Tuesday, August 12, 2014

where there is no burn unit

I already don’t like this post, and I haven’t even started writing it. It goes against my blogger ethics to share personal stories like this with a broad and unknown internet audience, but I’d like to say that I have obtained permission from each person featured in this post. My friends pictured here want your help. I want your help. We both want the first world to know the rural third world reality.

Please read, and feel, and respond. I’m praying for a flood of advice from real live Peds and PTs, ER nurses and good Samaritans.

~~~

I started to post more info about this on facebook and realized that I do not have the space (or patience of thumb typing) to make this happen.

Let me start with the background info: a story of three burn victims.

Michael’s foot and leg were burnt by boiling water that tipped from the fire. His mother took him from the clinic and they kept him over night for observation. They gave him acetaminophen and washed the wound with bleach water. Before sending him home the next day, they drugged him up with sleeping pills so that he wouldn’t be too active and get the wound dirty. After a time, the wound got infected. He had been discharged from the clinic a few days prior with no instructions, and so his mother turned to traditional medicine. She put toothpaste and ashes on the wound and left it. The infection got worse and Michael’s pain increased. I asked if I could wash the wound each day, which the family was glad for and it eventually cleaned out and healed.  The skin around the ankle grew back tight and he has thick scaring at the site, but is otherwise fine.





Kalunga tripped into a pot of boiling water and burnt his leg from hip to toe. His mother also took him to the clinic where they also gave him acetaminophen and washed the wound with bleach water.  After being discharged, his mother took him to the clinic for regular cleansings with bleach water during which Kalunga screamed so badly at the pain, breaking his parents’ hearts. They could not stand watching the clinical cleaning procedure. They kept him at home and used ash to pack the wound and after a time it got severely infected. I offered to help him clean the wound and kept Neosporin on the area, re-bandaging his leg twice a day for two weeks. His skin did heal, though the area around the knee has limited range of motion and he limps a bit when running.



Bana Miri lost consciousness and fell into an open fire. No one knows how long her arms were laying in the fire, but her flesh was incinerated to the point that we could see bone. She was referred directly to the hospital where they gave her acetaminophen and washed her wounds with bleach water. After a few days, she was discharged. The family cared for the wounds with toothpaste and ashes. After a few weeks, the family called me because her wounds were so rancid that anyone who walked into the house commented on the rotting fish smell. I took her straight back to the hospital where they continued to soak her hands and arms in bleach water. After a few more weeks of negative progress, they transferred her to a hospital in Kitwe where the doctors started talking amputation. The family pleaded that she be able keep her hands, so after getting the infection under control, the hospital sent her home. Bana Miri no longer has any functional use of her hands.




Do you hear the commonality in each story? Tylenol, bleach, end of clinical care, ashes and toothpaste, infection, and permanent damage.

When Bronwyn was burnt in similar manner a few weeks ago, many people urged me to take her to the hospital. I hope you can appreciate now why I opted not to. If Tylenol and bleach were the solution, I could have done that myself. Thankfully the water that fell on her was not fully boiling and her skin never burst and nothing got infected. We are thanking God for this mercy.


But the prompting of this post comes from a more recent story.  Please keep reading.

Four days ago, Patience’s sister dropped a pot of boiling oil and the oil splashed across Patience’s legs. Her mother was not home, but the neighbor lady immediately covered the burned area with toothpaste and stared walking with her to the clinic. At the clinic, the nurses scraped the toothpaste off and kept the wound clean with bleach water. One tube of Silver Sulfadiazine was in the cabinet (and no one knows where it came from, so I’m calling that a miracle) which they put on the child’s knees until the tube ran out and they sent her home. (Note that Silver Sulfadiazine did not exist in Mansa at the time of the first three burn cases, which is why there is no mention if it in their stories.) Now at home, her mother is too afraid to hurt her child, and she has asked me to be the home aid nurse, which I am certainly not.



Naturally, I am terrified. I am terrified that her knees will not heal properly, that she will not be able to bend them. I am terrified that she will be in unnecessary pain. I am terrified that I do not know what I am doing. As I asked for help on facebook, many responded that I should take her to the hospital. I hope that the above stories shed some light on that option. The one difference in Patience’s story is that I now know about and have access to Silvadene. A newer pharmacy in Mansa now carries it and, after Bronwyn’s burn, I stockpiled. (It’s a shame that I am willing to buy this medicine, but the Ministry of Health is not. But that is a post for another day.)

