Burns management...

I am trying to space out the things I want to say or I'll end up writing War and Peace and some of you might pass away before you get to the end, or, and this would be far worse... you might get bored!

Burns department

Geoff has been asked by the Dutch Professor out here to take over the burns department from the 17th. This makes it sound like there's a department as there would be in the UK, but really there are just some dedicated beds on each of the male and female (plus children) wards. The hospital actually deals with a significant number of burns throughout the year - far more serious burns than any DGH in the UK would, and comparable at times to Chelmsford. Chelmsford is one of the UK's specialist burns units and Geoff has worked there for a year in plastic surgery - hence the request to help bring St Francis' up to date.

The burns can broadly be split into two categories - children burnt on the open fires used for cooking / hot water (efforts to persuade people to cook higher up are not really having any impact). These burns often occur because younger children are left in the care of their siblings who are typically not old enough to keep them out of harm. The luckier children only have scalds (as you would see in the UK) but some have very significant flame burns.
The second category is epileptic adults (mostly males). The theory is that untreated epileptics (of which there are many) are susceptible to having their fits triggered by the flickering of the flames. When they fall their family and friends believe they have been possessed by evil spirits and refuse to touch them. Thus, what might have been relatively minor burns tend to be more serious. It is not uncommon for an adult with burns to have had more than one burn in the past.

Geoff has been using the last couple of weeks to observe how the burns patients are treated and what level of burn is survivable given the lack of resources (there is no ITU for example, whereas Chelmsford has dedicated burns ITU beds). Survival rates are further reduced by late presentation - it is critical to begin to resuscitate (this doesn't actually mean do CPR, it's a bit more complicated than that - for burns victims the key areas are IV fluids and food) patients and cut off dead tissue within 24 hours (preferably 8 hours) of the burn occurring.

It transpires that, despite the best efforts of a specialist American burns team that visits for a month every year, there are several areas that could be improved to help prevent death or disfigurement (e.g. making sure burns patients move their arms / legs / hands to stop them stiffening and scars locking them in one position). Geoff has had animated discussions with nursing staff on two occasions now about the need for IV fluids in severely burnt children. Some education is needed in the critical care aspect of burns care, to improve the understanding of the underlying pathology and reasons why children die from burns. In theatre, there is similar resistance to him changing practices - with a lack of blood cited as a cause for not doing a particular procedure. In this instance the unit of blood they had was more than the entire circulating volume of blood of the child. 'I'm not yet fully trained but I back myself not to cause so much bleeding that we need a whole unit of blood' was the thought going through Geoff's head!

All of this means that it is unlikely that anyone would survive burns over more than 20% of their body here, sadly far lower than can be achieved at home. (You may want to review an excellent article by G Roberts et al in this January's edition of the Journal of Trauma regarding burns survival in the UK)

So, Geoff has a complex challenge on his hands. And I can hear you thinking, yes but how are you helping, Charlotte? Aaahhhh, well, I'll tell you how. To make the changes needed Geoff needs to have a lot of paperwork ready - he needs protocols for everything from standard drug treatments to wound dressings, to daily exercises to discharge notes. He also needs tables for the nurses to record all their observations and wound changing reminder sheets etc.

Therefore, I have been on a steep learning curve. I've been thinking about the 'patient journey' to record the 'care pathway' and the critical 'touch points'. Then I got bored of the managementese and decided that I'd just try to work out all the steps that should happen from a burnt patient arriving to being discharged, who sees them, what gets done and what instructions / recording would be needed. I had some notes from the Prof and Geoff (I feel sorry for his colleagues - the writing is worse than rubbish!) to get me started. Once I'd done that I cross compared against the notes the Americans had left (a thick textbook in a muddled flow so I'm not surprised no one else has read it) and a book on burns written for the Malawi hospitals to see what was missing / what we could learn from them.

I'm quite impressed with how much we've got pulled together and how neat it all is. I fear this is going to be the easy bit but I don't think we should underestimate how important it will be to have clear, simple instructions that everyone knows they should be following. I imagine this is what has let the American team down in the past - the knowledge they had was too complex and too easily forgotten after they left. Hopefully the new paperwork will encourage people to read their detailed notes in the future.

