+Anonymously helping burn patients and victims....

contact us: asktheburnsurgeon@yahoo.com

Friday, October 22, 2010

How to choose wound dressings? (Wounds, wound healing, wound dressings)

Dear doctor,
I read your article on ‘Wound Healing’, however you have not described anything on Wound dressings. I am often confused when different doctors advise different dressings for the same wound. Can you tell me how wound dressings are decided?
Nancy A,
Medical student,
Illinois, USA

Dear Nancy,
Thank you very much for your letter. Wound healing is a complex process and was exhaustively described in

1. Wound healing, scars, mature scars, hypertrophic scars, keloids

2. Part II: Wound healing: why wounds fail to heal, factors affecting wound healing, chronic wounds, non healing wounds.


Wound dressings must be selected according to the nature of the wound. A wide variety of wound dressings are available and choosing the ideal one is critical to the healing of the wound.

An optimal wound dressing:
1)Must promote normal wound healing process (epithelisation)
2) Must absorb the discharge or exudate from the wound
 3)must help the wound clear away the dead tissue in the wound (autolytic debridement)
4) Must not damage the normal surrounding skin.
5)Must destroy the bacteria in the wound.

 A wound in general must be kept moist, since drying will lead to cell and tissue death. If a wound is producing a lot of exudate (discharge), a dressing which is highly absorptive will help to prevent the wound from being soggy and wet. It will also avoid maceration of the skin. If a wound is showing local signs of infection, then a wound dressing which has antibacterial incorporated into it will be helpful.

Some wounds may have dead tissue in them that may appear pale, grey, black or white in colour. The presence of dead tissue hampers the normal wound healing process and such a wound will never heal unless this dead tissue is removed by the use of dressing with enzymatic preparations or by the surgeons knife (a process called debridement)

If a wound is dry then a dressing which will prevent moisture to pass through and provide a moist environment will help the normal wound healing process and epithelialisation.

A wound that is clean and showing signs of healing like good epithelisation (growth of skin cells) will need less frequent dressings since changing the dressing frequently will damage the delicate new epithelial cells.
If a wound is badly contaminated or infected and producing a lot of discharge then it is important that frequent dressing changes be made to keep the wound clean and promote healing.

Infected wounds must have culture study to know the organisms or germ causing the infection and appropriate antibiotics must be give for the same.

Some wounds are small and may heal spontaneously. Some wound are large and will need new skin to applied over them (Skin grafting) to heal, otherwise they will remain as non-healing wounds. To make the wound ideal for skin grafting and promote good granulation tissue (new blood vessels and cells) - dressing which have hypertonic saline impregnated in them can be used.

Some wounds are not dry or exudative (producing too much discharge). A polyvinyl film dressing which in impermeable to bacteria but allows oxygen and moisture to pass through partially can be used. However one must be cautious as polyvinyl film dressing can cause skin maceration especially in those who sweat a lot or live in humid areas.

Some wounds are large and cannot heal spontaneously. These wounds may need the help of dressings supported by negative pressure suction (Vac therapy) which will help to decrease the bacteria, increase the blood supply, increase the granulation tissue, reduce the size of the wound and prepare the wound for skin grafting.

Types Of Wounds
Dry wounds
Exudative wounds
Neither dry nor wet wounds
Infected wounds
Sloughy wounds
Hyper granulating wounds
Poorly granulating wounds

Different dressing materials that are presently available in the market for different wounds will be described in detail in a future article.

Friday, September 24, 2010

Burn videos links on the web (how to treat sunburns, electrical burns, road accidents and burns, infection and burns, how to treat minor burns and scalds, first aid and minor burns, plastic surgery and burns, MRSA, antibiotics)

Dear Burn surgeon,
I found your website very informative. I saw a number of burn videos on YouTube but I was confused as there are no explanations many times. Could you suggest some good videos and advice? 
Katie Jones,

Dear Katie,

Thank you very much for appreciating our site. Asktheburnsurgeon is specifically written in a manner that both lay persons as well as burn professionals will understand burn management and is aimed at creating burn awareness and simplifying burn treatment in the community. There are a number of burn related videos available on the web which can be helpful. We have put together a few links below- and included our thoughts and comments on the video.
(Asktheburnsurgeon has no financial or other interest in the video links displayed on this page)

Electrical burns

There are two types of electrical injuries
1)    caused by electrical flash
2)    caused by direct electrical current

The electrical flash burn causes a burn injury, and in this type of accident the electric current does not touch or pass through the victim’s body. A flash or flame only affects him and he can be treated as a flash/ flame burn victim. On the other hand, in the direct electrical current injury patient, the electrical current passes through the body and this patient must be admitted and monitored in a burn ward as he may manifest problems and complications associated with direct electrical injuries even where no apparent injuries are evident. This is because the electrical injury affects the heart and severe changes in heart rhythm (arrhythmia) can lead to death if the patient is not kept under observation. Further other injuries like muscle damage and myoglobinuria (release of muscle protein in urine) which can block and damage the kidney may occur. Again, muscle damage may lead to compartment syndrome (tissue edema or swelling which causes reduced blood flow and ischemic injury).

Staffs who work with electrical lines and devices must be careful to avoid burns. Rescue officials have to make sure that all electrical currents have been switched off and it is safe for both the rescuer and the victim. Backup, ambulances and first aid experts in CPR, burns and injury managements must always be available in any rescue effort, if mishaps are to be prevented.
Electric burns will be discussed as a full article in a later issue.

