Introduction
Severe burn injuries evoke strong emotional responses in most people, including health professionals who are confronted by the specter of pain, deformity, and potential death. Intense pain and repeated episodes of sepsis, followed by either death or survival encumbered by pronounced disfigurement and disability, have been the expected sequelae to serious burns for most of humankind’s history. However, these dire consequences have been ameliorated so that, although burn injury is still intensely painful and tragic, the probability of death has been significantly diminished. During the decade before 1951, young adults (15–43 years of age) with total body surface area (TBSA) burns of 45% or greater had a 49% mortality rate ( Table 2.1 ). Forty years later, statistics from the pediatric and adult burn units in Galveston, Texas, show that a 49% mortality rate is associated with TBSA burns of 70% or greater in the same age group. Over the past decade, these mortality figures have improved even more dramatically, so that almost all infants and children can be expected to survive when resuscitated adequately and quickly. Although improved survival has been the primary focus of burn treatment advancement for many decades, today the major goal—because survival rates have highly increased—is rehabilitation of burn survivors to maximize quality of life and reduce morbidity.
Table 2.1
Percent Total Body Surface Area Burn Producing an Expected Mortality of 50% in 1952, 1993, and 2006
| Age (years) | 1953 (% TBSA) | 1993 (% TBSA) | 2006 (% TBSA) |
|---|---|---|---|
| 0–14 | 49 | 98 | 99 |
| 15–44 | 46 | 72 | 88 |
| 45–65 | 27 | 51 | 75 |
| 65 | 10 | 25 | 33 |
TBSA, Total body surface area.
Such improvement in forestalling death is a direct result of the maturation of burn care science. Scientifically sound analyses of patient data have led to the development of formulas for fluid resuscitation and nutritional support. , Clinical research has demonstrated the utility of topical antimicrobials in delaying onset of sepsis, thereby contributing to decreased mortality of burn patients. Prospective randomized clinical trials have shown that early surgical therapy is efficacious in improving survival for many burned patients by decreasing blood loss and diminishing the occurrence of sepsis. Basic science and clinical research have helped decrease mortality by characterizing the pathophysiologic changes related to inhalation injury and suggesting treatment methods that have decreased the incidence of pulmonary edema and pneumonia. Scientific investigations of the hypermetabolic response to major burn injury have led to improved management of this life-threatening phenomenon, not only enhancing survival but also promising an improved quality of life.
Optimal treatment of severely burned patients requires significant healthcare resources and has led to the development of highly specialized burn centers over the past decades. Centralizing services to regional burn centers has made implementation of multidisciplinary acute critical care and long-term rehabilitation possible. It has also enhanced opportunities for study and research over the past several decades. This has led to great advances both in our knowledge and in clinical outcomes, with further advancements being expected.
Implementation of a wide range of medical discoveries and innovations has improved patient outcomes after severe burns over the past half century. Key areas of advancements in recent decades include fluid resuscitation protocols, early burn wound excision and closure with grafts or skin substitutes, nutritional support regimens, topical antimicrobials and treatment of sepsis, thermally neutral ambient temperatures, and pharmacologic modulation of hypermetabolic and catabolic responses. These factors have helped to decrease morbidity and mortality after severe burns by improving wound healing, reducing inflammation and energy demands, and attenuating hypermetabolism and muscle catabolism.
Melding scientific research with clinical care has been promoted in recent burn care history largely because of the aggregation of burn patients into single-purpose units staffed by dedicated healthcare personnel. Dedicated burn units were first established in Great Britain to facilitate nursing care. The first US burn center was established at the Medical College of Virginia in 1946. The same year, the US Army Surgical Research Unit (later renamed the US Army Institute of Surgical Research) was established. Directors of both centers and later, the founders of the burn centers at the University of Texas Medical Branch in 1947 and Shriners Hospitals for Children–Galveston in 1963, emphasized the importance of collaboration between clinical care and basic scientific disciplines to improve patient outcomes.
The organizational design of these centers engendered a self-perpetuating feedback loop of clinical and basic scientific inquiry. In this system, scientists receive firsthand information about clinical problems, whereas clinicians receive provocative ideas about patient responses to injury from experts in other disciplines. Advances in burn care attest to the value of a dedicated burn unit organized around a collegial group of basic scientists, clinical researchers, and clinical caregivers, all asking questions of each other, sharing observations and information, and seeking solutions to improve patient welfare.
Findings from the group at the US Army Institute of Surgical Research point to the necessity of involving many disciplines in the treatment of patients with major burn injuries and emphasize the utility of a team concept. For this reason the International Society of Burn Injuries and its journal, Burns, as well as the American Burn Association and its publication, Journal of Burn Care and Research, have publicized the notion of successful multidisciplinary work by burn teams to widespread audiences.
Members of a burn team
The management of severe burn injuries benefits from concentrated integration of health services and professionals, with care being significantly enhanced by a true multidisciplinary approach. The complex nature of burn injuries necessitates a diverse range of skills for optimal care. A single specialist cannot be expected to possess all skills, knowledge, and energy required for the comprehensive care of severely injured patients. For this reason, reliance is placed on a group of specialists to provide integrated care through innovative organization and collaboration.
