Taking care of patients that suffer major burns is a difficult process. Let me first mention how burns are classified. First comes ‘degree’ of burns. First degree burns primarily involve the outer part of the skin and hurt a lot but virtually heal themselves, second degree burns involve deeper but not all layers of the skin, third degree burn involve the entire thickness of the skin and more severe burns also destroy tissues under the skin.
When referring to the ‘per cent’ burns, what is meant is the per cent of the body area that is involved. The ‘rule of nine’ is used to figure this out. Each leg counts as eighteen per cent, each arm as nine per cent; the entire head as nine per cent and the trunk or torso counts as thirty six per cent. The space between the legs makes up the last one per cent. Third degree burns involving more than forty per cent of the body surface carry a relatively higher chance of dying.
Why do people die from burns? Most victims of fires in homes or buildings die from ‘smoke inhalation’. What that means is that the air a person is breathing is replaced by smoke and that deprives the person of oxygen so that the death is essentially from suffocation. Interestingly, people ‘burnt at the stake’ usually died from smoke inhalation rather than the burns.
Another reason for early death is the damage to the skin and the underlying tissues. The skin not only stops things from entering the body but also prevents things from going out of the body. So, the initial response to a major burn is a massive loss of body fluids producing low blood pressure and eventually death. This loss of fluids combined with heat damage to the lungs from breathing hot air is the major cause of death in the early period after a burn.
Even though the explosion of the oil tanker in Ahmedpur East is a great tragedy, more people die every day all over the country from fires in homes, traffic vehicles, factories and office buildings. We need burn centres for these daily burn victims and not just for major disasters. Frankly, we can never have enough specialised burn treatment areas to take care of major disasters like the one being discussed.
And now a major gripe. Just building a big building and calling it a heart or kidney or liver institute or centre does not make it such a centre. It takes trained doctors, nurses, ancillary staff, equipment, medical and surgical supplies and above all continuous and appropriate financial support to make a viable and functional specialised medical facility.
Is there any such fully functional burn centre anywhere in the Punjab?
To the question whether we have enough properly staffed and equipped burn centres, the answer has to be an unqualified no. We have many public hospital wards or buildings called burn centres but they are just that, buildings with probably a couple of well paid ‘project directors’.
Recent investigative news reports suggest that the burn centre in Jinnah Hospital was recently converted into a centre for cosmetic surgery while the one in Faisalabad is essentially non-functional due to a lack of staff and equipment. My personal experience with the burn centre in Mayo hospital built with great fanfare about a decade ago is quite similar. And the recent reports that skin grafts had to be imported from the United States for the burn patients that survived the disaster speaks well enough about the availability of vital materials needed to treat such patients with major burns.
I have a feeling that after the recent tragedy a few dozen new burn centres will be built in time for the next election but few, if any, will have the required staff or equipment. And once the elections are over, these centres will stagnate and eventually die a natural death.
More than burn centres what is needed is prevention of most tragic events that lead to major burn injuries. Before I approach the present tragedy, let me go back a few decades to my own experience with major burn victims.
During my training in surgery some four decades ago in the United States, one of the more frequent causes of major burns we saw was ‘nylon’ night dresses that caught fire due to smoking in bed or from a kitchen stove. Burning nylon would melt and stick to the skin causing severe and widespread burns. Putting such fires out was virtually impossible. So what stopped these fires? All flammable clothing was essentially banned.
About the roadside accident that caused all these burns, during my years in the US, such accidents would often happen. A cordon was immediately thrown around these accidents and in addition the population in the area that could be affected would be evacuated until the accident had been controlled. Other than this all traffic vehicles and drivers had to be properly licensed and the vehicles registered and inspected. As an example, every year I had to get my cars inspected for being ‘road worthy’ before I could get them re-registered.
In Pakistan, such inspections are virtually nonexistent. It was reported in Dawn (July 26) that according to Oil and Gas Regulatory Authority (OGRA) an estimated eighty five per cent of oil tankers and lorries are not complying with the ‘prescribed’ standards. I rarely believe ‘official’ estimates and in this case I would not be surprised if the real number of noncompliant vehicles is closer to a hundred per cent. So we can build as many burn centres we want but tragedies of this sort will happen again. All we can hope for is that the next time the army will provide the cordons.
Accidents will happen even in the best controlled circumstances so it is impossible to prevent major injuries including burns. What are, however, needed are rapid response medical teams that can provide first aid and then triage and transport patients to appropriate treatment facilities. Burn centres come into play once the severely burnt patients have been stabilised. Treatment of burns really starts after the immediate danger to life has been delayed or minimised.
Removal of dead skin and skin grafts to replace the uncovered areas, prevention of infection and treatment of other complications become the next stage of treatment. This is followed by long term care to prevent scarring of the skin and severe disfigurement often with the help of compression dressings; contractures (unnatural bending) of the limbs due to skin shortening requiring prolonged physiotherapy and emotional trauma and a myriad of other problems requiring treatment that can last not just for weeks or months but for years.
To the question whether we in the Punjab or even elsewhere in the country have enough properly staffed and equipped burn centres, the answer has to be an unqualified no. We probably have many public hospital wards or buildings called burn centres but they are just that, buildings with probably a couple of well paid ‘project directors’.
I strongly suggest that the College of Physicians and Surgeons of Pakistan (CPSP) should take the lead in this issue and start a training fellowship within the plastic surgery realm devoted to burn treatment. And all ‘burn’ centres should include teaching positions that bring them under the regulatory ambit of the CPSP.
That in my opinion will be the start of development of proper burn centres in the country.