Please know that all of these people are dear to us. Michael is named after my husband. Kalunga has the most contagious laugh and has been on my top-five-people-on-the-planet list for a long time. Bana Miri is the wife of one our former staff members (he stopped working with us to care for his wife full time) and she is the BEST. Patience is one of Bronwyn’s friends – they have played together since birth. These people are important to us – they are not just names or pictures or case studies.

But I am not a medical professional and other questions remain. Questions about the sloughing that the clinic seems obsessed with – scraping back the clean-but-dead tissue until her knees bleed. Questions about their wrapping technique. Questions about the Silvadene application. I don’t want this little girl to end up like the others. I cannot distance myself emotionally from this situation either. Her cries are fierce and I’ve wept for her pain. I look at her laying miserable and imagine Bronwyn and I can’t not commit to her healing.

There are complicated sub-stories woven tightly into each of these burn scenes. Stories of poverty and the daily hazard of cooking on fires. Stories of inadequate health care and sub-par patient education. Stories of apathy in resource sparse locations. Stories of traditional medicine and witch doctors and mothers that would do anything – try anything – to make their babies feel a little better.

And these are stories that also need to be told and hopefully will be told at some point. But right now the clock is ticking and I have one hour, thirty three minutes until I am due to arrive at Patience’s house to “help” her mother and my cheeks are tear stained and my hands are trembling.

This is me reaching out. Who will skype facetime with me from inside Patience’s house? Who will look at pictures and advise wisely? I have access to google and I am using it. I’m looking for specialized advice for individualized care, not because I think webMD is wrong but because I can’t stand being involved in another burn victim story without reassurance of a qualified, live person telling me that this is the best anyone could do.

Please.

And thank you.










11 comments:

  1. Oh Bethany, I am praying for God to give you wisdom and courage in this heartbreaking situation. I wish from the bottom of my heart I could help you. I've reached out to some MD and MD-to-be friends in hope that they, or someone they know will be able to help you. In the meantime, I'm praying hard for you sister.

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  2. Praying for you! I sent your info on to several friends who are nurses. Trusting God to provide!

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  3. My heart goes out to you... this was passed on to me by some friends. These burns are obviously serious and it's unfortunate that you can't rely on the local clinic. My advice is first and foremost hydration and frequent dressing changes. Make sure she's drinking enough water and eating as well as possible. Change the dressings at least three times a day and any time they are dirty. If you're using cloth, wash with bleach or boil them to kill germs, but I wouldn't put bleach directly on the wounds, and don't scrub them with a toothbrush.

    As far as the dressings themselves, I would put a very thin layer of silvadene on (large amounts aren't better), then a piece of sterile gauze or cloth, and then wrap it to keep it on. The sillvadene should help debride the wound (remove the sloughing, dead skin) gently allowing the tissue underneath to heal without scraping. As long as there are no huge black areas (which I don't see in the pictures) scraping will only make the wound bigger and prevent good tissue growth.

    As the skin starts to heal, and as long as there are no signs of infection, you can switch to bacitracin or some sort of antibiotic cream if that's available. Don't rub the wound to clean it, just pour sterilized water over it to wash it out and gently blot the area. (Boil the water to sterilize it if necessary)

    Wounds like this take time and patience, but the girl seems young enough that hopefully her body can recover. It will likely still scar but hopefully she will have the resilience to bounce back. Hydration and good nutrition (esp protein) are vital. Good luck and God bless!

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  4. http://www.nationwidechildrens.org/Document/Get/38987

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  5. http://www.urmc.rochester.edu/Encyclopedia/Content.aspx?ContentTypeID=90&ContentID=P01760

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  6. I agree with the post above. Silvadene is what i use in my practice. Do gentle range of motion of the knee as she can tolerate to keep her flexibility as she makes new skin.

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  7. (1/2)

    “The best anyone can do” is very difficult and up for debate, even among people who are experts in the field. A blog comment will never suffice for the treatment and expertise that come with years of experience and training, but you’re asking for any help. I have tried to provide scientific references and studies to show that I am not just making stuff up.

    The most pressing concerns with burns are the injury itself, the metabolic demands of healing that injury and infection. (In most cases, we worry about airway compromise, respiratory insufficiency, and inadequate circulation.)

    Immediately following a burn:
    1) Any hot clothing/jewelry/debris should be removed.
