Tips to Help Serious Burn Injury Victims

When a friend or family member suffers a catastrophic medical event, he is often at a loss for the best way to show concern and to offer support. An article in The Pheonix Society focuses on the needs and issues of burn victims. Here are some specifics dos and don’ts for hospital visits and the post-hospital recovery period:

  • Don’t send or bring flowers. Although a well-intentioned first instinct ,if someone is hospitalized or recuperating at home, flowers present a potential risk. The bacteria carried by real flowers may threatened the patients weakened immune system.
  • Do send a humorous book or a blank journal.
  • Don’t stare or avoid eye contact. Burn patients usually have a greatly heightened awareness of their appearance.
  • Do try to look at them squarely and naturally. Be aware of your body language and the messages your non-verbal cues may be sending.
  •  Don’t lie. The patient knows they have physical changes and a serious condition. It is unlikely you “know how they feel”. So don’t say it.
  • Do listen and acknowledge their feelings. An appropriate response: “I can see that this is a really difficult time. I’ll be here for you.
  • Don’t make vague offers to help.Do help. Be proactive with suggestions such as “I will set up child care for the week or walk your dog every morning”. Assume the offer will be accepted and ask for specific instructions.
  • Don’t pressure the victim to make a decision about filing a lawsuit.
  • Do research names of attorneys who specialize in the issues that gave rise to the victim’s injuries. Experienced attorneys can consult with the family and help preserve important evidence or gather witness statements.

A strong support system of family and friends is invaluable to a burn patient. Most burn patients say the things people DO are more important than the things people SAY.

 

Critical Burn Care: The Early Stages

What is the biggest challenge facing doctors in the first days after a burn injury?  Fluid loss.  

When a victim suffers severe burns, much of his skin may be gone and to put it very simply, his capillaries begin to leak. Instead of sticking together, keeping blood inside of the vessel, the tissue cells separate and become very porous. Huge amounts of fluid pour out into the tissue. In small burns this fluid accumulates only in the burned areas but in very large burns fluid can accumulate everywhere in the body. A burn patient can develop a significant amount of swelling at the expense of blood flow. The blood volume goes down as the patient becomes more swollen.  Because his heart is unable to pump enough blood to the body, he develops shock.  This shock may cause other organs to stop working.  Doctors will combat these effects by providing the patient with fluids, electrolytes, antibiotics, pain medication, tetanus vaccination and often by inserting a catheter.  The catheter is needed to measure urine output and monitor fluid levels. 

Also, with the infusion of fluids the doctors must constantly monitor the patient’s circulation in his arms and legs.  A condition called compartment syndrome can arise in a burn patient when

  • stiff scars wrap around the limb and the tissue in that limb causing fluid loss; and/or,
  • swelling results from all the fluid administered to combat the losses fluid in the blood vessels and tissues. 

Compartment syndrome can even occur in the chest/abdomen if the patient’s trunk is badly burned and the skin cannot handle the swelling.  When necessary doctors will relieve the compartment syndrome by performing an escharotomy or fasciotomy

Approximately 50% of all deaths that occur within first 10 days following burn injury are due to inadequate fluid resuscitation necessitated by the burn. 

Debridement of Burn Wounds

Following a burn, dead tissue provides a breeding ground for bacteria to grow and bacteria can lead to infection. The dead tissue will eventually fall off as part of the skin's natural healing process. However, when burns are particularly severe, the natural healing process can take too long. Surgeons must act to reduce the risk of infection by "debriding" the wound. Debridement is the process of removing dead tissue and contaminated material from and around a wound to expose healthy tissue.

The surgeon may debride the wound in several ways: surgically, chemically, mechanically and autolytically. To decide which method to use, the surgeon will consider the wound's depth, its extent and location, whether it lies close to other structures like bones, the risk of infection and antibiotic use, and the type of pain management that will be used during and after the procedure.

Surgical debridement:
Dead tissue is cut from the wound by using scalpels, forceps, scissors and other instruments. Surgical debridement is the most effective method if the wound is large or deep. It is often the best choice if the need for debridement is urgent. The wound is cleaned with saline and then the dead tissue is cut. Surgical debridement often needs repeating. Sometimes skin grafts may need to be transplanted into the debrided site.

Mechanical debridement:
This method is one of the oldest, potentially the most painful, and most controversial. It is done by applying a saline moistened dressing over the wound and allowing it to dry and adhere to the dead tissue, when the dressing is removed the dead tissue will be pulled with it. Ouch! It is controversial because it may not remove reliably all of the dead tissue.

