New Zealand Volcano Eruption: A volcano rained superheated ash, steam and gas over White Island (AFP)
They packed the human skin in cardboard boxes lined with foam and dry ice, and shipped it off. With that, the workers at a facility in southwestern Ohio became part of an incredible drama unfolding 8,000 miles away.
A volcano had just rained superheated ash, steam and gas over New Zealand's White Island, a tourist site that dozens of people from around the world were visiting for the day. Some people perished before they could be rescued. Many of the survivors were left badly burned.
And doctors were now struggling with another huge problem. They were low on human skin to temporarily cover the burns.
Urgent calls went out to skin banks - a vital but niche part of the world of rapid-response medicine.
At Community Tissue Services in Kettering, Ohio - on a campus overlooking a quiet pond outside Dayton - a shipment was quickly pulled together of around 300 square feet of human skin, or enough to fully cover more than 15 bodies.
"It takes a huge amount of skin when you have an international catastrophe and this is one for sure," said Diane Wilson, chief operating officer at Community Tissue Services, which has one of the world's largest supplies of human skin. "We are very, very fortunate that we keep the amount of skin on hand that we do."
There's been a global outpouring of support in the days since the volcano erupted on White Island, also known by its Maori name Whakaari, unleashing a scorching torrent onto unsuspecting tourists.
But nothing has been as critical as stabilizing the burn victims.
Doctors have been overwhelmed by the unusually high number of patients needing emergency surgery for severe burns - injuries that require not only highly trained surgical specialists but also heaps of human skin for temporary grafts.
Burn response teams there have been working 24 hours a day to treat more than 20 badly burned patients after the incident left some victims with severe burns on up to 90 percent of their bodies. At least eight people, including two U.S.-born brothers, died and eight other people were presumed dead.
On Wednesday, Peter Watson, chief medical officer in Counties Manakau, told reporters that New Zealand had ordered 1,292 square feet of skin from tissue banks in the United States to help treat the patients. At least a quarter of that skin was shipped from the facility in Ohio, one of the largest skin-providing tissue banks in the world. Australia has also provided more than 20 square feet of skin.
Skin is the largest organ in the human body. It protects humans from infections and helps maintain the body's moisture, which is crucial to survival. Adults typically have between 10 and 20 square feet of skin, depending on their height and stature.
When patients are badly burned, doctors try whenever possible to use skin grafts from uninjured parts of the patient's own body to cover their burns, said Branko Bojovic, a surgeon in pediatric plastic and reconstructive surgery at Mass General Hospital for Children in Boston.
But patients with burns on more than 50% of their body's surface area often cannot act as their own donor.
That's when skin from cadavers comes in.
Bojovic said that donor skin is usually removed from "larger surface areas which are easier to harvest - the torso, the back is very easy to take off with good quality and amounts of skin, and the thighs."
Unlike many other organ donations that require patients to share a blood type or even a similar ethnic background for a transplant match, skin from any cadaver can generally be used on anyone's wound. That's in part because grafts are never intended to be permanent.
Instead, they temporarily alleviate a patient's pain, protect them from infection and allow them to stay hydrated as their body heals and attempts to rejuvenate its own skin.
Wilson, the Community Tissue Services chief, said they accept donations from deceased people up to the age of 80 and have provided skin in response to other major catastrophes in the United States and abroad, including in the aftermath of the Sept. 11 attacks in 2001, a tanker truck explosion in Pakistan in 2017 and a night club fire in Rhode Island in 2003.
The skin, which is kept at extremely cold temperatures, has a shelf-life of up to five years, Wilson said, and one adult donor can typically provide up to 20 skin grafts.
When her facility ships large amounts of skin - like they did to New Zealand this week - it packs between 30 and 40 pieces of skin into each box, with around 60 pounds of dry ice to keep it cold. The pieces are typically half or a quarter of a square foot each. Because the organization is nonprofit, they only charge for processing fees, which include testing to ensure the skin is safe to use, and shipping, she said.
Her organization tries to keep the maximum amount of cadaver skin it can fit in its facilities at any given time. And demand is high.
Brian Gastman, medical and surgical director of the melanoma and high-risk skin cancer program at the Cleveland Clinic, said that when doctors perform a skin graft, they don't try to match the graft to a patient's skin tone, because they know it will be replaced soon after.
"When you're beggars you can't be choosers," he said. "You're using this for a specific purpose: to keep a barrier. You don't care how you get it or how temporary it is, you'll just keep replacing it."
In some cases, depending on the depth or severity of the burn, doctors may opt to use pig, fish or synthetic skin to treat a patient, said Taryn Travis, an attending burn surgeon at MedStar Washington Hospital. That can at times mean using a combination of options on a single patient.
One person could have "an arm that can be treated with pig skin but a foot that needs cadaver skin," she said. "You might have a patient with skin from multiple different donors on the same wound because you take what you can get."
Some patients opt not to use pig skin for religious reasons, she said.
At MedStar's burn center, Travis said they keep cadaver skin in a special freezer set to minus 112 degrees Fahrenheit (negative 80 Celsius). The skin is then thawed in a warm solution just before it's used in treatment.
The scale of burns and sheer number of victims in New Zealand have overwhelmed the country's hospitals.
On Friday, Watson told Radio New Zealand that all 13 Australian burn victims had been transferred home, a move he said will allow them to be closer to their families and "really take the pressure off our New Zealand burns units."
That leaves 15 other victims being treated in New Zealand - including many foreigners - 11 of whom are in critical condition. Friday would be the first night all week that doctors did not have to perform overnight surgeries. At least one burn specialist from Australia has arrived in New Zealand to help with the workload, and more foreign doctors are likely travel to New Zealand soon, he said.
John Kenealy, clinical director of surgery and perioperative services at Middlemore Hospital in Auckland, told reporters Wednesday that his team expects to perform around 500 hours of surgery in the coming days and weeks.
"This number of burns at one time is certainly unprecedented in New Zealand, and it's unprecedented in most countries in the world," he said. "Fortunately, these are rare events."
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