‘Wonder why some people make offensive comments at others misfortunes’

The following video link shows a rescue official getting electrocuted while trying to rescue a person who is on top of a high voltage electric pole.

has already been explained in our previous blog

The following video link tells you how to take care of sunburns.
1.How to protect your kids from sunburn

2. Child Care & First Aid : How to Treat a Sunburn

3. How to Treat a Sunburn

Road accidents and burns.

This video link shows a movie clip scenes where multiple road accidents occur simultaneously. To avoid accident and burn injuries, please read our previous article.
24 tips from asktheburnsurgeon on-How to avoid road accidents and burns at

First aid and minor burns

This video link tells you about the first aid management of minor burns. Please read our detailed article on first aid and burn prevention before you follow other links


Burn Prevention

+How To Treat Minor Burns & Scalds

Handling Burns

Case 2 - Accidental flame burns

How to treat a burn - How to treat burns at home

First Aid Tips : How to Treat Second & Third-Degree Burns

First Aid Tips : How to Treat Mouth Burn

how to Treat a Chemical Burn

Nurse TV: Burns Unit

Burn Survivor

Plastic Surgery And Burns

Burns can lead to severe contractures and limitations of joint movements, but with the recent advances in tissue transfers and microsurgery, it is possible to correct severe deformities and let patients lead normal life styles. The following video link shows a young girl who suffered burns to her leg, walking after she underwent surgical corrections. Burn surgery will be discussed as a full article in the future.
‘There is always light in the end of the tunnel’

Electrical burns

Burns - First Aid

first aid - Dealing with burns

Live Burn Mishap

How the Body Works : When the Skin is Cut

Basic First Aid Tips : How to Treat Burn Blisters

First Aid – Burn

How To Treat Someone For Shock

Why are burn patients prone to infection?

Infections and burns.

Burn patients are prone to infections because

1)   They carry a lot of dead burnt tissue (Eschar) which is a good bed for microorganisms to grow
2)   Burn patients are immucompromised or they have a low immunity, so that their body is unable to defend itself from attack by various germs.
3)   Besides burn to the skin, inhalation of smoke or smoke inhalation injury damages the lungs and makes them prone to lung infections.
4)    Monitoring of burn patients may involve insertions of intravenous lines, central venomous lines, Foley catheter, arterial lines, schwan ganz catheter and others. Sometimes theses lines are passed through burnt areas as there are no un-burnt areas to do so. These lines are a potential source of infection. So also is the Foley’s catheter or urinary catheter which can causes urinary tract infection that can be serious if untreated.

5)   Burn patients need to have dressing changes for their burn areas regularly and this can be a source of infection, if infection control protocols are not observed by the attending staff during the dressing changes. In fact, infection control protocols need to be strictly observed from the time of admission, to the time of discharge from the hospital.
6)   Burn patients tend to be infected sometimes by multiple organisms. The use of some antibiotics have be shown to kill the organisms against which they are effective, but sometimes their use promotes the growth of other organisms which attack the burn patient.

7) The indiscriminate use of antibiotics promotes the development of 'antibiotics resistance’ where the organisms are able to survive and grow in the presence of powerful antibiotics. Hence all antibiotics should be used with extreme caution after studying the microbiology and culture/ sensitivity of the microorganism that have infected the burn patient.

The following video links give you a brief idea about burn infection, MRSA and antibiotic resistance.

Antibiotics - Dangerous or Safe?

Antibiotic Resistance

MRSA - Why, How & What Happened ?

MRSA Can Kill You! What You Need To Know!

MRSA: Methicillin-resistant Staphylococcus Aureus


Thursday, September 23, 2010

How to treat sunburns? (Management of 1st degree burns)

Dear burn surgeon, last weekend we spent a long time on the beach and my daughter had sunburn on her face. Now the skin is peeling off and I am wondering if we did not treat her well and is she going to have a scar?
Mrs Mabel

Sunburns is usually a first degree burn and does not need special physician care as first degree burns does not cause fluid loss and is not included in the calculation of burn percentage for fluid resuscitation. The patient usually has been exposed to sunlight for a long time as on the beach. The skin shows redness and when you press your fingertip on this area, there is blanching (skin becomes pale and pink again). The outermost layer of skin (epidermis) is intact but red. If there is blistering of skin then this is a 2nd degree superficial burn and the management will be different as we have seen before..

Management of 2nd degree superficial burns- (2nd degree burns)

However patients with sunburns may have severe dehydration and should take plenty of fluid orally like water, juices or oral rehydration preparations. For small areas of sunburn, one should cover the area with a piece of cloth soaked in cold water. This will ease the pain and one can combine it with regular analgesics like ibuprofen, paracetamol, aspirin, diclofenac sodium etc. For burns that are extremely painful, a local anaesthetic like xylocaine can help. Avoid aspirin in children. For larger areas one can take a cold shower or soak in a bath tub. In children, this should be avoided for fear of hypothermia (abnormal lowering of body temperature). This can be followed up with applications of mild lotions or Aloe Vera preparations, or moisturisers. One should wear light and loose cotton clothing to avoid irritation of the burn area.
To avoid sunburns one should use a sunscreen with a SPF (sun protection factor) more than 25. If you are a fair complexion person, use one with an SPF greater than 45 to prevent sunburns. This burn usually heals in a week’s time.
First degree burns do not cause a scar normally and as the healing takes place the damaged epidermis may peel of slowly revealing the new epidermis underneath. Protect this new skin from sunlight by using a sunscreen and avoid direct bright sunlight for a few weeks.
So don’t worry Mrs. Mabel, your daughter should be fine by God’s grace.