    2) Generally, wounds are cooled immediately to 12C during the first several hours (although this is debatable. Most would agree that this should be done for at least the first half hour). We use sterile gauze and cool sterile water (sometimes just normal sterile saline, too). Water used here should never be below 8C. [1-2]
    3) We monitor core body temperature (our skin keeps heat inside), and keep the patient well above 35C (normal is 37C). Ideally, we’d use something like warm IV fluids, but you’d have to figure out a solution.
    4) Managing pain/anxiety (again, ideally morphine or another opoid; not sure what you’d do, sorry  )
    5) It is especially important to monitor a patient who may have had an inhalation injury. Classically, patients who have these sorts of injuries do well and can even talk until it is too late. If you suspect the patient has inhaled smoke, has visible soot in the throat/airway, they may need to be intubated, which would require a hospital. These patients are especially high risk for dying from respiratory failure.

    Secondary survey:
    1) Ideally, we’d monitor the patient’s CBC, lytes, BUN, etc. That’s probably not going to happen for you. We’d also give them a tetanus booster. [3]
    2) Every non-superficial burn will need topical antibiotics. [4] Silver sulfadiazine is fortunately one of the most classically used topical antibiotics. It should be avoided near the eyes, mouth, pregnant women, nursing women, and newborns. [5] We give antibiotics until the skin grows back completely. Bacitracin is an alternative to silver sulfadiazine. You may also have success with polymyxins and neomycin (not to be confused with Neosporin, which does contain polymyxin, neomycin and bacitracin.) A thin layer should do, but I would go with more than less. (Define ‘thin’ you say? This is an art. There really is not a correct answer, but there are unfortunately wrong answers.)
    3) The best treatment of blisters is unclear. Generally, we just leave them alone because they are theoretically sterile inside, but they may become infected. Ruptured blisters should be removed, but intact ones are controversial.
    4) Wounds should be cleaned. Remove foreign material with copious amounts of sterile irrigation. Do NOT remove healthy tissue. Scraping should not be done.
    5) Disinfectants (eg, bleach) are generally discouraged, however, there is growing support for using mild soap and water. [6-9]
    6) Non-adherent mesh gauze dressings should be used (we use Telfa, arguably inexpensive online). We use a thin amount of a topical antibiotic. Dressings should not be tight, due to threats to circulation – you can minimize this problem by putting dressing on in layers rather than wrapping it circumferentially.
    7) Sometimes an escharotomy (not to be confused with fasciotomy) may need to be performed. I pray that this never happens to you. Additionally, a feared complication of burn injuries is compartment syndrome, requiring a fasciotomy. Both of these cases essentially prevent blood flow (or return) to areas distal to or near the injury. It would be helpful to monitor if the patient has pulses in their distal arteries (eg, radial, tibial), and watch for signs of color change, poor capillary refill, or temperature change.

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  8. (2/2)

    In the end a thin layer of antibiotics, sterile dressings, and a clean wound are probably all anyone would expect you to be able to do. Staying hydrated and well nourished is especially important, as the wound requires extraordinary amounts of energy to heal. In addition to water, please ensure that patients are receiving electrolytes (a simple solution can be made with 1 L of water, 6 tsp sugar, 1 tsp salt; alternatively, just ensure that the patient is eating food.) We like to see patients making > 0.5mL/kg of urine a day to demonstrate adequate rehydration.

    It is impossible to prevent scar formation following severe burns. Often, these lead to problems (eg, contractures.) The average time to scar maturity is 9-12 months. Various modalities have been used to limit disability as the scar matures, including silicone gel, onion extract gel, (both applied for 3-6 months after wound closure), pressure garments (although no studies conclusively prove they do anything [10]), and laser therapy. Surgical reconstruction is also used, but well beyond the pay grade of this comment. There has been some anecdotal success with ‘massaging’ the scar to loosen the collagen forming it after it is dry and closed. Given the limits of your situation, I would encourage your patient to be as mobile as tolerated.

    Godspeed.

    [1] http://www.ncbi.nlm.nih.gov/pubmed?term=7150995
    [2] http://www.ncbi.nlm.nih.gov/pubmed/9019694
    [3] http://www.ncbi.nlm.nih.gov/pubmed/3167589
    [4] http://www.ncbi.nlm.nih.gov/pubmed/18316972
    [5] Silver Sulfadiazine causes a theoretical risk for hyperbilirubinemia and kernicterus. It is also contraindicated in patients with sulfa- allergies (as the name might imply). That said, I would probably still use it if I had to.
