The fire was one of Baltimore's worst: Five never got out of the East Baltimore rowhouse that spring morning in 2007, and three more died at area hospitals.
Doctors say they were certain another would be added to the list: 3-year-old Amira Williams, who was burned over 95 percent of her body.
"When you see a child burned as badly as she was, you think in the back of your mind that she will not survive, she's not expected to survive," said Rick Redett, a plastic and reconstructive surgeon at Johns Hopkins Children's Center who treated the girl.
But Amira, now 6, has the bulk of her recovery behind her. She not only survived but has become an independent and outspoken first-grader at Dallas Nicholas Elementary School with plenty of friends. Credit, those who know her say, belongs to some three dozen medical professionals at Hopkins and high-tech skin grafts, as well as to her family and her own strong will.
Her mother, Chrissy Thomas, watching Amira skip around her grandfather's house, said last week, "She's just a normal kid."
Though no official cause was determined, firefighters suspected that the blaze, like so many others, was started with an errant cigarette. Flames quickly devastated the Cecil Avenue house, which was packed with four generations of family. Thomas, 20 at the time, woke in the early hours to find thick, black smoke and flames coming down the second-floor hallway.
She ordered Amira's father to jump out of the window so she could drop her older daughter, then 4, to him. She positioned herself on the sill, the window propped open on her shoulder, but as she reached for Amira, she fell.
The next time Thomas saw Amira, the little girl was in an ambulance and paramedics were pouring water on her. More than 60 firefighters were still battling the blaze and carrying out the dead and injured, some so badly burned that it would take days to identify them. Thomas remembers Amira saying, "'Don't cry, Mommy.' She was only 3 and she was comforting me."
It would be days before Thomas would see her again. Thomas, with burned hands and a neck injury, was sent to Hopkins Bayview while Amira went to the children's center.
The center is where all Baltimore's youngest burn victims are taken, but Redett said few of the 150 or so kids seen a year have such extensive burns.
In all, Hopkins treats hundreds of burn victims annually. And, according to Baltimore fire data, about two dozen people die from house fires every year in the city.
Doctors told Thomas that those with burns over 80 percent of their bodies don't normally survive. But they saw fight in Amira. She would battle death many times over her year and a half in the hospital, enduring about 30 surgeries. Thomas remembers each one, as well as each setback. She called Amira her "miracle baby."
Redett said Amira's treatment was complicated because of her age — the very young and very old aren't always strong enough to withstand such trauma — and to a lesser degree her asthma. An initial assessment, however, showed that her lungs didn't suffer the deep damage from smoke and flames that afflicts many victims.
First, Redett said, medical workers got her on intravenous fluids. Burns cause cells to weep fluid, leaving blood vessels unable to support proper blood pressure. But the weeping and IV fluids caused her to swell, and when her leathery burnt skin couldn't expand, her circulation was cut off.
She had been put on a breathing machine before the swelling closed off her throat, but she needed immediate surgery to relieve pressure and restore blood flow to her extremities. Redett made incisions around her body.
For the next 24 hours, other teams made sure her lungs were working, her heart was beating and her kidneys were functioning. At various times, each failed.
The medical staff followed a protocol established by National Institutes of Health more than three decades ago. Doctors said badly burned skin needed to be removed and replaced as quickly as possible to avoid infection.
But Amira didn't have enough of her own to graft. Without skin, hypothermia was inevitable, so the heat was turned up and she was covered with skin from a cadaver. That wouldn't be a permanent fix, however. Redett said after about 10 days, the body rejects foreign skin.
Redett turned to another established procedure. He took cells from her scalp and groin and sent them to a Massachusetts lab that grew small patches over weeks.
In the meantime, the cadaver skin was helping grow new blood vessels. New skin was sewn onto Amira. It was thin and fragile, and Redett had to be particularly mindful in the operating room of how he would construct her eyes, nose, mouth and ears.
Some cadaver skin was left as a base, or dermis, for her new skin. (Research is under way at the University of Cincinnati and elsewhere into developing skin that also includes a dermis.)
After six months, Amira was well enough to go to a rehabilitation hospital to relearn to walk. But the recovery lasted only a month before her heart stopped working. She went back to the Hopkins' pediatric intensive care unit.
There was only one choice to save her — a system that takes blood, oxygenates it and returns it, as a heart would. Her mother had refused such a treatment once before because of the chance that it would cause Amira to have a stroke or bleed in her brain. Amira stayed on the machine for two weeks, far longer than anyone thought she could withstand it.
"I'm not sure anyone thought it would work," Redett said. "She surprised people multiple times."
He credited love and support from Amira's mother. And he pointed to the 24-hour-a-day care she got from the large staff of nurses, doctors and other rehabilitators.
Redett said Amira is in for more procedures to treat burn scar contracture, or tightening, that prevents her from moving well. She has already had four of those operations. Her mother is mulling a new set of procedures to straighten her ankle, which buckles a bit when Amira walks.
Other physical limitations early on were tough, Thomas said. Amira came home in December 2008 in a wheelchair, with a feeding tube and 10 medications to keep her heart and kidneys functioning.
Thomas was also concerned about Amira's older sister, Aniyah Williams, who had been particularly traumatized by the loss of her grandmother, Deneen L. Thomas. The family matriarch who had taken all those relatives into the Cecil Avenue house died about a week after the fire from burns over half her body. And there was also an infant to care for — Thomas discovered she was pregnant the day of the fire.
While she was able to replace clothes and other belongings with the help of family, friends and the Red Cross, finding a suitable place for her and three kids to live remains a challenge today.
Still, Amira's recovery has provided a salve for the extended family that lost so much — Thomas' mother, two brothers, a nephew, a friend, her grandfather, a cousin and his girlfriend.
The young girl is now more independent and self-assured. She can make herself snacks. At school, she says, gym is her favorite class and she doesn't mind her homework.
Though she loves posing for pictures, on a recent day she seemed to prefer climbing on her grandfather, Fred Johnson, sharing the computer with little brother DeSean and flipping the beads in her hair into her face.
She remains a little scared of ambulance sirens, but Thomas said, "She lives as if nothing happened. You can't tell her she's not gorgeous."
Thomas said Amira's experience has changed everyone around her, making them more thankful for what they have.
And once Thomas earns her GED in January, she plans to go to Baltimore City Community College to study nursing. She wants to help other pediatric burn victims like Amira.
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