In addition to including burn-specific providers, the burn team consists of epidemiologists, molecular biologists, microbiologists, physiologists, biochemists, pharmacists, pathologists, endocrinologists, and numerous other scientific and medical specialists. Because burn injury is a complex systemic injury, the search for improved treatments leads to inquiry from many approaches. Each scientific finding stimulates new questions and the potential involvement of additional specialists.
At times, the burn team can be thought of as including the environmental service workers responsible for cleaning the unit, the volunteers who may assist in a variety of ways to provide comfort for patients and families, the hospital administrator, and many others who support the day-to-day operations of a burn center and significantly impact the well-being of patients and staff. However, the traditional burn team consists of a multidisciplinary group of direct-care providers. Although burn surgeons, plastic surgeons, nurses, nutritionists, and physical and occupational therapists form the core, most burn units also include anesthesiologists, respiratory therapists, pharmacists, spiritual therapists, and music therapists. The increasing number of survivors has consequently also added psychologists, psychiatrists, and, more recently, exercise physiologists to the burn team. In pediatric units, child life specialists and schoolteachers are also significant members of the team of caregivers.
Patient satisfaction can be formally measured through questionnaires to provide positive feedback to caregivers and highlight potential areas of improvement. Allowing patients to feel as if they are part of decisions about their care, listening and responding to concerns, providing encouragement, and displaying empathy are all important for maintaining satisfaction in patients and their families. These approaches also reduce fear, apprehension, and misunderstandings.
Healing relies on a complex array of factors. These include individual factors such as motivation, preexisting health status, obesity, malnutrition, comorbidities, family support, and social support. They also include wider societal factors such as reintegration, individual perception, and coping strategies, as well as factors specific to the mechanism of injury such as trauma, bereavement, grief, and loss.
Patients and their families are infrequently mentioned as members of the team but are obviously important in influencing the outcome of treatment. Persons with major burn injuries contribute actively to their own recovery, and each brings individual needs and agendas into the hospital setting that may influence the way treatment is provided by the professional care team. The patient’s family members often become active participants. This is even more important in the case of children but is also true in the case of adult patients. Family members become conduits of information from the professional staff to the patient. At times they act as spokespersons for the patient, and, at other times, they become advocates for the staff in encouraging the patient to cooperate with dreaded procedures.
With so many diverse personalities and specialists potentially involved, purporting to know what or who constitutes a burn team may seem absurd. Nevertheless, references to “burn teams” are plentiful, and there is agreement on the specialists and care providers whose expertise is required for the optimal care of patients with significant burn injuries ( Fig. 2.1 ).
(A–B) Experts from diverse disciplines gather with common goals and tasks and overlapping values to achieve their objectives.
Burn surgeons
Ultimate responsibility and overall control for the care of a patient lies with the admitting burn surgeon, the key figure of the burn team. The burn surgeon is either a general surgeon or plastic surgeon with expertise in providing emergency and critical care, as well as in performing skin grafting and amputations. The burn surgeon provides leadership and guidance for the rest of the team, which may include several surgeons. The surgeon’s leadership is particularly important during the early phase of patient care when moment-to-moment decisions must be made based on the surgeon’s knowledge of physiologic responses to injury, current scientific evidence, and appropriate medical/surgical treatments. The surgeon must not only possess knowledge and skills in medicine, but also be able to clearly exchange information with a diverse staff of experts in other disciplines and lead the team. The surgeon alone cannot provide comprehensive care but must be wise enough to know when and how to seek counsel, as well as how to clearly and firmly give directions to direct activities surrounding patient care. The senior surgeon of the team is often accorded the most authority and control of any member of the team and thus bears the responsibility and receives accolades for the success of the team.
Plastic surgeons
Next to burn surgeons, who are particularly involved in the immediate and acute phase of surgical treatment, are the plastic surgeons, who are typically involved instead in long-term surgical treatment. The plastic surgeons aim to deliver care that yields the best functional and aesthetic results for the burn survivor. The burn surgeon should always work in close collaboration with the plastic surgeon. Most burn surgeons are plastic surgeons, but in instances where this is not the case, the presence of plastic surgeons in the team is essential. Ideally, this collaboration should start during the initial phase of surgical treatment. The plastic surgeon’s duty is primarily to care for the patient in terms of functional improvement through surgeries that aim to lessen scarring and decrease the functional limitations created by scarring. This surgical treatment often requires numerous operations, which may take place for years after the burn injury.
Anesthesiologists
An anesthesiologist who is an expert in the altered physiologic parameters of burned patients is critical to the survival of the patient who usually undergoes multiple acute surgical procedures. Anesthesiologists on the burn team must be familiar with the phases of burn recovery and the physiologic changes to be anticipated as burn wounds heal. Anesthesiologists play significant roles in facilitating comfort for burned patients, not only in the operating room but also during the painful ordeals of dressing changes, staple removal, and physical exercise.