Thursday, September 16, 2010

Burns in the OR and how to avoid them.

Doctor my wife had back surgery and the next morning the nurse while checking her incision asked her how she burned her buttock because she had large blisters on it. She said she hadn't burned her buttock. The blisters burst that evening and they treated her with topical ointment. They kept her a 2 days longer then they had originally told her she would be able to go home. I took her to the family doctor and he just wasn't sure but thought they were 2nd and 3rd degree burns and prescribed Silvadene ointment which seemed to help it heal faster.
They won't give a explanation of the blister other then to say she scooted on her buttock and they were bed sores. She had these less then 24 hours after surgery and only was lying on her side in the bed.

Please give us your opinion.
Thanks for your help Sir,


Dear Mr JB,
Thank you very much for your letter. I am sorry to hear your wife had a possible burn in the theatre. From the history it appears that this resulted after the operation. Whether it occurred in the theatre or afterwards in the ward prior to being noticed the next morning is difficult to say.
If it is did occur it the theatre, there are a few causes that can lead to this clinical presentation:-

1. Allergy to the scrubbing agent

Some patients are allergic to the skin scrubs or antiseptic that are used to clean the skin prior to surgery: like betadine , hibiscrub or cetrimide solution.
I have seen quite a few of these in some unfortunate patients. However they are usually 2nd degree superficial burns- with blistering on the following day and often tend to heal with conservative treatment i.e. dressings and local wound care.
Patients going to the OR must specifically be asked for any allergy to chemical and scrub agents.

2. Bedsores/ pressure sores.
Sometimes the patient is put in a particular position during surgery and due to the long hours of surgery pressure areas may show redness and blistering. Often this pressure area is superficial and tends to heal well with local wound care. Surgeons and OR staff must take great care to monitor pressure areas and change them if possible or provide extra padding.

3. Thermal Burns.
Electrocautery is used during surgery for the purpose of cutting tissue and coagulating blood vessels to control bleeding. When a monopolar cautery is used a cautery pad is applied over some part of the body to complete the circuit for the device to function. If for any reason there is a malfunction a burn may result over the area and skin pad to which it has been applied. If this is discovered early the burn may be superficial but often this is noticed when the pad has been removed after surgery and by this time the burn is normally a deep burn as every time the surgeon uses his cautery, probably the skin gets a burn. Deep burns of this kind often need surgical excision and skin grafting to heal the wound.

4. Thermal burns for the O.T lights.
In the past the lights used in the operation theatre generate a lot of heat and focusing the light on a area of skin for a long surgery sometimes resulted in a burn. In some patient who had a sensitive skin it formed a 2nd degree burn while in others it resulted in a 1st degree burn akin to a sunburn.
In recent times the quality of the OR lights have improved significantly and rarely does one see a burn for this source.

5.Thermal burns from materials used during surgery
Sometimes accidental burns can result from any hot materials used during surgery. If hot water is used for any purpose such as to soften a thermoplastic elements or otherwise and falls accidentally on the patient, a burn can result . This depends on the type of surgery and techniques used there in. However this is quite rare as surgeons and OR staff are extremely cautious when it comes to procedures that can cause burns in patients. High speed drills and mechanical devices should be used with care to avoid friction burns.

6. Lasers.
The use of laser can sometimes result in burn on the patients depending on the skin sensitivity, type of laser , intensity of the laser, the laser machine and the surgeons experience. Laser machines should be used carefully and always a test patch should be carried out before the complete procedure is undertaken.

7. Sticking tape allergy.
Many patients show allergy to skin tapes that are applied after the surgery is over. Prior history and allergy to skin tapes should be asked for. Similarly use tapes that are hypoallergenic and light on the skin. However these appears as redness or blistering when the tapes are removed and settle down and heal with local wound care.

I have put together a number of circumstances that can lead to burn like presentation in operation theatre. However surgeons and OR staff are well trained and take great care in preventing accidental injuries to patients entering the theatre. I hope that this reply is used only for educational purposes and is not for purposes of litigation or otherwise. Creating awareness among patients and medical professionals will help decrease these unfortunate OR incidents.


Saturday, September 4, 2010

Is the abnormal becoming the ‘norm’(al)?

When Edmund Hillary and Sherpa Tensing scaled Mount Everest in 1953, it was glorious moment in the history of mankind. Human abilities were pitted against nature, in a test of strength, determination and grit. In their success we rejoiced and applauded them and transformed them into heroes overnight. Over the past few decades human values, customs, traditions and perceptions have changed. In my youth, riding a bicycle meant going round the country side and enjoying the beautiful scenic views, the fields, the mountains, meadows, waterfalls, and lakes. We came home refreshed and ready to take on the next day. Ask any child today, what bicycle he wants and he will reply- one which can go up a mountain terrain or down the stairs, kerbs, planks and more. Simple old fashioned fun has been replaced by adventure’? To design a vehicle or device that will go up or down a mountain is ‘normal behaviour’, but to take a bicycle, motorbike or car and attempt this task is insane and abnormal even if it is disguised as an ‘adventure sport’! Abnormal venture promoters must be discouraged but the spirit of adventure must prevail within normal limits.