Chemical debridement:
This is done by using enzymes and other compounds to dissolve dead tissue in the wound.

Autolytic debridement:
This method involves using dressings that retain wound fluids, allowing the body itself to naturally get rid of the dead tissue. It is not used if the wound is infected or quick treatment is needed, since it takes more time than the other methods and is a good method if the body cannot tolerate more aggressive treatment.

Debridement may be done under general or local anesthesia; pain medications may be administered afterwards. The debrided burned area of the wound must be properly dressed and kept clean and dry. The patient and family members must be attentive to signs of infection: discharge from the wound, color change, swelling, redness, increasing pain, excessive bleeding, fever and chills. Infections will often lengthen the hospital stay and if not treated properly may lead to pneumonia and even death.

In personal injury cases, the testimony of the health care providers who manage the burn care and debridement is helpful in explaining to the jury the nature of the care and the risks involved. 

Stem Cell Discovery Brings New Hope for Burn Victims

Scientists have found the stem cells that produce all the different cells of the skin. The discovery offers a promising development for wound repair or skin transplants.  Stem cells are original cells that have the potential to regenerate tissue over a lifetime. The skin has three different types of cells -- hair follicles, inter follicular epidermis, and moisturizing sebaceous glands.

Scientists had previously thought that stem cells in each of these three skin populations were capable of producing only their own cell type. Scientists are already able to grow new skin in laboratories using a badly burned patient's existing skin cells, but the new skin is often thin, brittle, dry and does not have hair -- making it look unusual. The Science journal recently published a study by a team of Dutch and Swedish researchers who found in mice that the "mother" of all skin stem cells - the stem cells that produce all the different cells of the skin actually live in hair follicles. The advantage offered by the "mother" stem cell -- Lrg6 -- would be that skin can be grown from its original basis -- allowing it to be "real new skin" with moisture from sebaceous glands and the ability to grow hair. Not just the superficial epidermis layer of skin.

One of the scientists, Hans Clevers, of the Royal Netherlands Academy of Arts and Sciences in Utrecht, told Reuters,

the promise is that these cells are probably going to be much better than anything we have had to date at making new skin.

It may take researchers 2 to 3 years to learn how to isolate the Lrg6 cells in human skin but the results should be far superior to current methods.

We anticipate that experts retained by defendants in burn cases will seek to use the new research to minimize the lasting nature of the injuries that the burn victim has suffered.

Surgical Interventions to Release Burn Swelling

Victims with full thickness burns, as discussed here, on their arms and legs experience tremendous swelling from the fluids necessary to heal. The swelling puts pressure on the nerves and tissues of the healthy sections of the burned limbs.  The pressure may cause a complete loss of blood flow and tissue damage to the distal limb.  To relieve the pressure and promote blood flow, the burn surgeon may perform the following procedures:

  • Escharotomy -- slitting of the burned skin (eschar);
  • Fasciotomy -- slitting of the burned  skin and splitting of the fascia (the thick white covering of the muscle) to inspect how the muscle is doing.

Although gruesome, the surgeons often take photos before and after the procedure to document the health of the tissue and progression toward recovery.  Such photos may be helpful to educate the jury about the victim's pain and suffering.

 

Filing A Lawsuit -- What Evidence is Needed?



When a person is injured, the initial investigation might not provide all of the answers. For example, when a product such as a Blue Ember gas barbecue grill causes an injury, victims and investigators want to know: “When was the manufacturer first aware of the problem? And, should they have warned earlier about the potential to cause serious injuries? ” 
To get answers, the victim's attorney needs to review internal documents and interview employees and supervisors. Unfortunately, wrongdoers seldom allow their victims' attorneys to review their internal files voluntarily. To get their cooperation, the victims' attorney needs a subpoena. Only then will the manufacturer or other defendants be legally required to open up their files and submit to questions under oath. But to get the subpoena, the attorney needs to file a lawsuit.

 So, then, how much evidence does a victim need before he can file the lawsuit?

It's a bit of a catch-22. An attorney needs to file a lawsuit before he can conduct a thorough investigation. But he needs to investigate to unearth the facts that justify filing a lawsuit. So what facts must an attorney know before filing a lawsuit? In California, the law requires a mere "statement of facts constituting the cause of action, in ordinary and concise language."  What does that mean? Mere allegations of fact which, if true, would entitle the victim to be compensated, are good enough. At the beginning stages of the lawsuit, the victim’s ability to actually prove the allegations is of no concern.

