Full Text:

Health Monitor: Bridgeport Hospital Burn Center Works To Protect Largest Organ

Of The Body

(with photos)

BY SHANNON HICKS

BRIDGEPORT -- Three-quarters of the 1.5 million burn- and fire-related

injuries that occur each year in the United States are preventable.

Unfortunately, even with education and prevention, burns still occur daily to

people of all ages.

In Connecticut, serious burn patients are treated at the Bridgeport Hospital

Burn Center, the only dedicated facility for burn care between New York and

Boston. The center is located on Schine Four, the fourth floor of the hospital

in downtown Bridgeport.

Opened in 1972, the Bridgeport Hospital Burn Center provides both immediate

(outpatient) and long-term (inpatient) treatment for burn victims across the

state. Outpatient treatment began three years ago, when changes in health care

provisions made the service necessary.

Because it is the only dedicated burn care center in the state (the closest in

New York State is in Westchester County), the center receives more than 2,000

visits annually on an outpatient basis alone. But any one patient may visit

four or five times for treatment or check-ups on one injury.

On an inpatient basis, the center cares for an average of 100 patients each

year. The staff reports those numbers are decreasing.

"Many burns are accidents that never needed to happen," said Dr Michael

D'Aiuto, director of the center. "These accidents include children scalded by

hot coffee or tap water, newspapers carelessly left near a space heater, a

grease fire with no fire extinguisher nearby, or a candle left burning near a

curtain." In addition to loss of life, pain and suffering, the current

projected nationwide cost for providing intensive burn care totals more than

$1 billion annually.

Young children, in particular, are at high risk for burns, says Sally Dalton,

RN, clinical services director of the burn center. Burns are the leading cause

of accidental death in children under two, and more than 100 children are

treated each day across the country in emergency rooms for kitchen and scald

burns alone. Of all burn-related accidents, 65 percent happen to children

under the age of eight.

And children, because they have thinner skin, get severe burns at lower

temperatures and in less time than an adult, said Dr D'Aiuto. The same holds

true for senior citizens.

Exposure for just three seconds to water which is 140 degrees Fahrenheit (the

temperature of the average home's hot tap water) can result in a full

thickness or third degree burn on a child, which would require hospitalization

and skin grafts. An adult would have to be exposed to the same temperature for

up to five seconds to get the same degree of burn. At a higher temperature,

the time required to get a serious burn can be reduced to a fraction of a

second. Although the National Burn Awareness Coalition reports burn injuries

and deaths are down by more than 35 percent in the last two years,

"educational efforts must continue or the numbers could rise again overnight,"

cautions Dr D'Aiuto. The burn center is a key component of Bridgeport

Hospital's Level One Trauma Center, the first and only one in Fairfield

County. Aside from providing expert care, bandages, ointments and beds for

patients, one of the center's biggest tactics to treat burns is education.

"There is a national trend of fewer people being injured by burns because of

education," says John Palmer. A physician's assistant, Mr Palmer is a member

of the burn center team. "Also, because of fire alarms and [training of]

firefighters, firemen can get into burning buildings much faster."

"We teach fire prevention. And we will teach anybody," Ms Dalton said. "We go

out into the community and we teach about burns and burn care to paramedics

and EMTs. We also teach a prevention course where we've gone into grammar

schools, nursing homes. We teach people how not to get burned. It's an

important part of what we do.

"The best way to `treat' a burn is to not get one, to not have one at all,"

she said.

The Largest Organ

"Think about your skin," said Sally Dalton. "When you get burned, the organ

that is involved is your skin, and what are the functions of your skin? Your

skin is a covering for you. It's the largest organ of your body."

Bodies have three layers of covering: the epidermal, or outer, skin; the

dermal, or vascular, layer of skin; and then the fat covering.

"[Your skin] protects you from the outside environment, so [burn] patients are

very susceptible to infection," she continued. "It controls your body

temperature, so these patients are very cold when they have their skin burned

off. "Your skin also controls your nerve endings. When you get a second degree

burn, that's into your dermis, which is the second layer of your skin. Their

nerve endings are exposed and that's where they are feeling the pain," said

the nurse.

To illustrate her point, Ms Dalton drew a comparison between burn patients and

dental patients. When a dentist exposes nerves to the open air, the nerve

endings in your mouth react instantly, painfully. Burn victims feel the same

intense sensations anywhere they have been burned.

"We need to control that pain, to cover those nerve endings," Ms Dalton said.

Skin injured by a second-degree burn can heal on its own, given the right

situation. Third-degree burns, where the dermal layer has been burned

completely through, need skin grafts in order to begin the healing process.

