Six-year-old Noah Kelly finished Bible study at his Nashville church and asked to play soccer outside with his friends before heading home.
The electricity had been out at the church on that Saturday in July 2016, and the group had hoped that the electric company would arrive to fix the problem before the steamy day ended.
Noah’s mom, Rufta Aron, stood by the open door, waiting for Noah to finish playing. As she said goodbye to friends, Noah reached inside a bush to retrieve the soccer ball and touched a live electrical wire. One second. One touch. Lives forever changed.
Noah received life-threatening electrical burns over much of his body. Electricity runs rapidly through the body and not only chars the skin, but also burns muscle and bone, severely damaging tissue beneath the skin.
“Noah’s friends all started screaming ‘fire, fire,’ but when I turned around there was no fire,” Aron said. “Noah was lying on a little hill. When I got to him, I lost it. His eyes were open, but he was like stone.”
Aron began CPR, during which she pulled melted wire out of his mouth. “I tried to dump water on him. I wasn’t thinking right. I wasn’t even thinking that I shouldn’t touch him (because of the electricity). My reaction was to bring him back. I kept crying, ‘He’s gone. He’s gone,’ and my friend said ‘No, he’s not. Not today.’ I appreciated her giving me that hope.”
Aron was too distraught to continue CPR, so her friend, Rahwa Bereket, stepped in to perform CPR with help from one of the church members. They finally got a faint pulse. The paramedics arrived quickly and tried to stabilize Noah before transporting him to Monroe Carell Jr. Children’s Hospital at Vanderbilt.
“They wouldn’t let me ride with him. He was in very bad condition, and they didn’t want me in there,” Aron said. A friend drove her to the hospital. “I had his shoes and put them in my purse. They had melted. Everything smelled like burned wire.”
Every minute counted
Lisa Rae, MD, was on call that afternoon and met Noah at Children’s Hospital’s Emergency Department.
“Noah had horribly severe injuries,” said Rae, director of Burn Center Quality and Performance, Trauma and Surgical Critical Care. “With electrical burns you can’t always see the full extent of the injuries right away. Electricity can run through the body and burn muscle and bone under the skin. It can also injure the brain, heart and nerve function throughout the body.”
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The Pediatric Emergency Department team quickly determined that Noah was burned over 40 percent of his body, particularly his right arm and hand, the back of his head and the entire back of his body. “He had char burns clearly into the muscle and bone and you could see exposed burned bone on his hand. He had muscle that appeared to be ‘cooked’ in the wound. He was unconscious and we didn’t know his mental status and wouldn’t know for some time. With this type of injury there’s the potential for brain injury,” she said. It was the worst electrical burn she had seen.
Rae joined the Vanderbilt faculty in 2013 following general surgery training at Georgetown University in Washington, D.C., and burn and trauma critical care fellowships at the University of Washington at Harborview Medical Center’s Level 1 adult and pediatric trauma and burn center.
The team’s first focus was to stabilize Noah and replace fluid loss resulting from the burn injury in his small body. “We needed to keep him out of multi-organ failure,” she said. “He was having a storm of inflammatory responses. Days in, we would still be discovering the extent of his injuries.”
Within an hour Noah was transferred to Children’s Hospital’s Pediatric Intensive Care Unit (PICU) where he would continue to stabilize for about a month.
“Every minute counted,” Aron said. “Every minute that went by, there was hope.”
A blended unit
Burn patients with large burns — 15-20 percent of the total body surface area or more — often need critical care for at least the first 24 hours or more, said Blair Summitt, MD, assistant professor of Clinical Plastic Surgery and medical director of the Vanderbilt Burn Center, which opened in 1983.
Critically burned adult patients are cared for in the Burn Intensive Care Unit, a designated Level 1 burn center. Critically injured burn patients may need resuscitation; they lose large amounts of fluid and need to be taken care of by intensive care specialists.
The Center’s stepdown unit, however, treats children and adults. It is the only adult and pediatric blended unit in the Vanderbilt University Adult Hospital.
In 2016, of the Burn Center’s 572 admissions, 95 were pediatric patients.
“Pediatric burn patients are first taken to the Children’s Emergency Department for assessment, then will be sent to the Children’s Hospital’s Pediatric Intensive Care Unit for critical care monitoring and/or ventilation,” Summitt said. “Having these patients receive critical care in the PICU is invaluable for us. Our (burn) teams go there.”
Summitt said the two groups work extremely well together. Surgeries on pediatric burn patients take place at Children’s Hospital. When the patients are stabilized and moved to the Burn Center’s stepdown unit for continuing care of their wounds and rehabilitation, a pediatric hospitalist often continues to follow their care because children may have other non-burn related issues such as ear infections, etc.
Summitt said that most pediatric burns are from scalding, with about 10 percent being due to abuse or neglect. The first stop, the Pediatric Emergency Department, is critical for assessing whether the burn could be due to abuse or neglect, he said.
Electrical burns are seen less frequently at Vanderbilt’s Burn Center (about one a month) and are difficult to assess, Summitt said. “Many times there are no external burns, but the current runs through their body damaging bones, muscle, fat and skin. They need fluid replacement and they can quickly go into kidney failure. Their injuries can be disguised when we first see them,” he said.
One out of four electrical burn patients will require an amputation, he said. They may also have long-term neurologic issues and can suffer migraines and memory loss and longstanding pain in their hands or feet. “Electrical burns are terrible injuries,” Summitt said.
A collaborative, multidisciplinary team
Rae said Noah’s burns were severe enough to require amputation of his right arm while he was in the PICU. This was performed by Wes Thayer, MD, one of Plastic Surgery’s hand specialists. The burns to his head required the removal of dead tissue including his scalp and skull bone. He had several brain scans as they tried to determine whether his brain had been damaged by the current. It had not. “It takes a very collaborative team to get someone through these stages,” she said. It was about a week before Noah was stabilized in the PICU.