    [6] http://www.ncbi.nlm.nih.gov/pubmed/9060321
    [7] http://www.ncbi.nlm.nih.gov/pubmed/8695324
    [8] http://www.ncbi.nlm.nih.gov/pubmed/8222354
    [9] http://www.ncbi.nlm.nih.gov/pubmed/9115481
    [10] http://www.ncbi.nlm.nih.gov/pubmed/18249046

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    Replies
    1. Bethany - I have a friend in residency in emergency medicine who seconded this post as the procedure they would follow here. Praying for you friend, for strength and wisdom.

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  9. Hi, saw your post on a friend's facebook. I've been rotating through the burn unit of my hospital and can tell you that silvadene (silver sulfadiazine) is widely used in the US on burns. It helps to prevent infection and is cooling on application. Here are some quick guidelines for little Patience and other burn patients you might encounter:

    First, estimate the size of the burn. You can guess the size by estimating how many of the person's hand (the palm and the fingers) it would take to cover the burn, with 1% total body surface area for every hand. So for Patience, maybe 3-5% with both knees. This is important because the more percentage of the total body surface area that is burned, the more at risk a person is for being dehydrated. If a burn goes all the way around an arm or leg, it is called "circumferential" and the person should be taken to the hospital in case swelling cuts off circulation to the rest of the limb.

    Second, assess the depth of the burn. Your average sunburn with no blistering and surface redness is a first degree burn. It'll do fine with some aloe, and it won't scar. Then you get into superficial dermal (partial thickness) burns. These have gone through the top layer of your skin and into the second layer. They will be pink, moist, and very painful. Although they look terrible, these will heal within 3 weeks and won't scar or impair movement much. Put silvadene and clean wrapping on it at least once a day. The next depth of burn is a deep dermal burn. These burns have gone all the way through the top layer and more of the second layer. They are leathery white, dry, and not very painful, and sense of touch might be diminished over the burned area. These will usually heal within 3-8 weeks, but unfortunately will also usually scar a lot and contract and cause loss of function. An even deeper burn than that is called a full thickness burn, going all the way through the top and second layers and getting into the fat underneath. In the US, these (and deep dermal burns) would be grafted, otherwise lots of scarring and loss of function would occur.

    For wound treatment, it is important to clean the burn and keep it clean. It is also important to keep the burn moist. While it is true that a dried wound can theoretically decrease risk of infection, letting a burn dry out is not a good idea, as long as you can keep it clean. The reason is that if burns are exposed to the air, the air dries out the exposed collagen and skin, and this new layer of dead skin makes the wound deeper and prevents healing from taking place. That is why the clinic is so obsessed with the "sloughing," as you call it. We call it debriding, the removal of dead tissue that is impeding the healing process. As for what to put on the burn, silver sulfadiazine is good for burns deeper than a sunburn. Antibiotic ointments like bacitracin or triple antibiotic (neosporin) will also work. Other options that might be rather expensive or not readily available include silver coated products that only need to be changed every few days like mepilex, or santyl (collagenase) used to debride dead collagen on deep partial thickness burns, or sulfamylon (mafenide) that is used on full thickness burns- these last two are painful on application.

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  10. (cont)
    Lastly, other things you can do are pain control, hydration, nutrition, and physical therapy. The less pain someone has, the more likely they will be to move the joint (or knees) and at least maintain some range of motion. Tylenol is better than nothing, although you also have to watch out to not give too much acetaminophen or it could damage the liver. Here, patients get dosed around the clock to deal with background/constant pain as well as pain associated with therapy or dressing changes. Most kids I've seen get lortab (hydrocodone acetaminophen syrup or elixir) or morphine. Adequate hydration is important because burns increase fluid loss. Nutrition wise, people with burns have a higher need for calories in order to heal. As others have said before, protein, but also just more of everything. PT will do well to minimize any loss of function of that body part. It doesn't have to be with a certified therapist, although that would be ideal. Motion exercises that will move the affected joints and stretch the skin GENTLY are good. Don't wait too long before starting therapy. If you wait too long after the burn, the scar will contract and it will be too late.

    I hope that helps! This is by no means a medically comprehensive guide to burns. It's based on what I've observed the last couple weeks and hopefully will at least make you more comfortable with burns and more familiar with the terminology and types of treatments used.

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