In one of my early blogs here, I mentioned two children with burns, a 21-month-old with burns over 20% of her body surface and a 10-year-old with a 40% total body surface area burn. The hospital is a local referral center for burn treatment with a 13-bed dedicated burn unit plus the occasional patient in the intensive care unit. We treat a fair number of burns here and do a large number of the dressing changes in the operating room (OR) for two reasons; pain control and sterility. I saw both of these girls for dressing changes this past week. I’m happy to pass on that both have healed their burns almost completely and will be going home within a few days.
Contact burns are categorized as 1st, 2nd or 3rd degree depending on how far through the skin it goes. Sunburns are 1st degree burns. Any burn that develops a fluid filled blister within a few hours is a 2nd degree burn. A 3rd degree burn goes all the way through the skin and often has a leathery appearance. Because the burn is so deep, the underlying nerves are also injured and you can’t feel anything in the burn, even pain. If a 2nd degree burn isn’t too deep, it will heal itself (with proper care that is) within three weeks; a burn like this is called a superficial 2nd degree burn. After a week or three, the raw surface of a superficial 2nd degree burn starts showing small islands of new regenerated skin that in my training were called skin buds and are always a happy sign. But if a 2nd degree burn is so deep through the skin that it will only heal by scarring rather than growing new skin buds, it’s appropriately called a deep 2nd degree burn.
Most of the burns we see here are 2nd degree burns, largely from hot water accidents. The trick with a 2nd degree burn is to figure out if it is superficial or deep, then keep it from getting infected while it heals (if a superficial 2nd degree burn gets infected, it can turn into a deep burn that won’t heal with new skin), give your patient enough nutrition to grow new skin and control their pain. Like all burn units I’ve worked in or visited, Rutshuru has a number of protocols for nutrition, pain control and dressing changes.
For patients with large burns like the two I mentioned earlier, we do all their dressing changes in the OR. There they receive a strong anesthetic, often something called ketamine, and then the staff begins the routine. The old dressings are removed wearing clean non-sterile gloves. Then one or two of the team dons sterile gloves and places a sterile drape under the part of the body where the burn is. In the case of large burns, our patient is often lifted up entirely to place a sterile drape underneath them. Next the burns are cleaned with 4% Betadine solution, rinsed with sterile normal saline and them dried carefully. A new pair of sterile gloves is used to place sulfadiazine ointment on the burns, then a Vaseline impregnated gauze followed by sterile gauze pads and held in place with a sterile bandage wrapped circumferentially around a leg or arm or head or the trunk. It’s an efficient process by an experienced team. And just like I remember from my residency days on the burn rotations, if you waver from the protocol in Rutshuru, even with good reason, you’ll get a look that says “What the heck are you doing…don’t you know how to treat a burn?”.
My first week here, one of the Congolese nurses was explaining that they have more burns in the DRC than the US because everyone boils hot water and cooks on an open fire here. I’m not so sure. In my experience, kids in the US have the same tendency to pull pots of hot water off the stove, ending up with the same burn pattern on their dominant arm and half their trunk. I imagine that kids chase each other through the cooking area just before mealtime all over the world, be it an outdoor fire pit or an indoor kitchen. DRC has their open flames for their kids to fall into but the US has our propane grills that tip over, not to mention ubiquitous electric clothes irons, curling irons and hair straighteners to be grabbed by curious hands. When it comes to burns and kids, I think there are some universal factors at work that cross cultural differences.
There are some differences in the way we do dressing changes here compared to home. In Rutshuru, we do the burn dressings every two days which is a longer interval than most US units for sulfadiazine dressings. Some burn units in the US have moved away from using sulfadiazine for their dressing changes and use more so-called biosynthetic dressings, which better mimic the function of natural skin but can be expensive. We do more dressing changes in the OR here because we don’t have the monitoring equipment or staff to have nurses on the burn unit give the heavy sedation needed for adequate pain control and still be safe. But the basic idea is the same; treat the burn patient with a dressing that works, control their pain and maintain their nutrition, don’t let the burns get infected, skin graft patients who need it, don’t skin graft patients who will heal sufficiently on their own, and do all this within the framework of your budget and the hospital resources so that you can keep your burn unit open for business because as long as there are kids and boiling water or hot grease, there will be patients with burns that need to be treated. It’s as simple (or complicated) as that.
Having just summarized the basics of running a burn unit in one long, run-on sentence, I wish I could do the same for the DRC. Next time I’ll talk about why that seems to be an impossible task.