“Because all damage cannot be seen on a scan, then the question remained about his mental status,” Rae said. “He started waking up and opening his eyes, and was still on a ventilator to breathe for him, but even at a week out he would really only respond and look at his mother. Since he was hooked to multiple tubes and was on so many medications for pain, it took several weeks for him to respond to others and ‘act like his old self,’” Rae said.
After one month in the PICU, he was transferred to the Burn stepdown unit where he stayed for over three months. His total hospital stay: 145 days — just shy of five months.
Burn injuries require specialized care from burn surgeons, specialty surgeons, pediatric critical care physicians, medical physicians, nurses, Child Life specialists, physical and occupational therapists, nutritionists, social workers, respiratory therapists and mental health professionals. There are both physical and emotional injuries.
“It takes a very collaborative team to get someone through these stages,” Rae said. “Burn units are often touted as the model for multidisciplinary care because the patients are so complicated and so many people are required to help the patient get well.”
People with severe burns may require a lifetime of procedures and physical therapy. Their wounds require skin grafts (a surgical procedure that involves removing skin from one area of the body and moving it, or transplanting it, to a different area of the body); they have difficulty maintaining body temperature and fluids, are at high risk of infection and require significant physical and occupational therapy. Noah required about 15 skin grafts.
‘One of the most incredible families’
Keeping an emotional distance from patients isn’t always possible, Rae said. “There are certain patients and families that you can’t help but become attached to when you’re involved and you care so much,” she said, adding that much of a child’s adjustment depends on his family’s strength. “Noah’s family is one of the most incredible families I’ve ever dealt with. How they coped and stayed positive, how they were there in ways appropriate for Noah, was really remarkable.
“When they saw his amputated arm, they didn’t show their own shock. When Noah had wound care, they said ‘look at how great your skin grafts are. Look how you’re healing.’ They pushed forward and helped him not be afraid. They modeled acceptance. Kids pick that up from their parents.”
The recovery of a burn patient is lengthy and complicated, Rae said. “There’s no adequate education for what patients will experience with a serious burn, there is no way to truly prepare a patient or their family for how long and difficult recovery is.
“Patients and their families can’t know what’s ahead, but I do. It’s a very long road. It takes a huge amount of adjustment, and Noah is adjusting to his life as a burn survivor.”
Aron said the Burn Center team became like extended family. “They were very caring to the point I was like ‘oh my God, you’re doing more than what your job requires.’”
The day that Noah left the hospital, there was a celebration; the Burn Center team lined the hallway and cheered, blew bubbles, and gave him high-fives as he walked slowly down the hall.
“Our staff became so close to Noah and his family,” said Lindsay Miller, MSN, RN, the Burn Center’s Nurse Manager. “They used their own money to buy ingredients so he and his mom could bake pizzas,” she said. “Our nurses watched him so his parents could go out to dinner. We had staff who requested time off to go to his birthday party at his house after he had been discharged.”
Rae, his physician, said she had mixed feelings when Noah was discharged. “I was so happy to see him getting out of the hospital. It was a milestone, but he still has so much work to do and at that point he had skin grafts behind his knee that weren’t healing. It wasn’t the same sense of accomplishment that he and his family had. I know the hard work that’s ahead.”
Noah returned to the hospital in February for additional skin grafts behind his knee, an area that was difficult to heal.
“There’s only a very small part in the burn textbook about ghosting or wounds that don’t heal,” Rae said. “I had to talk to colleagues around the country about what to do for Noah,” she said. The wounds have now healed.
Noah will require lifelong medical care for his scars since scars don’t stretch and grow like the rest of a growing child’s body. The scars, which affect not only the outward appearance of the skin but also the muscle and fascia (connective tissues surrounding muscles) below, will limit his movement, so he will require physical therapy to keep his limbs moving appropriately and allowing him to continue to be mobile. He also must wear burn compression garments underneath his clothes that work by applying pressure to the affected area to help flatten and improve the appearance of scars. His prosthetic arm will also need to be adjusted as he grows.
“Noah’s grafts are softer than I would expect, they are more like normal skin, so his scarring is not especially bad,” Rae said. “He’s doing amazingly well. The muscle in the back of his right thigh was blown out down to the bone. There was a big deep hole where the muscle was missing. We didn’t know if the sciatic nerve (that runs from the lower back down the back of each leg) would be OK or if he’d have use of his leg. Today, he has no visible tissue defect. His recovery has really been remarkable — that’s part of the blessing of being a kid. They can do amazing things.”
Noah’s mom said that he is “goofy, quirky and smart,” and loves his two dogs, music, superheroes and playing games. He also has eclectic taste in food. He doesn’t eat any junk food or any fast food. He loves sushi and Ethiopian food. “He’s not your typical 6-year-old,” Aron said.
She recalls being fearful about how Noah’s classmates and others would perceive him (because of his scarring and prosthetic arm) once he returned to school in April 2017.
“I didn’t think we were ready for the outside world. I wanted him to be around people who knew him, who cared for him and who knew what happened — people who wouldn’t judge him. But going back to school was harder on me than it was on him. It just doesn’t faze him,” she said.
“One night, I was putting him to bed and I asked him if it (going back to school) was OK. He said that some of the kids said his arm was weird. I almost got a little teary, and I told him that being weird is good. ‘When people say you’re weird it means that they don’t understand something that has happened. So being weird is actually kind of cool,’” she told him.
“He just said, ‘OK. If someone says my arm is weird, I’ll just say yeah, that’s because I’m cool.’ Noah takes care of himself. He doesn’t let anybody put him down.”
– by Nancy Humphrey