Nurses
Nurses represent the largest single disciplinary segment of the burn team, providing continuous coordinated care to the patient. The nursing staff is responsible for technical management of the 24-hour physical treatment of the patient. They control the therapeutic milieu that allows the patient to recover. They also provide emotional support to the patient and patient’s family. Nursing staff are often the first to identify changes in a patient’s condition and initiate therapeutic interventions. Because recovery from a major burn is rather slow, burn nurses must merge the qualities of sophisticated intensive care nursing with the challenging aspects of psychiatric nursing. Nursing case management can play an important role in burn treatment, extending the coordination of care beyond hospitalization through the lengthy period of outpatient rehabilitation.
Physical and occupational therapists
Physical and occupational therapists begin planning therapeutic interventions at the patient’s admission to maximize functional recovery. Burned patients require special positioning and splinting, early mobilization, strengthening exercises, endurance activities, and pressure garments to promote healing while controlling scar formation. These therapists must be very creative in designing and applying the appropriate appliances. Knowledge of the timing of application is necessary. In addition, rehabilitation therapists must become expert behavioral managers because their necessary treatments are usually painful to the recovering patient, who will resist in a variety of ways. While the patient is angry, protesting loudly, or pleading for mercy, the rehabilitation therapist must persist with aggressive treatment to combat quickly forming and very strong scar contractures. The same therapist, however, is typically rewarded with adoration and gratitude from an enabled burn survivor.
Respiratory therapists
Inhalation injury, prolonged bed rest, fluid shifts, and the threat of pneumonia, all concomitant with burn injury, render respiratory therapists essential to the patient’s welfare. Respiratory therapists evaluate pulmonary mechanics, perform therapy to facilitate breathing, and closely monitor the status of the patient’s respiratory functioning and improvements during the recovery.
Exercise physiologists
The exercise physiologist has recently been recognized by many as a key member of the comprehensive burn rehabilitation team. Traditionally, exercise physiologists study acute and chronic adaptations to a wide range of exercise conditions. At institutions where there is or are exercise physiologist(s), they may perform clinical duties and/or conduct clinical research.
Clinical duties include monitoring and assessing cardiovascular and pulmonary exercise function, as well as muscle function. Additional clinical duties include writing individualized exercise prescriptions for cardiopulmonary and musculoskeletal rehabilitation. Clinical research conducted by the exercise physiologist mainly focuses on the effect of exercise on burn sequelae and the mechanisms by which exercise can reduce or reverse burn-induced catabolic and hypermetabolic conditions and improve a patient’s quality of life.
There is no licensing body or requirements for exercise physiologists to practice their profession. However, many organizations, such as the American College of Sports Medicine and the Clinical Exercise Physiology Association, offer national certifications and have national registries. These certifications include the exercise test technologist, exercise specialist, health/fitness director, and clinical exercise specialist. We recommend that if the exercise physiologist is primarily involved in clinical duties, they should have a minimum of a master’s degree and be nationally certified by a well-known and respected organization. If they will direct clinical or basic research projects as part of their duties, then we recommend a doctorate degree and a national certification.
Nutritionists
A clinical nutritionist or dietitian monitors daily caloric intake and weight maintenance. These specialists also recommend dietary interventions to provide optimal nutritional support to combat the hypermetabolic and catabolic responses to burn injury. Caloric intake, as well as intake of appropriate vitamins, minerals, and trace elements, must be managed to promote wound healing and facilitate recovery. Nutritionists and exercise physiologists may work together in implementing methods to increase daily physical activity (caloric expenditure) to counteract any sequelae due to a sedentary lifestyle.
Psychosocial experts
Psychiatrists, psychologists, and social workers with expertise in human behavior and psychotherapeutic interventions provide continuous sensitivity in caring for the emotional and mental well-being of patients and their families. These professionals must be knowledgeable about the process of burn recovery and human behavior to make optimal interventions. They serve as confidants and supports for patients, families of patients, and, on occasion, other burn team members. They often assist colleagues from other disciplines in developing behavioral interventions for problematic patients, allowing the colleague and patient to achieve therapeutic success. During initial hospitalization, these experts manage the patient’s mental status, pain tolerance, and anxiety level to provide comfort to the patient and facilitate physical recovery. As the patient progresses toward rehabilitation, the role of the mental health team becomes more prominent in supporting optimal psychological, social, and physical rehabilitation.
Spiritual therapists
Not all patients and relatives are religious or spiritual, but for those who are, the presence of a spiritual therapist or guide can be extremely important and can help to overcome or deal with the difficult times the burn survivors are experiencing. The power and efficacy of prayer and religious-spiritual involvement during illness and recovery have been often discussed and have been demonstrated to be very important for many patients. For these reasons, hospitals and especially burn centers should have a spiritual therapist in the team to assist not only the burn survivors but also their relatives.
Music therapists
Music therapy is the use of music interventions to accomplish individualized goals in a therapeutic relationship between the patient and the figure of the music therapist. The principal goals and interventions can be designed to promote wellness, manage stress, alleviate pain, express feelings, enhance memory, improve communication, and promote physical rehabilitation. As reported, music therapy can improve a patient’s range of motion and help during the hospitalization and rehabilitation periods. The music therapist has an important role to play for burn patients and should be considered an essential member of the burn team.
Students, residents, and fellows
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