U.S. hospitals are increasingly shutting down their burn centers in a trend experts say could leave the nation unable to handle widespread burn casualties from a fiery terrorist attack or other major disaster.
Associated Press interviews and an examination of official figures found that the shrinking number of beds is a growing cause for concern in this post-Sept. 11 world.
Experts say burn centers are expensive to maintain and often lose money because they are staffed with highly specialized surgeons and nurses and stocked with sophisticated equipment designed to ease patients' excruciating pain, fend off deadly complications and promote healing.
The number of burn centers in the U.S. has dropped from 132 in 2004 to 127, and burn beds have fallen from 1,897 to 1,820, according to American Burn Association records compiled from voluntary reporting by hospitals.
The U.S. Department of Health and Human Services puts the number of burn beds even lower, at just 1,500. And most of those are already filled, with the number available on any given day variously estimated at just 300 to 500.
"If something happens and we need the beds for burn patients, it is going to be a real catastrophe," said Dr. Alan R. Dimick, past president of the American Burn Association and founder of the burn center at the University of Alabama at Birmingham.
Some states - Mississippi, North Dakota, Montana, Wyoming, Idaho and New Hampshire among them - have no burn centers at all. South Carolina has only a children's burn center, and there are just a few dedicated burn beds in Maine, Alaska and Hawaii.
"People ought to be pretty frightened by this," said Dr. Barbara Latenser, burn center director at the University of Iowa Hospitals. "Some people who live out West, they are 800 miles from a burn center."
Many hospitals contend their general trauma units can handle burn victims adequately. But many authorities say burn units are far superior because of the equipment and expertise they offer.
"You need a burn team to take care of folks, not just docs and nurses," Dimick said.
HHS oversees the Homeland Security Department's efforts to prepare the nation's medical system for a disaster. HHS preparedness spokesman Marc Wolfson acknowledged that a disaster such as nuclear blast in a large urban area could produce thousands of burn victims, and that there would not be enough burn facilities to treat everyone.
"The number of total beds available in hospitals, we don't have direct control over that," he said.
But he said he hopes some of the money the government has been dispensing to hospitals since 9-11 for disaster readiness goes toward preparing for a surge of burn victims, even if does not lead to an increase in burn beds.
Wolfson said that if burn beds are full, patients can be taken to trauma units. Also, he said some veterans hospitals have beds that could be used in a fiery catastrophe. And he said burn centers can be expanded in an emergency.
Some burn experts are not reassured.
Severely burned patients suffer extreme pain, their bodies lose the ability to regulate temperature and fluid levels, and they are highly vulnerable to infections because their skin has been stripped away.
Burn centers are staffed by medical professionals specially trained in treating people with severe burns.
They also have special features such as individually temperature-controlled rooms, mattresses with circulating air to support a burn victim, and beds that automatically turn immobile patients to prevent further skin damage.
In addition, there are warming devices for beds since burn patients get cold easily, and tubs in which patients can be immersed to clean their wounds and promote drainage.
Other burn center features include synthetic material that serves as a temporary skin substitute, and a device that uses ultrasound to determine the severity of burns without having to touch a seriously burned patient.
The exact number of burn beds in the U.S. is a matter of dispute, and may well be overstated, because hospitals do not always distinguish between specialized burn beds and beds that are used for various traumatic injuries, including burns.
Wolfson said one recent report to the federal government showed that only 520 beds were actually available for use. Dr. William B. Hughes, director of the Temple University Hospital Burn Center in Philadelphia, said that more commonly, only about 300 beds are available at any one time.
Hughes said the United States had easily more than 3,000 dedicated burn beds in the early 1970s. But there has been a steady decline since then.
"We keep hearing we are ready for a terrorist attack," said Dr. Jeffrey Guy, director of the 29-bed Vanderbilt University Burn Center in Nashville. But even now, "our space is full almost all the time."
Guy said it is not uncommon for regional burn centers to be full and for patients to be transported long distances. "There are days we are taking burn calls for Chicago," he said.
Burn center directors say more beds are likely to disappear. Most burn centers are losing money because Medicare and Medicaid reimbursements have not kept up with the cost of providing care, experts say. Private insurers often follow Medicare's lead.
Since it costs about $10,000 a day to treat a patient with severe burns, and such patients typically require 50 days of intensive care, a single uninsured patient can wreck the finances of a small burn program.
Some burn centers around the country have lost a lot of money treating uninsured adults and children who were severely burned in explosions of clandestine methamphetamine labs.
"Burn units are money-losers," Hughes said.
Some health industry officials say that it is unreasonable to expect the nation's hospitals to be prepared for a worst-case burn scenario at all times.
"You don't want to have so much capacity you lose your shirt on it," said Jim Bentley, the American Hospital Association's senior vice president for strategic policy planning.
Dr. David Mozingo, director of the Shands Burn Center at the University of Florida in Gainesville, said state officials there have, in fact, begun committing some terrorism and disaster-preparedness money to burn care.
"They have been buying equipment and training. A lot of supplies and equipment have been distributed that are burn-care specific," he said.
Some burn-care experts warn that in an all-out disaster, health professionals would have to conduct a pitiless form of triage and decide which patients get sent to burn centers and which ones do not.
"The person on scene is going to look at people who have the best chance of surviving," Iowa's Latenser said. "We will not have the resources."
Burn care professionals "spend a lot of time talking about, `How do we get the government to listen to this?'" Latenser said. "You can't have the disasters and then say, `Oh golly, we should have had the centers.'"
On the Net:
Health and Human Services: http://www.hhs.gov/disasters
Vanderbilt Burn Center: http://www.vuburncenter.com
University of Iowa Burn Center: http://www.uihealthcare.com/depts/burntreatmentcenter