In the old days, pets were kept for fun- the pets had fun, the keeper enjoyed it and the people around admired the pets. This was supposed to be the principle and norm. Pets then were cats, dogs or birds that were safe and adorable. Visit any pet shop today and you will feel like you are on a safari- snakes, spiders, garials and others that will frighten you and make sure that you will never visit your friend who has one of them. Today’s TV programs on wild animals, show men playing with crocodiles, elephants, komodo dragons and snakes- we who encourage them and cheer them are responsible for their mishaps and deaths.

The Guinness world records have slowly turned from the normal to abnormal. For why should a man walk on his hands when he has legs or why should a man lie distressed in a tub of snakes when he can lie peacefully in bed? We have started to be abnormal to create records and society has started to promote these records- or abnormal events.

In the Roman era gladiators killed each other in an arena where spectators cheered. It took us some time to do away with this inhuman and abnormal sport. In present times we still have remnant of this sport – Boxing – where boxers attempt to bring their opponents down by hitting them. We stand around and enjoy this barbaric bloody sport, little realising the pain and suffering they go through and the brain injury which they suffer that will last a life time.

When Steve Irving died from the barb of a sting ray in Australia, it was a signal that the world ignored. We watched, shocked, petrified and guilty. Wild animals are supposed to live in the wild. We are part of their food chain. To take a tiger, a lion, a snake or any wild animals and try to live in harmony with it is wrong and ‘abnormal’ and can be likened to taking a guest to KFC and asking him not to eat the chicken!

For those who believe in religion, God made Adam and Eve to care, love, support and procreate. God did not make two Adams or two Eves. For the atheist, science confirms that men and women were made to be with each other, the anatomy supports this fact and if it were not so, man would have become extinct.

In 1993, when bill Clinton tried to lift the ban on homosexuals serving in the army through his ‘don’t ask don’t tell’ policy, he was attempting to legalise and normalise the ‘abnormal’. Since the evolution of mankind the ‘abnormal’ has always survived on the periphery. Our forefathers knew it but ignored and often turned a blind eye to it, but never accepted it as normal. Hitler used his mental abilities to wipe out a part of the human race but with the same Einstein solved the mysteries of the universe and unified the many branches of science with his ‘theory of relativity’. When rulers and nations join this band of accepting the ‘abnormal’ as ‘normal’ the end result can be catastrophic.

The use of alcohol in medicine, as an appetizer or accompaniment to food, or at a party can be considered normal but to get drunk everyday, loose ones senses and end up doing all sorts of things that one does not remember in the morning- has become the ‘norm’. Simple old fashioned partying has been replaced by drink, drugs and sex.

Promiscuity, alcohol, drugs, prostitution, gambling, homosexuality and more- we are promoting as the ‘norm’ and our children have begun to accept them as the normal. Artist paint with blood and body fluids and promote them as ‘art’. We have legalised prostitution in the hope of protecting our women. But did we really achieve what we aimed for? Perhaps we pushed more of them into this arena.

Cloning has been a dream for many scientists. Cloning of cell, tissue and organs is beneficial. Many diseases that cannot be treated successfully can be cured by replacing the cells, tissues or organs themselves. Dolly proved that cloning an animal was possible but showed the world that we understood very little of the many abnormalities- physiological and anatomical that would occur in this process.

Our scientists are attempting to clone human beings- they did not perfect this technique in animals?

Do we want to create abnormal babies and then decide whether they should live or die? Who gives us the right to play the terminator?

Creating ‘scientific wonders’ and ‘medical first’ has been a craze among our learned scientists. But to let a woman deliver at the age of 63 years and face the possibility of her dying at anytime in the near future leaving behind a motherless child, borders on the absurd. Besides we are nowhere with our creams, lotions, capsules and elixirs in our quest for living eternally.

As scientists, we sometimes plagiarise, copy research work, and put ourselves in papers we never contributed to: did we stop for a moment and think- what are we doing?

Scientists should be scientific and follow normal and accepted scientific methods. Their work and research must culminate into something that is not only scientifically accurate but also socially and morally acceptable.

As businessmen prosper and their businesses flourish, their principles change from normal to abnormal- for the men who make 5%, 50%, 500% or a 5000% profit on the same item they sell, all strongly believe that they are doing legitimate business.

Where do we draw the line which separates business and cheating?

Can we apply the same standards to the medical profession? We would definitely be charged with fraud and cheating!

A child is born innocent, but as he grows up, he observes that the evil and corrupt prosper, they become powerful, suppress the meek and appear successful. He begins to think that this is the ‘normal’ way of life. His thought processes and actions function is this direction. Unless he is made to realise the truth and learn to filter the right from the wrong, the normal from the abnormal, he will end up being part of the cesspool of corruption. In our fast life results and goals are stressed upon, the path is ignored. We need to teach our children that along the way we need to support and encourage our colleagues rather that to put them down. The path we take is as important as achieving the goal.

For what did Ben Johnson achieve? Though he won the race, he lost everything that he appeared to have gained.

For what did Saddam, the dictator of Iraq, gain when he plundered his nation and massacred his opponents? Cornered in a rat hole, he was hung like a criminal.

When bill Clinton became the president of the United States of America, he achieved the ultimate goal that few people could dream off. As he sat in power in the white house, he indulged in an ‘abnormal affair’ that destroyed his career and reputation and put him to indescribable shame.

