stripped away his bandages. Soon Alvaro was naked.

From his scalp to his waist, Alvaro was one gaping, oozing wound. His hands, grafted three weeks earlier, were a brownish purple, bloated to twice their normal size. His hair and a chunk of his right ear were missing. The sides of his torso were concave. The burns there were so deep that the surgeons had to cut away layers of flesh to reach healthy tissue to support the grafts. His back was the worst: a skinless bed of raw, red and yellow exposed tissue. Even his legs, which were not burned, had not been spared. So much healthy skin had been taken from his legs to graft onto his torso and his back, they looked like a patchwork quilt.

Alvaro's injury was so catastrophic that even some of the professionals had a hard time looking without choking up, but the team got right to work.

They soaked him with warm tap water from the overhead hoses. Then they smeared him with antibacterial soap and began scrubbing his burns with 4-by-4-inch gauze pads, which felt to him like steel wool.

The scouring was a fundamental step in burn treatment. Proteins leak from the wounds and form a film that looks like the cooked white of an egg. The film, which provides a haven for deadly infections, dries into a hard, waxy scab. When it is scrubbed away early in the treatment process, permanent scarring is minimized and the risk of infections is limited.

Though Alvaro was in a deep morphine sleep, he felt the pain. While the team scrubbed Alvaro, Mellini kept an eye on his face to gauge how much pain they were causing him.

Technician Nelly Delgado, a grandmother who had worked in the tank room longer than anyone, was overcome by tears when he grimaced, then lifted his right arm as if to ward her off. If he was screaming, no one could hear him because he was hooked to a respirator and unable to make sounds. "Okay honey," Delgado said, tears rolling out of her eyes. "I'm so sorry I'm hurting you. Poor baby. God help our poor, poor baby."

Horvath, a gentle man, beloved by the patients and the rest of the staff, stroked Alvaro's bare hands. The 56-year-old nurse had already become attached to him. He had seen the pictures the Llanoses taped to the wall near their son's bed: Alvaro holding his girlfriend, Angie Gutierrez; posing with his parents and sisters in their kitchen; mugging for the camera with his buddies from Paterson. The photographs showed a beautiful boy with romantic eyes and a cocky smile.

Horvath was fiercely protective of him. "I'll take care of his face," he told the others. "Okay Al. It's okay. You're doing fine, buddy. I'm going to clean your mouth now. Good boy."

Alvaro was moved to the other side of the curtain that divided the tank room. There, he was placed under a heat shield to keep him warm.

Burn technician Toni Schmidt picked up a silver nitrate stick. It looked as harmless as a Q-tip. She touched the tip of the stick to one of the open wounds on Alvaro's right side to burn off unwanted scar tissue. To Alvaro, still unconscious, it felt like he was being burned all over again. Tears streamed from his eyes.

Nearby, a table had been prepared with his new dressings - large pieces of gauze slathered with silver sulfadiazine, a topical antimicrobial cream.

The team wrapped the gauze around him from his head to his ankles, rolled him onto a stretcher, covered him with a blanket and, at 9:55 a.m., pushed him back to his room.

The procedure had taken one hour and 55 minutes.

Tomorrow morning it would begin all over again.