On the Fourth of July, 1987, Holly was co-leading a group of ten 14- and 15-year-old females, and they had set a camp in the woods, near the shore of a large lake that had recently felt the pull of their canoe paddles. Although the morning had been bright and beautiful, storm clouds shadowed the site as dinner water neared boiling on the Peak One stove. Holly wore cotton shorts and a T-shirt.

When the water bubbled furiously, the other instructor moved the pot, a large one, to a rock and turned hurriedly away, knocking the pot to the ground. Most of the scalding liquid landed in Holly's lap. Some of it splashed onto the lower legs of the second leader who immediately began to scream in pain and fright. Panic swept the group, and Holly's attention was diverted to settling the young women down and managing her co-leader's burns. "It was three minutes tops," says Holly, "until I noticed I was soaked in steaming water from my waist to my knees." Those three minutes proved critical.

She rapidly stripped off all her cotton clothes . . . "death cloth" she now calls it. Intense heat had been trapped against her skin, the burning process penetrating deeper and deeper. The only cold water in camp was in water bottles, water which she first began to pour on her abdomen and thighs, then used to wet bandannas that were placed on her burns. Holding the bandannas as best she could, Holly, followed by the entire group, hiked to the lake where she immersed herself in the cold water, and where she stood for almost an hour. When she checked herself, great boggy blisters had filled on her lower body around pale areas that continually weeped clear fluid.

Deciding on a plan of action, Holly and the group broke camp and paddled down the shore to a private camp accessible by road. Someone dialed 911 from the camp office, but the storm had broken in summer fury, flooding the roads and blowing trees to the ground. The ambulance arrived in gushing rain two-and-a-half hours after the call. In that time Holly felt "more pain than I can remember." By the time the ambulance pulled away with both burned women, the camp's director had assumed management of the group.

Scalding hot liquids and erupting flammable fuels produce the majority of serious paddling burns. Burns from campfires, hot cooking gear and stoves typically cause minor injuries requiring little care other than cooling. The Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care (Globe Pequot Press, Old Saybrook, CT, $12.95) says initial burn care, despite the seriousness, should be directed toward stopping the burning process, "within 30 seconds, if possible." Cool burns with water, or with a dressing designed especially to cool burns such as Burnfree™, a gel solution of water and plant extracts created for rapid cooling. Remove clothing and jewelry from the burn area. Do not try to remove anything stuck to the burn such as melted synthetic clothing. Check the patient for injuries that might have occurred in addition to the burn.

How long does the cooling process take? No definitive answer exists. As long as cooling makes the patient feel better, and hypothermia is not a threat, you can keep the process going for up to two hours. "Trust me," says Holly, "every little bit helps."

After cooling, burns should be assessed in three ways:

(1) Depth. First Degree burns are superficial damage to the epidermis that look red and feel painful. The most common paddling first degree burn is sunburn. Second Degree burns are partial thickness burns of the dermis (the true skin), forming blisters in addition to redness and pain. Third Degree injuries penetrate the full thickness of the dermis, produce no blisters, and look pale (scald burns) or charred (burns from other high-heat sources such as open flames). Third degree burns may not cause pain themselves, but they will be surrounded by areas of intense pain. Burns are often a combo of one or more depths, and it may take time, an hour or more in some instances, before you can judge the depth of the burn. The greater the degree of damage, naturally, the greater the need for professional medical attention. "All burn wounds are
sterile for the first 24 to 48 hours," says the Practice Guidelines. But infection almost invariably results eventually without professional care to deep burns.

(2) Extent. To determine the amount of the patient's body surface area that has been burned use the Rule of Nines. Each arm represents nine percent of the total body surface area (TBSA). Each leg represents 18 percent (nine for the front, nine for the back of the leg), the front of the torso represents 18 percent, the back of the torso 18 percent, the head nine percent and the groin one percent. First degree burns are easily managed no matter their extent. Second and third degree burns covering more than 15 percent TBSA are often life-threatening and require immediate evacuation. Serious burns to the face may cause airway damage, and should be considered for immediate evacuation. Third degree burns to the hands, feet or genitals require professional attention as soon as possible to prevent loss of function.

(3) Pain. The patient's level of pain will help you evaluate the seriousness of the burn. Pain should resolve within 24 hours for first degrees burns. Deeper burns will cause increasingly severe pain. If the pain can be controlled on the river bank or lake shore, the burn can often be managed in the wilderness.

After cooling and assessment, your outdoor care should be directed toward keeping the wound clean and reducing the pain. Dirty burn wounds should be washed with great gentleness, tepid water and mild soap. After washing, pat the wound dry. To protect burns and ease the pain, leave the blisters of second degree burns intact. If the blisters pop while a physician is still far away, or if you're dealing with third degree burns, you can do one or more of several things: (1) Cover the burn with a thin layer of antibiotic ointment. (2) Cover the burn with dressings such as 2nd Skin® or Burnfree™. (3) Cover the burn with dry gauze or clean dry clothing. Covering burns reduces pain and evaporative fluid losses.

Do not use an occlusive dressing, one that prevents all air or water from passing through. Do not place ice on large burns.

When the trip to the doctor will not be a long one, do not re-dress or re-examine the burn. If evacuation will take more than a day, change the dressings at least once a day: remove old dressings, remove old ointment (you may have to gently wash off old ointment with tepid water) and re-apply fresh ointment and dressings.

Serious burns will swell and, when possible, such as burns to arms and legs, the extremities should be elevated to minimize swelling. Burned patients should gently and regularly exercise burned body areas as much as they can tolerate.

"Ibuprofen," says the Practice Guidelines, "is probably the best over-the-counter analgesic for burn pain (including sunburn)."

Burned patients should be encouraged to drink as much water as they can during the entire evacuation process.

Approximately seven hours after the incident Holly arrived at the nearest hospital. The hospital staff gave their immediate attention to the second instructor, the one "obviously" in pain and distress. Holly's quiet lack of complaint relegated her to a room for observation and later treatment. She should have complained. After three days, she says, "the lower front of my body looked like leather and steady doses of morphine failed to keep the pain away." She had burns to the second and third degree over approximately 15 percent of her body. It was almost three weeks before Holly left the hospital. It was months before her treatment ended.