They faced grueling treatment after last year's Harris fire east of San Diego. Some thought they should have been deported instead of receiving free care.

By Marjorie Miller : Times Staff Writer

Second of two parts

SAN DIEGO — They arrived by ambulance every half-hour, their blistering wounds caked in soot and mud. In the hospital trauma bay, doctors examined their scorched backs and limbs, black in the sterile, white light. They smelled of burnt flesh.

Nurses removed clothing. In went the breathing tubes and catheters, the intravenous liquids. Blood and X-rays were taken. Some patients were rushed from emergency to intensive care to make room for others.

"They just kept coming; it was challenging to keep up," said Dr. Bruce Potenza, director of the UC San Diego Regional Burn Center. "The burns were covered with all sorts of debris, their faces, . . . their noses, every part of them. . . . You couldn't tell what was burned because everything looked burned."

The men and women had been caught in last October's Harris fire after illegally crossing the border from Mexico. Most of them didn't speak English, so medical and hospital staff doubled as translators.

Of the eight people who died in the fast-moving blaze, seven were illegal immigrants. Sixteen migrants were admitted to the burn center, and all but one needed surgery. Moises Ramirez, 34, a laborer on his way to work in Oregon, was among the most seriously injured, conscious but dazed, with burns to his face, hands, arms and back.

Nicolas Beltran and his sister Maria Guadalupe had gone south to attend their father's funeral and were on their way back to San Diego County when the fire overtook them. At the hospital, Beltran, 24, looked to be the more severely injured of the two, with burns over 40% of his body and face. Doctors quickly decided to put him into a coma to spare him the unbearable pain.

The first time Rosa Beltran, the sister of Nicolas and Guadalupe, saw her brother, she recoiled in disbelief. "The burns on his face. . . . I told the nurse this is not my brother," she said.

Guadalupe's injuries were less apparent. She was burned over two-thirds of her back, but the worst problem for the 29-year-old mother of four was her lungs, badly damaged from breathing smoke laced with particles and toxic gases. "And then there's the actual heat of the smoke," Potenza said. She was burned inside and out.

Angry at the treatment

Word spread quickly that undocumented immigrants were among the hospital's burn patients, and angry callers telephoned the emergency room to protest against providing free care to people who were in the United States illegally.

In keeping with federal law, said Potenza, director of the burn center, "the hospital will treat anybody who requires emergency medical services."

Potenza is a Midwesterner by background, a surgeon by profession. He worked around the clock treating burn victims last October, stopping only to evacuate his own house, which was under threat from a second fire. He speaks carefully, knowing that illegal immigration is a politically charged issue. An estimated 12 million undocumented immigrants live in the United States, and their health emergencies pose a burden to hospitals. He knows many people were enraged that the victims were treated rather than deported. "Their injuries give them something of a pass," he said. "But it's a huge price to pay."

For Moises Ramirez, the price was angry second- and third-degree burns. He needed skin grafts, but the soot and dirt from the fire made that difficult. "We could never get their wounds completely clean," Potenza recalled.

Second-degree burns affect the epidermis, or outer layer of skin, and may go deeper into the dermis. Third-degree, or "full thickness," burns destroy the dermis as well as the epidermis, plus hair follicles, sweat glands and pain receptors, and prevent the growth of new skin.

Doctors put a sterile cover over Ramirez's wounds to allow them to begin healing. Once the risk of infection had lessened, they returned to the operating room with an instrument like a cheese slicer to take skin from Ramirez's stomach and legs and place it over burned areas on his arms and hands.

A native of the Mexican state of Jalisco, Ramirez had come north to make money for a new start with a new woman back home. His girlfriend had left her husband and children to be with Ramirez, who was separated from his own wife and three children. They agreed that he would take a job alongside his brother in Oregon for a year or two to save for a house, furniture and perhaps a tractor or cars to work as taxis. This was a second try for both of them, and they were determined to make a life together as soon as he returned.

Ramirez knew he was lucky to be alive. The "coyote" guiding him into the United States had died in the fire, and another man in the group had lost several fingers.