Regardless of the severity of a burn, injuries can take anywhere from days to

months to heal.

Skin grafts can be performed for a number of reasons. When a patient has a

second-degree burn, a surgeon will do a skin graft by taking a piece of the

epidermal layer from one part of the patient's body and using it to cover the

injured area. Epidermal skin will grow back, but the immediate covering for

the patient is necessary to start the healing process.

When someone is burned to the third-degree level -- right through the fat

layer -- their nerve endings are also burned. They feel no pain, but a skin

grafting is still necessary in order to effect healing and prevent infection.

Just as people can donate eyes or hearts or livers, organ donors can also

donate their skin. Open wounds need to be covered immediately, so doctors use

donated skin as a biological dressing when first receiving a burn patient.

"Our bodies reject someone else's skin, but at least it covers the nerve

endings," Ms Dalton said. "It makes you feel better."

A new form of treatment is called Integra, which is a synthetic dermal

(second) layer of skin. This was used extensively on the late Dr Betty

Shabazz. Just last month, experts instructed Bridgeport Hospital Burn Center

physicians on Integra's use so they can incorporate this into their treatment

plan. "We haven't used it yet, but we'll be using it soon," Ms Dalton said. "I

think it's a new thing with burns that's going to be really helpful."

Burn Unit Staff

The Burn Center, open 24 hours a day, is comprised of a team of 25 doctors and

nurses. While everyone takes their jobs seriously, the team's nickname is a

playful acronym for Burn Center Nurses; the team calls itself The BUNS.

There are five burn doctors, all general surgeons, including Dr D'Aiuto, who

works exclusively with the unit. The team's physician's assistant (PA), John

Palmer, serves as a liaison between the physicians and all other staff

members. The physicians are responsible for the overall care of the patients,

says Ms Dalton. She has been with the hospital for 24 years, the last 13 of

which have been with the burn unit.

The PA sees patients on a daily basis, offers reports to physicians who may

have other patients to also oversee, and assists in surgery.

"There are a lot of things the attending physician cannot be here to do," Mr

Palmer explained. Mr Palmer, who has been with the burn unit for eight of his

ten years at Bridgeport Hospital, also has teaching responsibilities. He works

with the surgical residents -- the surgeons in training -- who move through

the unit on a monthly basis.

Also on the team are 12 nurses, a physical therapist and an occupational

therapist, a social worker, a case manager, a dietician/nutritionist, a

respiratory therapist, and a child-life therapist. These are all full-time

staff positions.

Pediatric Services also works with the unit, on a consulting basis. In

addition to the ongoing education to the community on preventing burns, the

unit also offers a self-help group for former patients and their families.

A lot of the nursing staff has been with the unit for "a long, long time,"

says Ms Dalton.

"That's one of the things about nursing here -- you are very dedicated to what

you are doing and so you stay for a long time," she said. " We work all

together, all the members of the team. It's nice, you get to be like a

family."

Inpatient Treatment

In its inpatient wing, the center has ten beds. There are four critical-care

beds, and four step-down beds. Every room is equipped with heating shields, to

keep the patients warm; refrigerators, and monitors for blood pressure,

temperature, etc. The refrigerators are needed because if a burn is severe

enough, a body's metabolism greatly speeds up to try to heal the wounds.

"Their engines are going really fast at this point," Ms Dalton explained.

"When you get a cut, your immune system goes to town. When you're open, your

metabolism speeds up that much more." Higher metabolisms need high-protein

diets, which is where the team's dietician comes into play.

Patients may be given tube feedings because initially they need a higher

amount of protein and calories. Once they are off tube feedings, they are put

on a diet. Patients who do not need to be tube fed are also instructed on what

to eat and, in many cases, are permitted favorite foods brought by family

members. While one room in the unit is capable of holding two patients at one

time, the team prefers to have one patient in each room.

"They enjoy their privacy," Ms Dalton said. There are also a few sleeping

rooms in the wing, where a patient's family member is welcome to stay if

traveling a long distance or staying with a patient for a number of days.

Dressing changes take place twice a day. After administering medication for

pain (usually morphine, which takes 30 minutes to take effect), patients are

then brought to whirlpools in the treatment rooms.

Small whirlpools can be used to treat one small area of a body (a hand, an

elbow or foot, for instance), while the largest ones in the unit are capable

of holding a grown adult. The small whirlpools are also used when children are

burned; a child can be fully submersed in one of the smaller tanks, if

necessary. Once medication has numbed some of a patient's pain, the whirlpools

are used to clean and wash a patient's wounds. A water-Betadyne-salt solution

is used for this process.