Our forefathers lived in the wild; they were lawless but realized that normal values had to be set up if they and their future generations had to survive. They established a society based on these values, the normal was separated from the abnormal, so that every individual in the society knew when something seemed wrong. We are reversing the cycle, going downhill, from civilised to uncivilised, from culture to cultureless, from normal to abnormal; in vain did our forefathers struggle!

This trend has to be changed and the responsibility lies on the rulers of this nation, on the teachers, on the parents and on each one of us; to turn around tell our folks and children- let us do the normal, if not for us, for our future generations to whom we are accountable. We are living in an era which has the best of everything: from the first invention- the wheel to the best invention-electricity. We have travelled afar from the Stone Age to the Space Age, from unknown to the known, from darkness to light.

Let us not destroy what we have gathered so far in our journey through time. If we start discouraging the abnormal, the idea will sink into our kids; though it will take time, the results will be acquired, slowly but surely. Let our conscience be our judge.

We must act now!
Good must overcome the evil,
Right must replace the wrong,
Normal must replace the abnormal.


Thursday, August 26, 2010

How to avoid propane gas barbeque grill burns and explosions

Dear doctor,

Sunday evening my Dad was going to barbeque dinner. There was a leak in the propane tank and there was a flash when he lit the barbeque that burned his arms, hands, legs, and face. His hair caught on fire, most of his beard and hair is now gone. Eyelashes and eyebrows are gone as well.

He was immediately taken to the ER where they gave him morphine for the pain. This made him vomit and his blood pressure dropped to 58/27.

They intubated him as a precautionary measure and his blood pressure was stabilized. They then moved him to a burn unit in a hospital in SF. After examining him that night, they said that most of his burns are 1st and 2nd degree. They extubated him late Monday morning and lifted his diet restrictions. Their main concern is infection at this point and his left leg. This area saw the worst damage and they are observing him for 2-3 days to see if he will need surgery.

I read your information on 2nd degree burns and feel that it was extremely well written and understandable for the lay person. Thank you so much for that.

The history with my Dad is that he had a staph infection 4 years ago and endocarditis. He had 50% damage to his heart at that time due to a previous heart attack and the damage from the infection. He had a quadruple bypass 10 years ago and as of the last appointment a month ago the bypasses (sp) are holding.

They did say that he is in the beginning stages of liver failure last month as well as congestive heart failure. He is 62 years old. His blood pressure has been holding steady after that initial drop and he said that he isn't in any pain right now.

He is an 8 hour drive away from me right now and they tell me that he is stable, but I can't help but feel that any surgery on him at this point would be very rough on him. Today is the second day of observation and I am planning on heading down to be with him either later today or tomorrow.

My question is, are my concerns warranted? I feel silly because they say he is stable and to not come, but my gut tells me otherwise. I'm sure by the time you read this I will already be there, I guess I just wanted some reassurance. I am worried that his previous health issues will make this current trauma worse.

Sorry to take up your time, I just found a lot of comfort in your posts and hoped you might have a thought or two.

Dear Ms. Lori,

Thank you very much for you question. I am sorry to hear that your father had a burn accident. We are sorry for the delay in replying because we have a lot of queries waiting. The loss of hair is not significant since one can have the hair burnt and lost from the heat though the skin may not be burnt.

Some patients react to morphine by vomiting and lowering of the blood pressure this usually gets controlled once corrective measures or medication are given. That he was intubated appears more of a prophylactic measure since they extubated him within 24 hours and he appears to be stable. Also the fact that the BBQ must likely have been in an open space means that inhalation injury to the lungs are unlikely.

Most of his burns were 1st and 2nd degree burns- as you said- 1st degree burns- should not be of any worry- it’s like sunburn and will heal quickly.

For the 2nd degree burn areas it will depends on whether they are superficial or deep. From what you describe and by the history I feel it may be a 2nd degree superficial burn which will heal, but we can’t be sure till we examine the burn itself.

In view of his medical illnesses and cardiac problems prophylactic antibiotic coverage should be discussed with his treating surgeon and may be a good idea.

A physician should also be involved to manage his medical problems. Finally the area of the deep burn if present may be small as I presume from your description.

Good timely analgesics should be helpful along with local dressings and care of the wound.

An ophthalmologist should also check his eyes to rule out any burn injury to the eye which is quite common in patients with face burns.

I hope he recovers quickly and that he may not need any surgery by God’s grace.

With best regards,

Dear doctor,
Thank you so much for your response. You are correct that the BBQ was in an open area. An update on my Dad.

The enzyme cream that they used to eat away at the dead tissue is working really well. They do not believe that surgery will be necessary for now. He is continuing with the debridement (sp) baths every day for now, which have become very painful for him, but they are working.

There has even been talk about discharge this weekend. We are so grateful that he is progressing so well. Seeing the other patients in the burn unit made me realize how lucky he was.
Thank you again for your response. Of course you can put this up on your website. The posts on there helped me at a time when I had no idea which way this would go. If our story can help someone else, please use it.

Thank you again.

Dear Ms Lori
Thank you very much for the reply and it is nice to know that dad is recovering. Burns can be very painful physically and psychologically depressing. Yet the support that friends and family can provide will help the patient overcome his burns and it is nice to know that your dad has a wonderful daughter like you to take care of him. Following the tips below may help to prevent burns in other propane barbecue grill users.

