Around Christmas 2024, a five year old was burned over 50% total body surface area in a car fire where all other occupants died. The burns were such that he underwent bilateral forearm amputations upon admission; his eyelid burns went through to parts of the posterior lamellae. Head burns left the vast majority of the skull devoid of soft tissue coverage. The child's household was divided by divorce and the mother and maternal relatives (including two physicians) took an ethical stance that every effort should be made to survive the child. Of note, consultation with a quaternary pediatric burns referral center concluded that curative intent was futile.
A breakpoint in the first two weeks revolved around the decision to stop and desist should the child's vision be unsalvageable; this was based on careful judgement that meaningful rehabilitation (even in a young child) from bilateral upper extremity amputations without vision would be patently impossible. Much of the first week of near-daily surgeries revolved around protection of the cornea, ocular globe, and earliest determination if the retina, optic nerve, and visual cortex remained intact or not.
We are now six months into the child's hospitalization and have been able to create seamless soft tissue coverage of the skull. The technical dilemmas and discussions for this aspect of reconstructive care in and of itself represents a topic worthy of debate. All burn wounds were closed promptly (as expected in a previously healthy 5 year old child). Heavy lift reconstruction moves ahead centered on the eyelids, nose, mouth, external ears, and severe neck contractures.
The patient is running (with assistance) around the burns unit and is out on the hospital front lawn daily. It still haunts me, however, if the child someday returns and curses our decision to have acted with curative intent.