Still, the struggle to heal was sometimes overwhelming. The physical therapists were taskmasters. Again and again, they had him clench and unclench his fist, stretching the new skin over his hands.

"You just work it and work it and work it to make it soft," said physical therapist Allison Helm. "It doesn't have as much elastin as regular skin."

Ramirez called his girlfriend from the hospital to tell her he was recovering and not to worry; he would still build that house for her. Her response wasn't what he expected. "She said she was leaving. She was going back to her husband," Ramirez said.

'They told me she was dead'

In his coma, Nicolas Beltran was oblivious to the many trips he made to the operating room for skin grafts.

"If we're taking him back to surgery every fifth or seventh day . . . there's really no benefit to waking him," Potenza explained.

Beltran also wasn't aware that his sister Rosa and girlfriend Estela Matlala sat beside his bed week after week, talking to him, or that his sister Guadalupe was failing in a nearby room. Her burned lungs wouldn't heal.

Burn patients are given fluids to replace what they lose through their wounds and to keep their kidneys functioning, but the fluids make the body swell like a balloon. "It's another reason they are given breathing tubes, because even their throats swell," physician assistant Catherine Ridgeway said. "The cells release the fluid, and it goes into the lungs. They all got pneumonia."

In Guadalupe's case, it was devastating. She was put into a special bed that allowed nurses to turn her upside down and backward to try to keep different parts of the lungs open as their scorched linings sloughed off, much as burned skin does. Although nurses suctioned it out time and again, "it was just too severe," Ridgeway said. "The pneumonia's too bad. She can't breathe. It killed her."

On Nov. 6, a little more than two weeks after arriving at the hospital, Guadalupe became the eighth fatality from the Harris fire.

Beltran, meanwhile, continued to improve. Still in a deep coma, he had been given paralytic medicines to keep him still and initially was put into hard splints to extend his arms and fingers.

"We don't want them lying in bed with their arms crossed; they need to be out and away from the body so they don't get stuck in a tight position," said Helm, the physical therapist. "Even if they're not participating, we have to move them and stretch the skin to keep it from contracting around the joints, so they won't lose movement. We're most concerned with the hands, because that's what we use to keep ourselves alive."

Once the grafts are in place, the patients must lie still again until the grafts take. The skin grafted onto Beltran's upper arms had been run through a mesher to stretch it across a wider area. The meshed skin looked like fish netting, and he wore a tight sleeve to keep it flat. Finally, it was time to bring Beltran back to consciousness.

Patients emerging from a coma sometimes do not remember the trauma that put them there in the first place. But when Beltran awakened, he recalled the fire, his sister's screams, his struggle to find help. He thought that perhaps he had been unconscious for just a day or two, during which he felt cold and dreamed of work at the nursery. He asked for Lupe. Was she still in the hospital too?

"They told me she was dead," Beltran said. Maybe his soccer playing had given him the strength to survive, he mused in a flat voice. Maybe his lungs were just stronger. "I never thought she would die."

Leaving the hospital

Ramirez decided not to let his girlfriend's rejection interfere with his plans. At least he was alive, unlike some of the others. He would build that house back in Mexico, even if he had to live in it alone. More than three weeks after he was admitted to the hospital, and having received $160,000 in medical care, he was released.

Leaving the cocoon of the hospital was frightening, Ramirez said. He sent his sister Rosa outside to make sure Border Patrol agents weren't waiting for him.

As soon as his strength allowed, he left for Oregon, a state with almost no migra, he said, referring to immigration authorities. He first worked as a dishwasher in the same Mexican restaurant where his brother had a job, but the soapy water irritated his newly grafted skin. His hands itched and burned no matter how much cream he rubbed into them.

In time, he was promoted to cook, which meant no more dishwater. But he now must snatch tortillas out of hot oil to wrap around shredded chicken, and pull hot plates out of a warmer with his bare hands. He cooks beef in a frying pan, and seems unworried by the spattering grease that occasionally ignites flames. His face shows barely a trace of the fire. The grafted skin on his hands already has a few small kitchen burns.

