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ROBERT SIEGEL, host:

This is ALL THINGS CONSIDERED from NPR News. I'm Robert Siegel.

MELISSA BLOCK, host:

And I'm Melissa Block.

Here is the latest casualty total for U.S. service men and women in Iraq. 2556 killed. 18,988 wounded. And on a recent hot summer night in San Antonio, six wounded men have come home.

(Soundbite of aircraft)

A C-17 cargo plane lumbers in. It's flown 12 hours from Germany, bringing patients from the U.S. military hospital in Lanschtul(ph). Inside, six men lie on stretchers. The most grievously wounded are sedated and covered by equipment, monitors and IV pumps and ventilators keeping them alive.

I watch them breathe and each rise of the chest seems like a miracle. Two of these men are headed for the burn unit at Brooke Army Medical Center in San Antonio.

Unidentified Man: On the count of three. One, two, three.

BLOCK: They're in very critical condition, full thickness or third degree burns over much of their bodies. Or as one of the hospital staff who is waiting for the plane puts it, the insult is huge. The servicemen are lifted into ambulances and buses, which speed off to Brooke Army Medical Center, known as BAMC.

BAMC has the Defense Department's only burn center and they're able to save people they never could before because they get them here so quickly. It could be as fast as 36 hours from the injury in Iraq to the hospital in Germany and then to Texas.

Over the next two days, we're going to spend some time at the burn center. Most of the inpatients are in no condition to talk. Today, we're going to meet some of the men and women who work at BAMC. They've treated more than 450 patients with severe burn injuries from the wars in Iraq and Afghanistan.

Major ELIZABETH MANN (Clinical Nurse Specialist, Brooke Army Medical Center): When they get here, they get their first real shower, cleaning and debreedment(ph).

BLOCK: Major Elizabeth Mann is a clinical nurse specialist at the burn center.

Major MANN: And that first debreedment's very important because you have to remove any blisters or dead skin. They'll almost, within the next day, go to the operating room and have a full excision of all the burn wounds.

BLOCK: That means cutting away the dead tissue to prevent infection. Then the exposed areas get covered with skin grafts. Lieutenant Colonel Edwin Alberto takes me into the tissue bank, two freezers.

Lieutenant Colonel EDWIN ALBERTO (Head Nurse, Burn Unit, Brooke Army Medical Center): And I have four drawers of skin or slots for skin.

BLOCK: This might be skin grafts taken from the patient if there's enough unburned tissue to harvest. It might be synthetic skin or pig skin, epi-cells, which are grown in lab from biopsies of the patient's own skin cells. Or it might be skin from cadavers, called allograft.

Lieutenant Colonel ALBERTO: We go through a ton of cadaver skin, and in fact, sometimes I'll run out. And tissue banks can't keep up with me when we're really busy.

BLOCK: Is that right?

Lieutenant Colonel ALBERTO: Yeah. So we have our challenges up here to meet the needs of our patients.

BLOCK: Without skin, burn patients can't maintain their core body temperature, so the patients' rooms and the operating room are kept hot, between 90 and 100 degrees. The hospital staff get drenched in sweat.

Lieutenant Colonel Alberto is the head nurse in the burn center's OR. He's been here a year now, an OR nurse for more than 20 years. And he's deployed three times, in Desert Storm, Somalia and this latest Iraq war. So he's seen a lot. But he says seeing these patients is especially tough.

Lieutenant Colonel ALBERTO: The kids that we get, I call them kids. They're 19, 20 years old. It's tough to see them. I get goose bumps. It's hard to work on them because you see that they're just so young, and you see the condition they're in. They're kids, making the ultimate sacrifice.

BLOCK: Major Sandra Wonnick(ph) has been a burn surgeon at BAMC for three years. Three long years, she adds.

Major SANDRA WONNICK (Burn Surgeon, Brooke Army Medical Center): For everybody who works here - nurses, therapists - What do we say? We're a little off. You live on the extremes. It's either really satisfying or it breaks your heart, and you kind of bounce back and forth and you don't - I don't, at least, spend a lot of time in the middle.

BLOCK: I wonder, as you see patients coming in all the time from this war, do you stop? Do you wonder, you know, when is this going to stop? When am I going to stop seeing 19 year old kids with burns over 90 percent of their body?

Major WONNICK: Yes, I wonder that. I'm not going to answer anymore of that. I'll be in trouble. But, yeah. We wonder that all the time.

The whole degree of injuries you see here is just exponentially higher than what I ever saw in the civilian world. And that they do as well as they do is an amazing tribute to them and their motivation, but still, it's hard. Because they're not just burned. They're blown up. Most of them are IEDs. That takes a toll.

Major WILLIAM AKIN(ph) (Head Nurse, Brooke Army Medical Center): How are we doing? Are you getting ready to go home?

Corporal MERLIN HERMANN(ph): Yes, sir.

Major AKIN: You excited?

Corporal HERMANN: Yes and no.

Major AKIN: Scared?

Corporal HERMANN: A little bit.

Major AKIN: Yeah, it's a big change. First time in over a year.

BLOCK: When we visited the burn center last month, Marine Corporal Merlin Hermann was the inpatient who had been there the longest - 484 days. And he was about to leave the hospital, briefly, for the first time.

Major AKIN: Okay. So we're just going to get you out for the weekend?

Corporal HERMANN: That's the plan.

Major AKIN: And then get you back and see how you do, right?

Corporal HERMANN: Yes, sir.

Major AKIN: All right.