Nurses are responsible for debriding the burns. Debriding is washing a burn

off, then cutting away and removing any loose, dead skin. The process can

cause quite a bit of pain for patients, said Ms Dalton.

Once the wounds are cleaned out, the wound is coated with an antimicrobial

cream, which prevents infection, and then covered.

"You have to be very aggressive with these patients in their treatments," Mr

Palmer said. "That dead tissue that's sitting in that wound is the ideal

environment for bacteria to thrive in. And that's what's going to eventually

cost these patients their lives, if that gets infected."

The Sickest Patients

"There's a lot of education going on with the patient," said Mr Palmer.

"Everybody's responsible for that, the therapists, the nurses, the doctors,

the PAs. ... When they're having a whirlpool treatment done, the therapist

will come in and evaluate the patient, do some exercises with them.

"I'll come in and assess the progress they've made in the past 24 hours, or

even since the last time I've seen them. And the physicians come up to take a

peek at the process, to see how the patient is doing," he said.

The length of time a patient will stay at the center depends upon how

extensive their wound is. Factors include how much area of the body has been

burned, and how deep the burn goes, and if grafting is necessary.

People who come to the hospital with burn injuries usually expect to be out in

a few days, says Ms Dalton. But this is not always the case.

A burn patient who needs surgery does not get into the operating room for four

days; injuries have to be cleaned and disinfected all that time before they

are considered safe enough to be operated on, the clinical services director

explained. "Of all the patients in the hospital, there is not a more

challenging patient," Mr Palmer said. "These people are at such risk for such

complications." Blood infections, called sepsis, can lead to organ failure and

be life-threatening. Pulmonary failure can also occur.

"Some of these patients face these challenges off and on during their hospital

stay," the PA continued. "I instruct patients and their family members these

hurdles can arise at any moment. You can be over one complication, thinking

you're doing well, and a few moments or a few hours later, there's another

complication. "These are the sickest patients in the hospital," he said.

An outside complicating factor where burns are concerned is how the burn

occurred in the first place. If a patient has been in a house or building

fire, they have inhaled smoke, which is another injury. The burn unit can save

people with large surface area burns much easier than patients that arrive at

the hospital with smoke inhilation.

"If they don't have any smoke inhalation, they do very, very well," Ms Dalton

said. "Once you add that pulmonary component to it, that causes the fatality."

Toxic poisons in the smoke -- from weather treated woods, curtains or rugs

that have a stain repellent on them, any kind of chemical in the burning

material -- create complications on top of burn injuries.

The resulting pulmonary damage can often lead to pneumonia, which is difficult

to treat on its own. When added to the burn unit's treatment, it makes for a

long road to recovery, according to the unit's staff.

"They [can] live, they do well, but it's a difficult, difficult time," Ms

Dalton said. "We are able to save these people's lives."

Fighting A Natural Enemy

The burn unit's largest enemy is scarring. The body's natural inclination when

injured is to pull toward itself. Because of this, past generations of burn

victims were not only scarred but could be disfigured once a wound had healed

on the outside.

Now, burn doctors know to fight the body's inclination. At their use are

splints that can be shaped to fit any body contour, as well as exercises that

fight against atrophy.

The physical therapy room has a treadmill, exercise beds, and a heating

machine used to make splints. Physical therapists are responsible for keeping

a patient exercising. As with the medication aspect, the post-burn life of a

patient is something the burn unit feels responsible for as a team.

Once it is time for a patient to go home, or if someone is visiting the

hospital on an outpatient basis, scar control becomes the priority. Patients

are measured for pressure garments, which are garments for specific sections

of the body that are made of a gauze material which covers the wound. These

are used to make the final scars after skin grafts or donor sites much

smoother than natural healing would have occur.

The garments are custom made. Patients build up to wearing them 23 hours a

day, for a duration of up to two years. The garments are somewhat tight to

wear, which is what creates the smooth scar surface.

If left to heal on their own, scars would be very bumpy and much larger than

without the use of a pressure garment. The scars will still be discolored, but

the cosmetic gain is that a patient feels more normal with a scar that does

not stand out and draw much attention, Ms Dalton explained.

The center's immediate function is to treat burns of any kind. But with the

continued education doctors and nurses are learning daily -- and passing on to

their patients -- the center also has another goal, one that extends outside

the walls of Bridgeport's Schine Four, says Mr Palmer.

"One of our major goals is to try to return a patient back to the same

functional level, or as close as possible, with the least amount of scarring,

as they were in their pre-burn state."

Bridgeport Hospital is at 267 Grant Street in Bridgeport; telephone

203/384-3000. For information on the educational programs the burn center

provides or the in-house self-help group for burn victims, contact Sally

Dalton, 203/384-3240.