And, if any of you are unfortunate enough to get burnt in the near future then I'm pretty much an expert (in theory anyway!) but you might be better off with Geoff! For starters, you will need to eat 2-3x your normal calorie intake so we'd prescribe Plumpy'nut [Geoff had no idea what this was until I found a recipe in the Malawi burns manual - it's a really high calorie peanut butter - probably far more tasty than Nshima]

And when you aren't learning about burns?

We had an exciting weekend - both Will and Rory had birthdays. We had managed on the last trip to Chipata to acquire a cake mix and candles without either of them realising (boys are not very observant). So on Saturday lunchtime, whilst Nat was working hard on the medical wards, Fiona and I went to her house to bake. Nat had left us a note next to the things she'd left out 'I've left things out for you. The milk and eggs are in the fridge. Charlotte, stop laughing at the pointlessness of this note!' How did she know?? Rory believed that Fi and I were doing Nat's Zumba DVD...... I'd picked up the cake tin from the Mess - it was filthy (I swiftly knocked off the mouse poo) and leaked but I figured that was going to be the least of our problems.

And I was right, for Fi and I are not really designed for baking without the supervision of a suitable adult. I normally have Helly keeping an eye on me. Surely it was simple enough to add eggs and milk to the powder? Except we had no electric whisk and neither of us was really sure what 'thick and creamy' looked like. We soon gave up on trying to do figure of eights for fear that everything would go on the floor. Thankfully Geoff arrived shortly and I was given a fork and told to carry on.

Fi was attending to the icing - surely that would be easy. All of sudden she says 'I don't see how this is ever going to be creamy'. I look over at the distinctly dry powder - 'have you added the milk?'. 'No, you aren't supposed to'. 'Yes you are....' repeat about 4 times [during which Geoff stays silent] 'Oh, yes, you are!'. At this point all ingredients had remained in their respective bowls, it was too good to last. Fi tries to remove the spatula from the cake mix and all of a sudden my leg is covered!! Whoops

Anyway, two uneven halves of cake were produced and Nat iced it perfectly. We were impressed but needed to wait for Will to come back on the Sunday before we could show them. I said to Nat that I thought she was very trusting leaving Fi and I to do the baking 'I didn't have any choice, did I?' Ha ha, nope :)

I took the position by the light switch as the others brought the cake in. Will's first comment 'This looks good. Did you get the Mess to make it?' If looks could kill! It tasted great though!

And, to burn off the cake and generally stay fit we have started to try and run at the weekends. The trying refers to people not being in the hospital and/or us getting up early enough to do it when it's still cool outside. Having embarrassed myself a couple of weeks ago (with Will and Nat this time) I decided that secret extra training was required.

So on Monday and today this week I have left the house just after Geoff to run to a school out in the countryside and back. I was told it was 5km total but the 'milestones' tell me it's more like 6 (and yes, that makes a big difference).

This morning a man on a bicycle taxi went past me. 'Are you going to Chisale? do you need a lift or are you OK?' 'Yes, I'm going to Chisale, I'm going to run all the way there, turn around and run all the way back' 'Why?' Um, what do I say to that? Do I try the 'because the roll of fat where my abs used to be [because I have neglected them too] was demanding attention'? Or, 'because my friend is going to make me do this on Saturday and I want to be able to do it properly by then'? I sense that neither will make much sense to him - they don't seem to do exercise for the sake of it here...

I got stared at a lot, especially back in the hospital grounds. I put this down to my ridiculous attire. Then I look in the mirror and see that my face is the same colour as a tomato!! Eeekkk. The best thing to do was to jump in a nice shower. The water got hotter and hotter - in fact it got so hot that it was slightly uncomfortable. On the principle that this is unlikely to happen to me again in the next 5.5 months, I stuck with it, hoping that somehow I could store up the sensation of a hot shower for a day when only a cold bucket wash was available.....