How to avoid propane barbeque grill burns
- from asktheburnsurgeon

Propane is highly inflammable gas which is commonly used as fuel for stoves, barbeques and others. LPG or liquefied petroleum gas is a mixture of propane and butane and is used commonly as cooking gas or vehicle fuel. Use of propane gas barbeque grills can result in burn or explosion injuries. Following simple safety precautions will help to avoid serious accidents.

1. Buy your gas tanks only from approved dealers who believe in high safety standards.

2. Make sure that all the valves and hoses are safe and undamaged and check them regularly.

3) Use propane tanks that have the ‘Overfill prevention device’ which will help to avoid leaks and accidents.

4) Using leak proof devices that detect leaks and shut off the gas supply can make BBQ grills extremely safe.

5) Keep the tanks upright and while transporting the tank secure it safely so that it doesn’t move or roll around and get damaged.

6) Use the barbeques with a minimum clearance at least 10 feet from any building- avoid rooftops, terraces or even balconies.

7) Barbequing within a closed space or home can result in carbon monoxide poisoning.

8) Avoid storing spare propane gas tanks indoors or near a store or grill.

9) Prevent children from being near the barbeque tanks and grill.

10) Make sure the regulator of your barbeque grill is not faulty lest the flame will be inadequate or an explosion can result with too much compressed gas.

11) Check the spark ignition regularly to see if it is generating a spark, if not the gas may be released without being ignited and can result in a fire or explosion.

12) Turn off the propane tank after use to avoid leak and accidents.

13) Water should be readily available nearby in case of a fire while using the grill.

Grill time now folks- and safe grilling.

Tuesday, July 13, 2010

24 tips from asktheburnsurgeon on-How to avoid road accidents and burns

Every year, thousands of people die from road accidents and burns. The sad fact is that most of these accidents can be avoided. Asktheburnsurgeon presents 24 tips on how to avoid road accidents and burns.

1. Drive only when you are well trained, confident and have a valid driving license.

2. Do not drive under the influence of alcohol, drugs or medication that will affect your driving. You are putting you life and the valuable lives of others at risk.

3. While driving avoid eating, drinking, smoking or using a cell phone.

4. Do not let children or passengers distract you while driving.

5. Drive carefully and follow the traffic rules.

6. Avoid over speeding- you tend to loose control and may cause an accident while over speeding. Reduce your speed especially during adverse weather conditions like sleet, snow, rain and ice. Drive carefully if the road is under repair.

7. Stick to your lane while driving, change lanes only when you want to take a new road.

8. Forget the ‘me first’ attitude and let others cross if needed.

9. Drive to reach your destination and not to race other cars – ‘racing is for race courses’.

10. Before changing lanes look in the side and rear mirrors. Don’t forget the ‘blind spot’ if your car has one, so turn your head and look if any cars are approaching.

11. Avoid being close to large sized vehicles like trailer vans and tractor- trailer rigs. The drivers of these vehicles have a poor vision due to the immense size of the vehicle and can cause serious accidents if you are nearby.

12. Honk when you are in danger or see a dangerous situation developing so that other drivers are also aware of it.

13. Do not carry inflammables in your car like petrol, turpentine or other chemicals which can convert your car into a potential bomb.

14. Never take your eyes off the road while driving –except when you have parked or stopped your vehicle.
15. Keep a ‘first aid’ kit in your car. Having a burnshield or other dressing, fire extinguisher, a large can of water, and a cell phone to call when in trouble can be of great help if you have an accident.

16. Be careful in parking lots- there is always someone crossing or coming out unexpectedly and that could be dangerous.

17 Never drive without your seatbelts on. Seatbelts prevent you from being thrown around or outside your vehicle and injuring yourself in case of an accident.

18. While driving at high permissible speeds, keep a safe distance from the vehicle in front. If the car behind is too close, put your hazard lights on to signal him about the ‘clear and imminent danger’.

19. Car radiator burns are common in hot summers. If you have to tinker with your hot radiator- be careful as you open the lid the hot water can splash and cause severe burns- wait till it cools down or get a car mechanic to repair your car.
20. Long drives can be boring and the monotony may put you to sleep. Have a driving partner who will replace you and prevent you from sleeping.

21. While driving, avoid being a navigator and checking maps and locations- doing both can lead to accidents.

22. Service your vehicle regularly; also see that the tires, breaks and windshield wipers are in good condition. Having a ‘flat tire’ or a ‘burst tire’ while driving can lead to serious accidents. Faulty breaks and non functional wipers can be disastrous.

23. Be careful at traffic signals- there is always someone passing through the yellow light or crossing the red light which could lead to a major accident. So watch out even if you have the green light.

24.                            Before you start driving
                                 Pray that you reach safely
                                After you reach your destination
                                Thank God for being merciful

Drive safely and avoid accidents and burns.
Asktheburnsurgeon +

Wednesday, June 2, 2010


Dear doctor,

One of my relatives who is in his 20th year is severely burnt (86 %) by a house fire 2 days ago and he is in Iraq now. His relatives are trying to bring him to UK for treatment and I think that it will not make any difference for his survival and may even make his condition worse by exposing him to pathogens in the plane and outside. I just want to ask you whether he has a chance of surviving or not please. He is also severely swollen now. Please answer me ASAP.
With best regards,
H Abdulla.

Dear Mr. Abdulla,

Thank you very much for the question. I am sorry that your relative suffered a major burn. You have raised quite a number of issues by your question which relatives of patients with major burns as well as burn professionals are often forced to ask. Let us consider in detail the factors that will influence the survival or outcome of burn management in patients with major burns.

