Recently, author Deena Adams asked me to help with some characters in her novel who were injured in a fire and suffered severe burns. The situation was a younger man had run into a burning building to find an older fellow in his 50’s. The younger man had very mild asthma; however the older man was dying from lung cancer. He had been trapped in the building for some time and was found with multiple burns on his body.

Most authors are familiar with first, second and third degree burn injuries. What you may not know about is the severity of what is called an inhalation burn.

Burns are categorized by depth and extent of surface area involved. First degree burns are your basic sunburn.

First degree burns are superficial, the skin may eventually peel but will not blister.

Second degree burns form blisters like this:

Back with second degree burn and blisters 24 hours after the accident occured. The burn was caused by boiling water.

Third- and fourth-degree burns (also called full-thickness) are more serious. They are quite deep and can expose muscles, tendons, ligaments, and even bone. A third degree burn will be painless (unless there are first and/or second degree burns around it) and appear white or charred. Fourth-degree burns look black and charred (eschar).

Burns are TRIAGED by emergency services using a system called the Wallace Rule of Nines to estimate the percentage of burned skin. The scale for children (Lund diagram) varies by age. Very small children have a greater surface area in their head compared to an adult.

Perform an internet search for online charts to see how burn estimates are used. Here’s my pathetic home-drawn Wallace Rule of Nines for people fourteen years of age and older.

Emergency room personnel use this rule to quickly add up the percentage of burned surface area to determine treatment going forward.


If you’re writing about burns, you need to consider INHALATION damage. The respiratory system can be hurt in multiple ways.

  1. Thermal damage – burns (direct damage) to the mouth, throat, and trachea.
  2. Smoke damage to the lungs – deposits of carbon and any other toxins in the smoke. This is what happened to many 9/11 first responders and victims. The smoke of the burning buildings and the cloud of dust after the buildings collapsed contained all manner of toxic materials including asbestos, which can cause lung cancer.
  3. Carbon Monoxide – Smoke contains high levels of carbon monoxide. has an outstanding article “Exposure to Smoke From Fires” for more info and resources.

A clue to inhalation or airway damage in a burn patient is soot staining around a character’s mouth or second- or third-degree burns to the face.

A clue to inhalation or airway damage in a burn patient is soot staining around a character’s mouth or second- or third-degree burns to the face.

Deena’s novel setting had the middle-aged man admitted to the BICU (burn intensive care unit) at the hospital. The problem was she had a reunion scene set in the ICU, where the man needed to speak with the fellow who saved him. The injuries her character had suffered would have required him to be intubated and on a ventilator. Therefore, he wouldn’t be able to talk.

The other issue is patients with severe burns and inhalation injuries are put into an induce comas because of the severe pain and respiratory failure. The pain from deep, extensive burns can put victims into shock. So if you have a severely burned patient, they may not be able to communicate, especially if they are intubated and on a ventilator.

Also, people who wake up from coma don’t always wake up oriented and talking – it takes time. For more information, see my article on Coma in Killer Nashville Magazine:

At the scene, all victims that have been exposed to smoke are immediately placed on oxygen by first responders. They are transported to the ER where they are triaged. The Wallace Rule above helps doctors make a quick assessment of the extent of burn damage. If other things such as fractures or open wounds need surgery, that is addressed. If the patient’s condition is critical, they will be intubated and placed on a ventilator, and probably into an induced coma.

Burn patients are allowed visitors. Generally visitors may be cautioned about the trauma of viewing a severe burn, but sometimes not. Burn units vary in allowing visitation, so check the rules for a hospital you intend to use, or for a hospital similar in situation or location to the one you in your book.

Some units allow more leeway in visitation than others – for example, some units will not allow balloons but others will. All units normally require visitors to “gown up” in clean (not sterile) gowns. Some may require head and foot covers.

You don’t normally have to “glove up” and don surgical gloves.

Pediatric burn units also have different rules from adult units. Some hospitals may have both children and adults in the same unit. At least in the hospitals where I trained, nurses made an effort to cover severely burned patients when family visited until family members had been oriented as to what they might see. A severely burned individual is a traumatic sight.

Respiratory failure is the most common cause of death in burn patients, followed by infection.

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Thanks for reading!