ACUTE BURNS Big or small - all burns best managed by plastic surgeons
How to manage acute burns
immediate care of the burns
1. How do burns happen commonly in Sri Lanka?
Burns could happen due to several reasons. In adults and children, accidental burns are common. Burn accidents could happen due to hot water, other hot liquid burns like hot oil, hot curry, gas cooker flame and kerosene oil lamp injuries. There can be burns due to contact with hot surfaces like hot cloth iron, in the kitchen or in the workplace. We also see burn injuries due to chemical burns and electric burns.
Due to the development in the country with the supply of electricity to the rural areas, the number of accidental kerosene oil lamp burn is reducing. We do not see real accidental burns which happened years ago especially in children, very commonly now. However, we see self-inflicted kerosene oil burns, unfortunately. Some of these burns are very severe and beyond the salvation of the plastic surgeon.
2. What is the cause for self-inflicted burns?
This is exclusively seen in Asian culture. I believe this is a learned behaviour and the movies and teledramas are probably responsible at least indirectly. Suicidal burns for teaching a great lesson to very powerful authorities are popular in our culture and sometimes gain a lot of publicity.
In this background, most of the married women in Sri Lanka are unemployed and has to depend on the husband for everything. In the usual scenario, the woman with two children is struggling to live with a man who is deviating from the expected level. The man is very powerful and the woman is helpless due to unemployment. Then there would be serious unsuccessful attempts to control the husband and ultimately the woman resort to threaten the husband with an attempt to suicide with kerosene oil poured on her upper body and she does not understand the end result. This might settle if the husband is a sensible person. Unfortunately, the husband never believes or cannot understand the real agony in the woman and try to win the situation by trying to suppress her. This drama could result in a severe burn which is life-threatening and challenging to salvage.
3. What are the first aid measures that could be practised?
It is very important to know what should be done and what should not be done. Our advice on the burn injury is to pour water for 20 to 30 min. The best guide would be poring water till it becomes painless. When this is done for chemical burns the clothes should be removed before irrigating with water.
Whatever is said and done in our culture people do various things as first aids and we do not recommend any of them and can not be superior to water. So please emphasize that people should think about water all the time. There could be myths about not using water and all should be discouraged. There could be myths on magic material like Aloe Vera, egg white or yolk, toothpaste, Ayurvedic oils as first aid measures and all should be discouraged and there is no scientific basis. The first aid should remove heat away and that can be effectively done only with water. Please understand Aloe Vera and Ayuvedic oils may be effective in burn wound healing but should not be used as first aid.
I hope it is quite understandable to remove the contact of the victim from electricity before pouring water as a man who is trying to salvage may get the electric shock.
4. What is your advice after effective first aid?
This depends on the extent of the burn and the areas of involvement. Usually, minor burns could be handled by local doctors or the local hospital. However, if the burn area is exceeding more than 10 to 15%, it should be managed by a plastic surgeon. Then the burns in the face, neck, hands, over joints, the genital area, buttocks etc should be seen by a plastic surgeon at least after some time in the clinic.
I think people should be wise to seek appropriate treatment as many things have advanced and burns should not be managed in a traditional way.
5. Do you practice ideal burn management in Sri Lanka?
Obviously not. But we as plastic surgeons manage burns to the surprise of the overseas visitors with the available resources. We have changed many aspects of burn care and it is experienced by the patients coming to teaching hospital, Kandy.
In order to practice ideal burn care, the government will have to spend a lot of money in establishing burns units. Unfortunately, our country does not have a fully equipped burns unit and we cannot salvage patients when the burn percentage exceed more than 50 – 60% which is sad and many important people have died of salvageable burns due to lack of facilities. I think it is time to think about these things and plan a way forward.
6. What are the changes made in the management of the burn in Sri Lanka?
I used to see open burn wounds when I assumed duty in a teaching hospital, Kandy beginning of last year. The burn patient was covered with a mosquito net and it is the most unpleasant sight one would get in a surgical ward. We have changed that practice and the burn wounds get appropriate treatment with proper dressings. We do not usually practice daily dressings which is really painful for the patients. Instead, we use special dressings which can be kept for about five days. This has given the burn patient a big relief from the pain coming from dressings and daily baths which are totally old and outdated practices.
7. Are these special dressings expensive and are they affordable to the public?
I guess this is a good question. I will explain this with a simple example. Will think about a child getting a hot water burn and for the special dressing, parents have to spend Rs 5000. Apparently, it is too much and should not be practised. However, that dressing will be only once and will peel off when the wound heals and the child does not suffer the burning pain and would give a nice smile in the clinic.
The alternative way of managing is daily dressings and the child will suffer for about two weeks of daily torture. There is a high chance it will get infected and need further surgery and prolonged hospital stay. If the wound is managed in the hospital then loss of parents working hours and lack of attention to other kids have to be counted. In addition, if the child has to be brought to outpatient department for wound dressings, the time spent and the money on transport like taxi has to be counted. Obviously, it is more profitable to go for the expensive dressing.
Therefore, we need to think differently and talk about cost-effectiveness rather than the cost alone and it is time for this attitude change.
8. What are the other strategies you are applying to make a better outcome?
We offer various strategies like early skin grafting and scar therapy to achieve a better outcome in acute burn care. The skin grafting techniques are better known to plastic surgeons and usually do not cause problems after surgery.
I see complications of skin grafts that were done inappropriately and without proper knowledge about it. It is sometimes disheartening that we can not offer many things to those patients as the limited resource of skin has been utilized inappropriately. We can not discuss all these in a single discussion. We will discuss the appropriate burn wound care and scar management in a subsequent article.