Is age an important factor in healing or outcome of ''major burn'' patients?

Age in general, is an important factor in wound healing as well as healing of burn wounds. http://asktheburnsurgeon.blogspot.com/2010/04/part-ii-wound-healing-why-wounds-fail.html

1. As we grow old, the wound healing processes as well as the ability of our cells to multiply and form new cells are reduced.
2. As we grow older our immune mechanisms grow weaker and our ability to fight infection decreases

With age
Only wisdom profits
Rests are all losses

3. While the mind becomes wise with age we attract a lot of diseases- diabetes, hypertension, ischemic heart disease, atherosclerosis, venous insufficiencies etc. All these conditions hamper the healing of burn wounds as well as cause problems in the management of burn patients.

Percentage of Burn
Is the percentage of burn an important factor in the outcome (prognosis) of burn patients?

As we discussed in http://asktheburnsurgeon.blogspot.com/2009/11/dear-charulata-you-have-raised-three.html the total area of burn (percentage of burn) will show us if it is a minor, moderate or major burn. Major burn patients (>40% burn) have more problems and have more complications (morbidity)such as fluid resuscitation problems, more infection rates, as well as high death rate (mortality) as compared to patients with minor or moderate burns.

What is the Baux Index?

The Baux index is an old method which helps in a simple way to assess the prognosis (outcome) in burn patients.

Baux index = Age + % Burn

The higher the Baux index, the poorer the prognosis.

In recent times, this is not considered accurate, because the Baux index is based on limited number of variables: age and percentage of burn. With the vast advances in burn care that have taken place, even patients with high Baux index survive.

Depth of burn
Does the depth of the burn influence the outcome in a burn patient?

In patients with minor burns even if the burns are deep, there is adequate normal skin (unburnt area) on the patient’s body that is available for skin grafting (a surgical procedure in which the badly burnt skin is removed and replaced by normal skin taken from the patient’s own body). However when a large area of body has deep burns( like >80% ) then the availability of normal skin (<20%) for the purpose of skin grafting becomes less and this make the management of deep burns difficult and the outcome worse. For example if all the body is burnt except the head and face- one wouldn’t want to harvest skin grafts from the face so that the normal skin available for skin grafting is limited. If the patient has a major burn (>80%) but most of the burns are superficial: this is good news because the superficial burns will heal and only small area with deep burns will need skin grafting and adequate normal skin will be available for this procedure.

Associated disease
If a burn patient has any associated diseases, will it influence the outcome or prognosis?

When a burn patient is resuscitated he may need large volume of intravenous fluid in the resuscitation phase (first 48 hours) because

1. When the skin and tissues are burnt, toxins are released that make the blood vessels (capillaries) to leak fluid outside (into the interstitial spaces) which causes severe swelling or edema. If this fluid is not replaced, the patient will end up in shock and die. Sometimes the fluid requirement may be more than 20 liters in the first 24 hours of the burn. This explains why your relative appears all swollen up. But within 24 hrs (>8 hrs) the capillaries begin to regain their integrity and the leak is reduced.

For example Fluid requirement for a 80 kg man with 86% burns

According to Parkland formula- (4 X %burn X body weight) ml

80 X86X4= 27,520ml or 27.5 liters in the first 24 hours

Half this volume should be given in the first 8 hours=13,760

One eighth of this volume should be given per hour for first 8 hours and one sixteenth per hour in the next 16 hours

That means 1720 ml or 1.72 liters need to be given per hour in the first 8 hours

which is quite a lot of fluid!!!

And 860 ml per hour in the next 16 hours.

This requirement becomes higher as the percentage of burn and weight of the patient increases; only 4 is the constant in this formula.

Imagine now if this patient has a heart disease or has hypertension or renal disease or renal failure- and you try to give him this large volume of fluid, the patient will develop new complications from heart failure or pulmonary edema and may die not from burn but from disease he had before the burn. Since the body is unable to excrete (pass out) this large amount of fluid, patients with preexisting diseases are very delicate and need advanced care facilities to manage their major burn. This patient therefore needs to be managed by an experienced burn care team in an intensive care unit.

If the patient has diabetes then he is predisposed to infection as we discussed in http://asktheburnsurgeon.blogspot.com/2010/04/part-ii-wound-healing-why-wounds-fail.html

The burn itself reduces a patient’s immunity and exposes him to infection. Further the large amount of burnt dead skin (eschar) is a good bed for microorganisms to grow. These factors will increase the complications (morbidity) and make the management of a burn patient with diabetes difficult.

Facilities available at a burn centre
What about the facilities available at a burn center- does this influence the outcome treatment?

The management of burn patients with major burns (>40 %) is a complicated affair and the outcome of the patient depends greatly on the facilities available at the centre that he is admitted to. The burn surgeon who heads the team must first of all be an experienced surgeon. He must be cool, calm and composed and make mature decisions after discussion with his team of surgeons and burn care professionals. The burn surgeon and his team must not give up at any stage and must fight to the end to save the patients life: ethical discussions and decisions must be left to ethical committees.

Ego must be last
The patient first
For if there is no patient
What worth be a burn unit?

Smoke inhalation
Is the outcome affected if the patient has inhaled a lot of smoke?

