Emergency: a burn victim's battle for survival begins after the fire is out.

This story is based on the true experiences of burn victims and the doctors who treat them.

It's a quiet night at the Children's Hospital of New Jersey. But when a paramedic's voice crackles over the emergency room radio, the doctors and nurses spring into action.

"We have a burn patient, male, age 12," the voice squawks. "Looks like a fireworks explosion. He's got second- and third-degree burns to his hands, face, and upper trunk."

Dr. Anita Falla and her burn treatment team quickly don surgical masks, gloves, and gowns. Minutes later, the ambulance crew wheels Mike through the door.

Dr. Falla takes charge. Her first concern: stabilizing Mike's condition. "We've got to get that hot clothing off to let the skin cool," she explains. The team starts to snip away at the remnants of Mike's charred T-shirt and jeans.

Next, the medical staff begins rinsing Mike's burns with lots of water. Any burn, says Dr. Falla--whether it's caused by fire, chemicals, hot oil, or scalding water--should be rinsed with cool tap water right away. The faster, the better, she says. Otherwise, the heat from the burns will continue to "cook" the skin, as if it were in an oven.

During the rinsing, Dr. Falla examines Mike's body and notes that almost half of it is covered with charred, leatherlike skin. These are serious, third-degree burns

Mike moans in agony. But it's not the third-degree burns that are causing his pain. All the nerves in those areas have been burned away. Instead, it's the nerves in less severely burned areas that are sending pain signals to Mike's brain. To ease his suffering, Dr. Falla gives Mike an injection of morphine, a potent painkiller.

SKIN DEEP

The next priority for the burn treatment team is to start replacing Mike's body fluids. "The skin is a cover for the body," explains Dr. Anthony Barbara, a burn-treatment specialist at the Hackensack Medical Center in New Jersey. "Once that protective barrier is gone, fluids [like blood, plasma, and the fluids that bathe and fill cells] ooze out," he says. Burn victims can leak gallons of fluid a day from their raw wounds. The treatment: Hook them up to intravenous (IV) tubes to pour vital fluids back into their veins.

Of course, finding a vein on a severely burned patient can be tough, explains Dr. Falla. "Sometimes the skin is so burned that you can't see any blood vessels underneath. And sometimes the vessels are completely destroyed." Fortunately, she quickly finds an undamaged vein on the underside of Mike's left arm.

Next, Dr. Falla turns her attention to Mike's uncontrollable shivering. It might seem odd that a burn victim would feel chilled. But skin, explains Dr. Falla, is also very important in regulating body temperature. "Whether it's cold or hot outside, the skin adjusts" to keep your internal temperature at a constant 98.6 [degrees] F, she says.

Here's how: Under the epidermis, or top layer of skin, is a thicker layer called the dermis (see diagram, opposite page). It's loaded with tiny blood vessels that carry heat from inside your body to the surface of your skin. When you need to dump excess heat--say, while exercising--the blood vessels dilate, or expand, so more blood can carry more heat away. You end up looking flushed. On the other hand, when you want to conserve heat, the vessels constrict, or get smaller, to keep body heat in.

But many of the blood vessels in Mike's dermis have been destroyed--and with them, his ability to keep cool and warm. In the 70 [degrees] F treatment room, Mike is losing heat fast.

To fight his chill, the doctors quickly wrap him in clean, dry bandages. The bandages form a temporary "skin" to hold in warmth. The violent shivers subside.

But now Mike's in danger of getting too hot. Without his dermis, he has no way to get rid of excess heat. So the doctors move him to a special cooling mattress and give him aspirin to fight off fever.

With his temperature stabilized, Mike has made it through the first phase of his race to recovery. Now, as he regains his strength, his body can get down to the serious business of healing.

REBUILDING SKIN

If you want to know what it takes to heal a serious burn, start by thinking about how your average scrape on the knee heals. First a scab forms over the wound as proteins and other substances make your blood clot. Then undamaged skin cells underneath the scab start to multiply and grow across the gap caused by the cut. When the scab falls off several days later, this brand new skin is in place.

After third-degree burns, you do get scabbing--with hard tough tissue called eschar, which looks like tree bark. Mike's wounds are covered with it after just one day. But he has no undamaged skin cells underneath to multiply and fill in his wounds. His skin is burned all the way through. It can't heal itself.

That spells big trouble for Mike, explains Dr. Falla. "First of all, without a protective layer of skin, germs (bacteria) that normally live on our skin and do no harm can seep inside and cause a massive, life-threatening infection." And bacteria thrive on the dead skin and dried blood of eschar.

So one of the primary goals of burn treatment is to take the eschar off--by shaving and scrubbing the wounds. The process can be very painful because nerve endings in the surrounding tissue are exposed. So patients have to regain their strength first--and endure having their wounds washed and rebandaged every day.

After removing the eschar, surgeons cover the open wounds with skin grafts. "We remove a thin, almost transparent strip of skin from a part of the body that isn't burned," explains Dr. Barbara. The strip is "as little as twelve-thousandths of an inch thick."

Next, doctors lay the graft over the cleaned wound and sew it in place. Now the living skin cells in the graft can multiply and adhere to the undamaged tissue around the wound.

THE HARD PART

It will probably take several trips to the operating room before Mike's burns are completely covered with new skin. But the biggest trauma of all, says Dr. Falla, is not the surgery: It's getting used to the scars.

When both the epidermis and dermis are injured, tough fibrous scar tissue forms in the place of skin. Scar tissue lacks the elasticity and sensation of regular skin. It can grow in thick, uneven layers. And it may look shiny and tight.

"Plastic surgery and other techniques can help reduce some of the scarring," says Dr. Falla. But it can't take away the fear that most burn victims feel.

Only people who have been through it understand, explains 21-year-old Jeff Taylor, who suffered third-degree burns on more than 65 percent of his body. But Jeff overcame his physical and emotional scars.

It wasn't easy, he admits. "'Normal' people can't relate to what I went through: the hospitals, feeling helpless and ugly," he recalls. He wishes he'd had someone to talk to.

Now Jeff is trying to be that someone for other burn victims. He's a member of a big brother program that counsels young burn victims like Mike, helping them face the fears he once faced.

"A lot of people just want to look on the outside," says Jeff. "I think I can help burn victims understand that it's what's inside that really counts."