Rehabilitating burn patients

CEBU, Philippines - As much as the Marvel’s Human Torch have  made spontaneous human combustion look cool, suffering from burns is not cool at all, nor does it make one hot, although it does, literally.

When I did my internship at St. Luke’s Medical Center, one of the patients that I was privileged to handle was a burn patient.

He was a seaman working on an oil tanker. Unfortunately, he met an accident which burned most of his body except perhaps his perineum (genitalia area). During his stay at the hospital, he was a regular at the clinic. We used to fetch him from his room and then bring him to the clinic where we then do a series of procedures aimed at wound care and for the prevention of what we call contractures.

You see, aside from the plastic surgeon or the general physician who’ll primarily treat a patient with major burns, other health care professionals also come into play for the patient’s total recovery.

In the Philippines, however, burn rehabilitation still has to take root, as burn treatment is still limited to the treatment of the wound. With regards to the limitations and disabilities that results from the condition, submission is the general attitude.

Late January, Rep. Jocelyn Sy-Limkaichong (Negros Oriental) and Dr. Liland Zoila B. Estacion brought to Negros Oriental Canadian specialist doctors and health workers to give out free medical, surgical, and dental services.

One of the patients treated was a woman in her early 20’s. The patient suffered from a major burn when she was 7 or 8 years old. The only treatment that she received was for her wounds.

When her wounds finally healed, she ended up with her arms fused to her body. One can only imagine the misery that this young woman suffered during her childhood and teenage years. Would there have been a difference had she undergone rehabilitation therapy?

Different causes of burns

In order to understand the importance of burn rehabilitation, one must first understand the causes of burn and the risk that they pose.

Heat is the most common cause of burns. It results when our skin comes in direct contact with the flame, a hot surface, or hot liquid.

Chemicals are another cause of burns, although incidence of chemical burns is rare. This happens when one’s skin is exposed to harsh chemicals. The extent of the burn is dependent on the strength of the chemical and the duration when the chemical was in contact with the skin.

Electrical burns are comparable to that of an iceberg. One may not see anything on the surface, but deep within, the body’s tissues are in disarray. That is why patients with electrical burns are at risk of heart or brain damage if the current pass near these organs.

Last are burns due to exposure to radiation rays. Example would be sunburn (which is caused by UV radiation) and microwave burns.

The complications that usually result from burns would include infection, which is the leading cause of death; pulmonary complications that include smoke inhalation, pneumonia (which accounts for over one third of the deaths of burn patients) and restrictive lung disease secondary to burns over the trunk; metabolic complications, that would result in rapid decrease in body weight and decreased energy stores; and lastly, cardiac and circulatory complications due to fluid loss following a serious burn.

Treatment

Minor burns are easy to treat.

Immediate care would include the removal of the body part from the agent causing the burn. This includes neutralizing chemicals causing the burn by simply washing it off with water. Icing helps decrease the inflammation and pain can be minimized with pain medications.

For major burns affecting the dermal layer of the skin (that’s the second layer of the skin that contains the hair follicle, nerve endings, and sweat glands), an issue to be addressed is dehydration. Since burn patients lose a lot of fluid, it is advisable that he drinks plenty of water or be administered with intravenous fluid replacement. The patient’s nutritional status should also be assessed since burns cause metabolic changes in the body.

Wound care, must also be given considerable attention. In extreme cases, skin grafting may be needed. This is performed by a plastic surgeon.

Usually, dead tissues, called eschar, are removed. This promotes healing by encouraging the healthy tissues to regenerate. Removal of the eschar is done by soaking the patient in a whirlpool tub filled with water mixed with disinfectant. Dry debridement can also be performed. This would involve the use of surgical scissors, scalpel, or forceps to manually remove the eschar.

The role of physical therapy

As the wound heals, scars would form. Scars are contracted tissues that are less flexible than normal skin tissue causing movement limitations. This contracting of the tissue also happens when an extremity is immobilized for a long period of time, which is what usually happens with burn patients.

Scar tissue formation should be encouraged to form in a stretched position, opposite that of the position that the extremity tends to assume (mostly to reduce the pain).

Example, in order to relieve the pain of a patient with a burned shoulder, the patient would usually assume a position with the shoulder rotated inwards and close to the body. This, however, should be discouraged, and the shoulder positioned away from the body with palms facing up. A splint, aptly called airplane splint, is used to maintain the shoulder in this position. The elbow, wrist, fingers, hip, knees, and ankle also have their own positions to maintain.

However, the best way to prevent limitations brought about by the scar tissue is to ask the patient to move his or her extremity every two hours within 24 hours of hospital admission. If the patient is unable to do this actively, assistance from the therapist would suffice.

Also, if the trunk is affected, breathing can become difficult as scar formation progresses. That is why exercises promoting deep breathing and chest expansion are recommended.

Of course all of these must be performed by a licensed physical therapist so as to avoid further injuries to the patient.

For one who suffered from a major burn, the burden of the disability that comes with the condition need not be experienced. With proper therapy and through a multidisciplinary approach to treatment, every aspect of the patient’s recovery can be addressed, including how he or she can cope with the challenges that the concurrent disability may pose.

Visit the author’s blog at http://tribong-upos.xanga.com. Source: Soothing the Burn by Rebecca Franzi, MD, et. al., Advance for Physical Therapy and Rehab Medicine, vol. 15, issue 6, p. 25; and Physical Rehabilitation (5th ed) by O’Sullivan SB and Schmitz TJ. (FREEMAN)