I expected to smell charred flesh on my way through the OR doors. I'd mentally prepared to manage a room in crisis, but instead I saw a surgical team frozen by shock and disbelief. On the table was a 52-year-old female patient. Everyone was staring in silence at the full-thickness burns on her left inguinal groin and thigh. "What is that?" asked the surgeon. Everyone knew exactly what it was: a catastrophic burn that happened on our watch.
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