BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme no. 8 - Childhood Burns
RADIO 4
TUESDAY 23/10/07 2100-2130
PRESENTER:
MARK PORTER
CONTRIBUTORS:
CLARE THOMAS
REMO PAPPINI
ELAINE YATES
DANNIE WINKER
GUS MCGROUTHER
PRODUCER:
PAULA McGRATH
NOT CHECKED AS BROADCAST
CLIP
I got a phone call from his mother, obviously in a mad panic, I couldn't actually understand every word she was saying. I rushed to his mum's house and discovered Ben in the bath being treated with freezing cold water, which turned into steam and it was quite a shock, yeah, quite breathtaking. The medical people were already informed before I'd actually got to the house. Fire engines, helicopters - just about everybody turned up at the same time. And then it was one just mad panic getting him out the bath and then getting him into the ambulance basically. So I was prepared to carry him down the stairs on me own and the paramedic says no, we'll get the proper facilities and we'll do it.
PORTER
A father talking about a day I am sure he'll never forget. The day in early September when his 13-year-old son Ben sustained severe burns following an accident with a bonfire.
Ben was admitted to nearby Birmingham Children's Hospital where, fortunately for him, there is a dedicated paediatric burns unit - one of only a handful of such units throughout the NHS.
The centre is purpose built, has only recently opened and is the perfect place to base today's programme on burns. Lead nurse Clare Thomas showed me around.
Well I mean the first impression is it's what you'd want every paediatric ward to look like really - it's brightly coloured, lots of murals on the walls. But there's something unusual in the floor here - there's a weigh bridge - why have you got a weigh bridge?
THOMAS
Weigh bridge is here because for burns patients it's extremely important that we know how much they weigh, not only then to give the correct medication but also to estimate how much fluid they will need because obviously a burns patient loses fluid when they have that injury, so it's really important that we know how much they weigh.
PORTER
So as every child comes in here, presumably many of them from accident and emergency downstairs, they're weighed on the trolley?
THOMAS
On the trolley or on their bed or their parents holding them and then we hold their parents afterwards so that then we get an accurate weight of what they are, whatever's most comfortable for the child.
PORTER
And where are these children coming from - I said from A&E, presumably most of them come from within this hospital but are you taking children from other hospitals as well?
THOMAS
The burns centre covers the West Midlands, so that's any hospital within the West Midlands catchment area. But as it's a burns centre we do take patients from all over the UK, if there's no beds elsewhere in another burns centre then we would accept patients from there because it's a specialised unit so they need specialised care.
PORTER
And as an overview what can you offer the children here that they might not get in your average district hospital?
THOMAS
Obviously there's the specialities - so there's special doctors and plastic and burn surgeons that look after them, there's special anaesthetists that if they go to theatre, especially being in a children's hospital and the specialist nurses that we've done appropriate courses in order to look after them. And then from an after care point of view there's special physiotherapists and occupational therapists.
PORTER
When you're full how many beds do you have in the unit here?
THOMAS
We have nine beds on the unit but we only currently use six.
PORTER
And we're just approaching the open part of the ward here, which is a sort of circular ward, the beds on the outside of the circle, with fantastic views out of the window by the look of it.
THOMAS
Yes, the children were involved in designing the unit, they've circled in the floor from a physiotherapy point of view, they like looking over the main road outside counting the cars. So we do have an area that's open - this space - there's lots of - the beds aren't close together, parents are able to stay with their child, they're able to play in the middle of the ward. But there are also cubicles on the ward as well because if the patient has a major burn or is at risk from getting an infection then those children will need to be in a cubicle.
PORTER
Last year nearly 40,000 children were seen in accident and emergency departments with burns or scalds, and inquisitive toddlers are at particular risk with the under fives accounting for nearly half of all admissions. The initial challenges facing the team at the centre at Birmingham are much the same whatever the age of the casualty. Remo Pappini is one of the consultant plastics and burns surgeons.
