After the fire

As in earlier tragedies, the lessons learned from treating the survivors of the Rhode Island nightclub inferno may help save lives in the future

By Stephen Smith, Globe Staff, 8/12/2003

The patients arrived in pairs, like passengers disgorged from some doomed ark. Through that frigid night and into the morning, they kept coming, their burns so penetrating that in certain patches no skin, muscle or tissue remained.

"I remember being in the emergency department and I thought they were going to send us 10 or less," recalled Dr. Robert L. Sheridan, among the burn specialists at Massachusetts General Hospital who treated the sickest survivors of the Rhode Island nightclub inferno. "We were up to 14 and they were still coming, and I remember saying, `I just hope they stop soon.' "

For 153 days, it never really stopped. There were hundreds of surgeries -- day and night. There were complications -- an unexpectedly high incidence of blood clots and evidence of stroke-like disorders and blindness rarely seen in burn victims. And there was second-guessing: Should patients be parceled out to hospitals in other states and, if they were, could they even survive the trip?

Like victims from another calamitous New England fire six decades earlier, the Cocoanut Grove disaster, patrons of The Station roadhouse will in life, and in death, yield vital clues to care for those burned in the future. Now, nearly three weeks after the last of the 17 patients treated by the Mass. General doctors left the hospital, the tale of their treatment remains a work in progress, with chapters still to be written.

The doctors engaged in the recovery of the survivors plan to recount their experiences in the nation's premier medical magazine, The New England Journal of Medicine. And they are weighing research to investigate the blood clots and other difficulties, hoping to advance a medical specialty just a few decades old.

"We're not at the end of the story here," said Dr. John T. Schulz, another of the codirectors of the hospital's burn unit. "With burn care, we're responding to the disaster, instead of figuring out a way to reverse it. We need better skin; we need to be able to fabricate tissue. And we're still quite a ways from figuring out a good way to protect the patient from the ongoing effects of smoke inhalation.

"There's a lot of room for improvement, but we're getting there."

The doctors' first sign that something dreadful had happened in Rhode Island occurred not long after midnight on that February Friday. Sheridan took a call at home from Dr. William G. Cioffi, surgeon-in-chief at Rhode Island Hospital. They were old professional acquaintances, their paths crossing ever since they met at the Army's burn research center in Texas, home to discoveries that revolutionized burn treatment.

"Dr. Cioffi said, `I don't know what's going on, but I've heard we've got about 100 burn patients, and we need some help with burn beds,' " Sheridan said. "I called the MGH and talked to the triage nurse, and we tried to get as many beds as we could."

The first patients landed shortly after 2 a.m., followed by a procession of others, most tethered to breathing machines.

"There are many enduring images, among them are the appearance of the patients when I first hit the emergency room," said Schulz, who made the short drive to the hospital from his Cambridge home. "They were just horrible injuries -- I'm not going to forget that. Is it worse than anything I've ever seen? No. But to see more than one at a time, that was distressing."

Of the three specialists who share leadership of the Mass. General burn unit, Dr. Colleen M. Ryan has labored there longest, studying in the 1980s under the graybeards who had, essentially, invented the specialty of burn medicine.

She'd been at the hospital to treat survivors of the rampaging Malden Mills fire in 1995, and she'd tended to firefighters injured in a 1993 chemical explosion at a Newton metal-making plant. And, certainly, she'd seen patients whose bodies had been so ravaged by flames or high voltage that there was nothing left in some spots save for charred bone. But, most years, even a burn unit as hectic as Mass. General's will only see a half-dozen patients with that kind of injury.

"That must have been extremely hot fire," said Ryan, in her 16th year at Mass. General. "This was a lot of patients all at once to have that kind of serious, deep burn. The depth of the injuries to the faces and the hands was exceptional."

Patients were dispersed to the burn ward, to various intensive-care units, and even to the Shriners Hospital for Children. A total of four operating rooms at the two hospitals were devoted exclusively to the nightclub survivors. And workers from throughout Mass. General and Shriners flocked to the 14 patients who were admitted and the three others who were treated in the burn clinic.

In the first hours and days of treating patients with potentially lethal burns, doctors work feverishly to maintain victims' ability to breathe. For the survivors from The Station, the battle to keep their lungs working proved especially arduous -- a sure sign this was a fire whose fuel was deeply noxious.

That was just the first of the distinctive challenges confronting doctors struggling to save The Station patrons. What happened the night of Feb. 20 wasn't just a fire. It was also a stampede, with bodies collapsing atop each other, resulting in crushing injuries and infections stemming from peeling skin and even the sullied snow that was used to douse flames.

So, Sheridan, endeavoring to make sure any internal injuries were detected, opted to take high-tech snapshots of each patient, head to pelvis.

"There's so many people, there's so many IV lines to put in, and so many airways to secure -- and they all could have head injuries, lung injuries, injuries in their abdomen, too," Sheridan said. "I was just fearful that if I missed something on one of them, they would die because I missed it."

As days turned into weeks and then months, the patients from the Rhode Island fire developed a disturbingly high number of blood clots in their veins, something that past burn-treatment experience suggested should be rare.

"With this fire, the incidence in critically ill patients was almost 50 percent," Ryan said. "That's outrageous. And I don't know what the cause of it is. It could have been the fire, the particular smoke. Maybe it's some new antibiotic we needed to use. It could be that our catheters are bigger. I don't know why, but we need to study it."

When they weren't treating patients for blood clots, the doctors were dealing with massive swelling that threatened to kill patients. Burns set off a cascade of reactions deep inside the body, unleashing hormones and other chemicals that typically keep the body in harmony. But in a burn patient, balance proves elusive. One result: Tiny blood vessels spring leaks that allow fluid to seep into tissue.

To relieve the swelling, surgeons cut through the bloated tissue. In one of the most dramatic examples, the Mass. General doctors made massive incisions on the distended bellies of at least two patients to ease abdominal swelling. Fluid gushed out and abdominal organs protruded, eventually secured with strips of silicone or Gore-Tex.

The alternative would have been to watch the swollen tissue strangle the veins that ship blood to the heart or lodge against the diaphragm, stifling breathing.

But such an operation is stressful -- and not just for the patient. During the first weeks of caring for the patients from the nightclub fire, the burn specialists had little time to sleep, let alone relax, as they attempted to patch deep wounds and confronted whether to amputate the fingers and hands of patients whose flesh had begun to die. Briefly, they weighed transferring patients to a hospital in New York.

"They wouldn't have survived the trip, they were so unstable," Sheridan said. "If they would have died in the air, I would have felt awful."

The experience of caring for so many patients so badly burned is already causing Sheridan to evaluate whether the burn unit should be ready to summon an out-of-state relief team in the event of another fire that floods New England hospitals with mass casualties.

Nearly six months after The Station calamity, the doctors who treated survivors at Mass. General and Shriners continue to see patients. Of the 17 sent to the two hospitals, four died.

For the 13 who lived, survival means varying degrees of disfigurement and disability. There will be permanent scars and, in some cases, sacrificed fingers, hands, and ears. And patients have experienced unusual bouts of neuropathy, a nervous system disorder that has produced stroke-like conditions and even transient blindness.

Ryan, Sheridan, and Schulz said they were impressed by the determination and courage of the patients from the Rhode Island blaze.

"My reaction is one of sorrow -- it always is when I see somebody that's badly injured," Schulz said. "That's where the clinic visits after they leave the hospital come in handy. That's where all the hope is. You've got to know the road can end in an outcome that the patient finds valuable, that there is happiness in the future."

Stephen Smith can be reached at stsmith@globe.com.