Not true for federal court. The requirements for filing a lawsuit in federal court are more stringent. In federal court, the attorney needs a "good faith basis" for each allegation of fact. It is no excuse that the attorney cannot conduct an investigation into the facts until after the lawsuit is filed. And, recently, the U.S. Supreme Court made it more difficult. The defendant who is sued in federal court can ask the judge to review the initial complaint and draw upon his or her judicial experience and common sense to determine if the allegations are " plausible. " If the judge thinks the allegations are not, then he can throw the case out before the defendant has to answer any questions at all.

This stringent federal standard is one of several reasons victims’ attorneys prefer to file lawsuits in California state courts. Under the federal standard, the Judge may close the door to the victims before important questions are answered.

 

Dealing with Pain: Virtual Reality Devices Assist Burn Victims

When burn victims are resting (most of the time), opioids (morphine and morphine-related chemicals) are adequate for controlling their burn pain. In sharp contrast, during wound care such as daily bandage changes, wound cleaning, staple removals etc., opioids are not enough, not even close.  Researchers at Harborview Burn Center in Seattle have developed a virtual reality program to fully immerse a patient in an alternative reality.  Patients are equipped with goggles and "enter" a computer-generated environment .  Entering another world distracts the patients from the painful wound care process and decreases their perception of the pain.

Moving and stretching are also very painful but crucial for a successful recovery.  Recently, physical therapists at New York-Presbyterian Hospital/Weill Cornell Medical Center have reported that burn patients who need to move and stretch benefit from "Wii-habilitation".  The Wii is much more accessible and affordable than the Harborview program.  It too promotes recovery while getting their minds off the injury and pain.

Recognizing the impact of long-term pain is important.  A recent article in Rehabilitation Psychology,  Pain, Depression and Physical Functioning Following Burn Injury concludes that that pain and depression may contribute independently to compromise physical function. And, when a burn patient suffers from both pain and depression, he is at a greater risk for reduced physical functioning over time.

Researchers look forward to further applications of virtual reality programs and games to promote successful rehabilitation in burn survivors.  However,one area of burn recovery that virtual reality will likely not reduce is the relentless itching of the healing process.  Although wound care, moving and stretching are undeniably painful, one of our clients felt tortured by the constant itching. The opioids and topical balms provided little or no relief.  While research may improve treatments, the reality remains, burn victims endure tremendous suffering at every stage of their recovery.

 

 

The Burn Pain Myth: "full thickness burns are not painful because the nerves are destroyed".

Full thickness (third and fourth degree) burn victims suffer pain

  • Nerves may partially function.  
  • Burns on arms and legs cause swelling and pressure on the nerves and tissues of the healthy sections of the burned limbs.
  • Repeated painful interventions to prevent infection and promote healing.

Burn pain worsens over time:

Unlike other types of trauma, in which pain over time plateaus or diminishes, the interventions necessary to prevent infection and promote healing actually worsen the pain of burn injury. 

Pain continues after scars heal:

  • Joint and skin stiffness 
  • Relentless itching
  • Emotional pain of scars and physical deformity

Because of the long, complicated, painful path to recovery, we advise family members of burn victims to photograph the various medical interventions necessary to promote recovery. Photographs of the stages of recovery may help the victims see their improvement and communicate the painful recovery process to a jury.

Partial Thickness and Full Thickness Burns

Overview of burn depths

 Partial thickness burns:

 First degree burns (superficial):

  •  May blister and peel in a few days (ie. sunburn). 
  • Heals in 3-6 days
  • Generally no scarring
  • Topical creams provide relief
  • Antibiotics not needed
  • Drink water

Second degree burns (deeper partial thickness):

  • Blisters are typical.
  • Heals in 14-21 days.
  • Blisters provide biologic dressing and comfort. (Don’t be in a hurry to break the blisters.)
  • Once blisters break, red raw surface will be very painful.
  • Usually do not require surgery.

Full thickness burns:

Third degree burns (full thickness): 

  • Waxy, white, tan or charred and possibly blistered.  
  • Swelling and hair loss are always present. 
  • May have areas of no sensation because the nerve endings are damaged. 
  • The area surrounding the full thickness burn is usually painful.
  • Natural healing of small burns is possible but with risk of infection and scarring
  • Surgery is usually required. 

Fourth degree (deep full thickness):

  • Charred and hard to the touch.  
  • The burn extends past the dermis into the tissue, muscle and bone
  • Even after the skin is no longer in contact with the heat source, damage may continue in the remaining cells.