PAPPINI
The skin has a number of functions - protection from the environment, protection from infection, keeps the water in - and all of those functions are damaged when you have a burn. Quite apart from the long term problems with appearance, the skin is the organ which we interact with each other if you like, express emotion and so forth. In the first instance what happens is that the top layer of the skin comes off, with the very superficial burns, for instance a hot water scald, you get blistering which is the very top surface layer, if you like. The skin has a number of layers. And then with the deeper burns then those other layers, the deeper layers of the skin, are injured as well.
PORTER
And how do you actually go about grading burns, because obviously you hear people talking about first degree and secondary - is that the classification you still use?
PAPPINI
No, we tend to talk about superficial and deep burns and we talk about superficial partial thickness and then we talk about mid dermal, deep dermal and that really gives you an idea of what layer of the skin is injured.
PORTER
And is that about exposure - duration of exposure - or is it about how the thing was because presumably ...?
PAPPINI
Well it's a function of both actually, it's the intensity of the burning agent and the duration of the contact with the skin really.
PORTER
So what sort of things might cause the most minor burns, presumably we're talking hot water and ...
PAPPINI
Yes I mean I suppose the most superficial burn you can get would be a sunburn, that'll be a - it just injures the epidermis and very often you don't even get even blistering, you just get a lot of redness and I'm sure most of your listeners will have experienced that at some stage. And then of course then you get scalds, where the dermis, which is the next layer down, is injured - the top layer of it anyway - depending on how long the contact time is. So then you get blistering and that say a superficial partial thickness injury. And then a deep dermal or deep partial thickness injury would involve a thicker part of the dermis and those injuries take much, much longer to heal and they leave worst scars. And then full thickness injury involves the whole thickness of the skin - that's the epidermis and the dermis right the way down to the subcutaneous fat. And those injuries will never heal from underneath because there's nothing left to heal from except the intact skin at the sides. And of course if that was untreated the dead layer would eventually separate and then it has to heal in from the edges and as it does that the body tries to reduce the amount of work it's doing, it contracts the wound, so you get a very puckered horrible scar, which takes months and months and months to heal. Those are the type of injuries that we would almost certainly graft.
PORTER
What about the size of the burn as well?
PAPPINI
We work on percentages of the body surface area. With children the head makes up a very much greater proportion of the total body surface area then it does in an adult. It's something in the region of 18% and you lose a percentage to - from the head for each year of life and gain half a percentage on each leg, if you like, so eventually by the time you get to about five or six you're almost up to adult percentage.
PORTER
This classification of burns is something that can be done in the A&E setting or here in the centre when the patient first arrives. And why is it important to look at the level of thickness of the burn and how much of the body is involved, how does that affect your management initially?
PAPPINI
Right, well coming back to the functions of the skin that are injured, obviously you get an increased water loss from a burn. In addition to that with - particularly with the larger burns you have - a leak develops underneath in the blood vessels supplying the skin and the soft tissues, they become very much more leaky to fluids, so that the fluid from the circulation leaks out into the tissues because of this intense inflammatory response that goes on. And in very large burns, those over 25-30%, that leak occurs all over the body and if we didn't correct it then you would lose all the fluid, if you like, that's circulating in your veins would leak out into the tissues and you would go into heart failure, you would go into shock. So we have to replace that fluid in order to preserve organ function.
PORTER
Remo Pappini, just one member of the multidisciplinary team that looks after patients here at the burns centre at Birmingham Children's Hospital. Elaine Yates is one of the physiotherapists.
YATES
We get involved from the first day of admission. Physios have a few roles with burns patients. They treat patients with inhalation injuries, so we help to clear lungs of patients that have had smoke inhalation or burn injuries to their lungs. So we help with their breathing to make that easier for them. But we also help with their mobility as well. So we'll get involved from day one to help them mobilise. Or if they're in ITU and unable to mobilise then we will help with their joint range of movement and to make sure that their skin stays nice and flexible as it heals.
PORTER
So your particular concerns would be what?
YATES
Well mostly we would be concerned if they have them over joints and especially over the flexion size of the joints, so if - on the inside of the elbow ...
PORTER
Back of the knee.