BLOCK: Corporal Hermann came to the hospital with burns over 97 percent of his body. He was a gunner with the 11 Marine regiment and was hit by a roadside bomb in Ramadi. When he came to the burn center, doctors gave him virtually no chance of survival.

Major William Akin, the head nurse of the acute burn ward, calls him an inspiration to everybody.

Major AKIN: Merlin is this rare individual that had a 97 percent burn, and basically, really never got sick. If we put graft on him, it stuck. And all of his grafts came from his scalp. That was the only place that wasn't burned.

BLOCK: So he has skin grafts over -

Major AKIN: Everywhere.

BLOCK: - pretty much his whole body.

Major AKIN: Pretty much his whole body, yes.

BLOCK: How important is that psychologically for him to be able to get out? Spend a weekend away.

Major AKIN: Tremendous. And it's a very hard move for them. We find that people that are burned, they're safe here. Everybody's the same. Everybody here knows how to take care of him. Everybody here understands, you know, that this is life changing.

There are a certain number of burn patients - because people are looking at them, people point at them - they do become shut-ins. They order their groceries over the internet. They order books over - they don't go out because they don't want people looking at them. We work with that. We have clinical nurse psychologists. We have case managers that watch for that and make sure that we don't let it get to a point where that becomes their life.

BLOCK: A huge part of the work at the burn center is trying to control the pain.

Dr. Ian Black is the chief of anesthesia. His description of what his patients endure is excruciating.

Dr. IAN BLACK (Chief of Anesthesia, Brooke Army Medical Center): There's this sort of cornucopia of pain. So there is the pain from the actual burn itself. There is the pain that's associated with the trauma. So whether it's the amputation or stump pain or even phantom limb pain. There is the pain that's associated from cleaning the wounds. There's a pain that's associated from harvesting the skin. All of those are sort of different pain signals and pain pathways and they feel all of them. And so we try our best to make them comfortable.

BLOCK: Do you feel like you understand that pain as a doctor, not going through it? Do you understand what your patients are going through?

Dr. BLACK: I wish I could say yes. But, I mean, it would be hubris on this unimaginable scale to say, oh, I understand. I mean, how can you understand? These guys are burnt 50, 60, 80, 90 percent of their bodies. They're missing digits. We take down skin until we get to healthy tissue that has raw nerve endings. Yeah. I can't imagine.

BLOCK: But even what they can imagine is hard on the staff. Again, clinical nurse specialist Major Elizabeth Mann.

Major MANN: To be a nurse, knowing your inflicting discomfort or pain on a patient, that definitely causes a lot of stress and a lot of anxiety for the caregivers.

BLOCK: Are there some nurses who just aren't emotionally cut out for this work?

Major MANN: Absolutely. This is the toughest group of folks I've ever met. A lot of strong-willed personalities to be sure. But that's what it takes to work in this environment.

BLOCK: We talked with Major Mann in a small anteroom connected to a patient's room, PFC Devon Givens(ph). He was injured on April 11th when a bomb exploded under the Bradley fighting vehicle he was driving in the Sunni triangle. Three fellow soldiers were killed.

Devon Givens suffered burns over 93 percent of his body, three amputations - both legs and one arm. His back was broken. Internal organs were exposed. As the hospital staff entered his room, they would see photographs on the wall, pictures of healthy Private Givens standing proud in his dark green Army dress uniform, posing with family and friends.

Major MANN: It's very important that the nurses see the patient as a person, because the majority of our patients have facial burns, they are unrecognizable and they're extremely disfigured. And it is absolutely critical that we have a face to put and remember that this is a gorgeous, handsome young man and that he has a loving to family, to see him with children, with his parents, with his friends. And know that there's a life that we need to get him back to. Many of these people, they lose their humanity almost. So you need a way to humanize them so that you can continue to care for them and love them.

BLOCK: Later, we met Private Givens's father, Mel. He and his wife, Bonnie, had been by their son's bedside for ten weeks.

Mr. MEL GIVENS (PFC Devon Givens' Father): It's still day-by-day. He's determined and he's strong, but he still has like 40 or 50 percent of his body's not covered by skin yet. So we're watching out for infection. Every day's a victory.

BLOCK: What do you tell him when you go to see him?

Mr. GIVENS: Well, the first thing I say when I walk in is, Devon, we're winning today. And I remind him that he's still a soldier and he's still on his mission. Devon may change a little bit physically but Devon's still Devon. Won't make any difference.

BLOCK: You could tell?

Mr. GIVENS: Oh, yeah. He's in there. He's winking at the nurses and smiling at them and giving them a bad time. And most of them are old enough to be his mother, but he's, yeah, Devon's still Devon.

BLOCK: Two days after we talked with Mel Givens at the hospital, on June 23rd, Devon Givens died. He was 19 years old. He was buried with full military honors in his hometown of Port Orchard, Washington.

The staff at the hospital handles these losses different ways. One nurse has a spot at the side of the road where he'll stop and cry or pray or meditate so he won't take the emotion home. One doctor says after a death, some of us kick the file cabinet, some of us hug the family members and some of us cast our eyes toward the ground and avoid the family we have failed.

And another doctor says this about the emotion when a patient dies, you cram it somewhere and go on. There are six more just like him who need care.

Tomorrow on the program, we'll meet one of the survivors, Sergeant Joe Fowler and his wife, Leslie. They're inching forward on the path to healing at Brooke Army Medical Center.

You can find a historical look at how wars bring about medical advances at NPR.org.

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