Definitely when a fire breaks out and the person is exposed to a lot of smoke and fumes, he may suffer injury to his lungs in addition to the burn – an injury referred to as ‘smoke inhalation injury’. Now this burn patient has two problems

1. The burn itself
2. The lung injury from ‘smoke inhalation’.

Obviously his management will be more difficult as the burn surgeon has to focus on the burnt area as well as manage his lung injury and this patient may die from lung damage though the burn areas may all be healed.

For those who are wondering what a burn team is, a list of professionals that are needed to make a complete team is given below:

Burn unit director
Staff surgeons
Nurse manager
Nursing staff
Physical therapist
Occupational therapist
Physician extenders
Surgical assistant
Physician assistants
Nurse practitioners
Social workers
Respiratory therapist
Clinical psychologists

Besides this, the following specialist must be available for consultation: orthopedic surgery, cardiology neuro- surgery, cardiothoracic surgery, plastic surgery, ophthalmology, neurology, hematology, otorhinolaryngology, General surgery urology, pediatrics,, radiology, psychiatry, obstetrics/ gynecology, gastroenterology, anesthesiology, infectious disease, Nephrology and Pathology.

An advanced fully equipped burn intensive care unit along with an intensivist trained in burns must be available at all times to take care of the burn patient where the patient can be admitted, resuscitated, monitored with invasive and non invasive methods, intubated and mechanically ventilated in case of severe inhalation injury or otherwise, where massive dressing changes can be done under general anesthesia if needed, where emergency escharotomies, tracheotomies and other procedures can be carried out and where all infection control procedures are strictly enforced. The patient’s survival also depends on whether a number of other facilities are available as outlined below:

1. Why are blood and blood products important for survival of a patient with major burns?

Burn patients are potential candidates for blood transfusions from many causes and at different stages of treatment. Severe burns itself damages and destroys the skin and tissues and cause a fall in the hemoglobin. Burn surgery can itself lead to significant blood loss which will need to be replaced. The resuscitation phase in burn patients may need colloid administration; fresh frozen plasma and albumin may be needed in large quantities. Massive dressing changes in operated patients can cause blood loss. If the patient has severe septicemia (blood bone infection) and ends up in DIC (disseminated intravascular coagulation) this will again require a large amount of blood and blood products including platelets.

2. Why is the availability of newer antibiotics important?

Burn patients are potential candidates for severe infection since they have a lot of dead tissue and skin (eschar) which is a good bed for germs or microorganisms. In addition they have a reduced immunity from the massive burn. Death from septicemia is one of the major causes of mortality in burns. Burn patients suffer infection from variety of strong bugs with sometimes are resistant to many antibiotics (multi drug resistant organisms or MDRO) like

1. Methicillin resistant staphylococcus aureus (MRSA)
2. Vancomycin resistant organisms (VRO)
3. Extended spectrum beta- lactamase (ESBL)
4. acinobacter baumanii (Few strains are MDRO)

The availability of culture facilities and highly specific powerful antibiotics like vancomycin, tiecoplanin, meropenem, linezolid and others is crucial to the survival of a burn patient with infection.

Burn patients are also prone to fungal infections and availability of fungus culture facilities as well as newer anti fungal agents are essential to the survival of patients with major burns.

Why is nutrition an important factor in the prognosis or survival of burn patients?

Patients with major burns are in a catabolic phase and their survival will depend on the burn team’s effort to push the patient to an anabolic phase. The nutritionist will need to prepare feeding mixtures that are high in calories, proteins, fats and have minerals and vitamins as additives. If hyperalimentation (gut feeding) is not possible then parental nutrition (through intravenous lines) must be available. Thus we observe that the availability of blood, blood products, antibiotics, antifungal agents and nutritional support are crucial to the survival of patients with major burns.

Treatment options
What are the treatment options available at the centre to which the patient is admitted?
Even if all the factors that have been discussed are positive, and the patient survives through the resuscitation phase, overcome the inhalation injury, is protected for infection and sepsis; the final outcome will depend on whether the burn surgeon can cover the deep burnt areas with skin obtained from the patient itself. This is quite a difficult and daunting task in patients with major burns who have severe shortage of unburnt skin, but if we have God’s grace and the treatment options mentioned below, the patient can be saved:

1. Skin bank
2. Skin substitutes
3. Meek grafting
4. Skin culture (Keratinocyte culture)

Each of these options will need to be discussed in detail in a future article.

So Mr. Hassan the survival of your relative will depend on all the factors that have been discussed. Managing a patient with major burn is a complex affair and though all these factors may be favorable to the patient, if the treatment options are not available for your patient in Iraq, then shifting him to a advanced burn care facility as in UK will be beneficial and can save the life of your relative. Unfortunately, patients in most of the underdeveloped and developing countries face the same problem and their relatives are often in a dilemma wondering where they should shift the patient to get better treatment. As for acquiring infection during the travel, I don’t think this should cause any worry since this usually does not happen if adequate precautions are taken and travel protocols are observed.

The field of burns may not be attractive to many, but for those who toil and focus on the burn patient, it is worthwhile. It is sad that most of the facilities we have discussed are not available to a large number people around the globe, especially in underdeveloped and developing countries and burn patients whose lives can be saved die a painful and miserable death. We at asktheburnsurgeon hope that this trend will change: more surgeons will join this stream, more research and funding will come in, more governments will take burn as a serious issue and the right of a burn patient to get proper treatment and survive is recognized in all countries.

May God help us in this endeavor!

With best regards

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