Ramirez works without a permit and drives without a license or insurance, moving in the underworld of the undocumented worker. He avoids public places, he says, and drives carefully. "I drive with the fear that I'll be stopped," he said.

He dreams of the fire even now, and in his dreams he's still burning, or his children back home in Mexico are on fire. Recently, watching "Bambi" with his nieces, he had to fight an urge to flee the burning forest with the animals.

More often, Ramirez feels at peace. The survival experience has given him a sense of resolve and a maturity that he says he lacked before the wildfire. He has begun to send money to his ex-wife and children in Mexico, and is trying to make the best of the "extra life" he wrested from the blaze. "My life is different. My decisions are more sound," he said.

'We're back to zero again'

Nicolas Beltran was weak and thin. Physical therapists had to teach him to sit on the edge of the bed and dangle his legs over the side, then to walk with a walker.

"You get them sitting, standing, make them try to stand at the sink and brush their teeth. It's quite painful when they're awake," Helm said.

Hospital staff helped him work his muscles and his mind, explaining to him that he was not a victim but a survivor.

Finally, Beltran was ready to leave the hospital and move into the suburban house in northern San Diego County that his sister Rosa worked three jobs to pay for. His girlfriend stayed with them and helped care for Beltran, the two of them living on $8,000 they had saved before the fire for a house back in Mexico.

"We're back to zero again," Beltran said.

Months after his release from the hospital, he felt strong enough to return to the nursery where he had worked for $8 an hour loading and unloading plants. He asked for his old job back, but the secretary said she needed to see his Social Security and green cards again, and he had lost them during his time away.

"I asked her to get me the numbers and said I'd get another copy made," Beltran said, acknowledging that the papers he used were fake. The secretary refused to help, saying she wouldn't break the law. "I said, 'You know that everyone gives you papers that aren't legal. That's against the law too.' "

Beltran has trouble understanding why so many Americans judge immigrants harshly for working illegally and accuse them of driving down wages and taking jobs from legal residents. He argues that he is doing work Americans won't do for a price they won't accept. "They know they can pay us what they want. Americans want to make $20 or $30 an hour. In the nurseries, there isn't an American there," Beltran said.

He also recognizes that many Americans are angry about the cost of medical treatment for illegal immigrants, estimated at $750 million to $1 billion annually. But he figures that taxes deducted from migrants' paychecks helped pay for the nearly $1 million in healthcare he received from the UC San Diego hospital.

Beltran lets out an ironic laugh when he says he never had to pay the $1,800 the coyote was to have charged for leading him and his sister across the border.

A soft-spoken man with a passion for fishing, he seems happy to be alive and able-bodied. He says he's a less fearful person than he was before the fire, more willing to take the bad with the good. He covers his scarred ears and fire-seared head with a watch cap but is not self-conscious about the grafts on his arms and legs. Now that he's stronger, he plans to work as a handyman for $10 an hour in cash, until he and his girlfriend can save enough money to go home.

In fact, he says, the only thing that scares him now is the thought of ever again crossing the border into the United States. "Next time I go, it will be the last time."

Bracing for the possibility

Amid another fire season, California firefighters and UC San Diego's burn center brace themselves. They hope to avoid another disaster like the Harris fire, but they know a year's worth of chaparral is dry and ready to burn. They know the Santa Anas are coming, and the migrants will keep crossing as long as they can find a route and a job that is better than the one back home.

"We see the underbelly of this," said Potenza, the surgeon. "We see the people who are involved in the motor vehicle crashes, the people who get dehydrated in the desert, burned in the fires, the ones who put 15 people in a van and the van rolls over. . . . Or the countless flow of people who jumped the border fence and fractured their lower extremities and can't walk and have to come here for care. It's young, healthy men, not drunk, not on drugs, coming here to work."

And to die. Since the dead were recovered from the ashes of the Harris fire, volunteer search and rescue workers have found 10 more bodies in the regrowth along the border.

marjorie.miller@latimes.com