YATES
Back of the knee - that type of area - because if the skin contracts over there obviously it's going to limit joint range of movement. Over the foot's quite a horrible injury to have as well. Under the armpit is not a very nice injury to have because obviously it's going to get tight under the armpit and they're not going to want to lift their arm up and if they're not going to lift their arm up then their skin's going to get really tight and contracted.
PORTER
But while the nursing and medical staff are looking at dressing the wound and preventing injury etc., what can you do as physio to reduce the likelihood of that troublesome scarring?
YATES
Okay, so we teach - well first of all we make sure that the patient if they're resting and if they're unable to mobilise that their joint is in a good position so that the skin in the burned area is nice and stretched.
PORTER
So that basically would be - if it was on the inside of the arm that would be a straight arm?
YATES
Yes, well fairly straight arm, straight leg. Then what we would do is would teach them to do stretches and exercises themselves to maintain the joint range of movement, to maintain the fluid within the joint and the tissue around the joint to make sure that there's no contractures.
PORTER
Are they painful those sorts of exercises?
YATES
Yes. Unfortunately it's not a pleasant thing to do and it's difficult for the patients because they're frightened because they've had an injury, they're frightened because they know it's going to hurt. So generally we have to make sure that they've got good pain relief on board.
PORTER
And how often - I mean say I had an injury to the inside of my arm, quite a nasty one - how often might I have to do those stretching exercises set by my physio?
YATES
Well I mean you know two or three times a day, every time maybe that they moisturise their joint or their skin where they've had their injury, probably we recommend that they do it then. But having said that if they're off school, if they're in hospital, there's no reason why they shouldn't be doing it a lot more regularly.
BEN
I was with my mate walking through big fields, rugby fields, and I saw smoke so we both ran up to it and it exploded on to me. Trousers caught alight and were on fire, so I had to stop, drop and roll, like I was taught to, and then took them off - took my trainers off, took the quarter lengths off, threw the quarter lengths, picked up my trainers and ran home.
PORTER
The incredible story of 13-year-old rugby fan Ben. Now one of Elaine Yates's patients, Ben ran home with his right leg smouldering after a bonfire exploded setting fire to his trousers.
BEN
I ran into - jumped into the bath of cold water and then waited for the paramedic. And then turned out to be - there was about 20 odd people outside.
PORTER
So you knew to get your clothes off immediately, you rolled on the floor, you knew how to do that and when you got back to the house you knew that you should try and cool - how did you know all of that?
BEN
Common sense. I just - been taught because I had a first aid course going on when I was doing it so ...
PORTER
Was it pretty painful at the time?
BEN
No, I just concentrated getting home.
PORTER
When you got home and your mother saw you with - well your leg was smoking presumably was it?
BEN
Yes, it were black on me legs because my quarter lengths had got stuck to it.
PORTER
So next time you're out and about on a walk with your friend and you see a fire what are you going to do?
BEN
Leave it and go and call the fire brigade.
PORTER
So this all happened about four weeks ago and you're walking around now, what was it like in the first few days after you'd done it?
BEN
Ouch!
PORTER
Very painful.
BEN
Yeah. And then I got used to it because she was doing all the exercises on me ...
PORTER
What Elaine the physio. And what was Elaine making you do?
BEN
Just bending my knees and everything and getting it straight and sitting down and even if I didn't want to she made me. So it worked.
PORTER
And presumably every time you straightened your leg it pulled on the burn did it?
BEN
Yeah and the scabs.
PORTER
Are you going to be able to go back to playing rugby with that leg?
BEN
Yeah hopefully but not this season, next season.
PORTER
So being a sportsman you're taking your physiotherapy seriously are you?
BEN
Yeah, I have to.
PORTER
Elaine, is Ben doing what he's told?
YATES
Umm I don't know whether he's doing quite as much as maybe he's been told but ...
PORTER
That means you're not then.
YATES
But he is doing very well. Obviously when Ben first had his injury he didn't want to move at all and was very reluctant to move his ankles or his knees because the burns obviously go round - they're at the back of his calf so any movement of his knee is going to pull. And the donor site for his skin graft is on his thigh, so again that's going to pull with any hip or knee movement as well. So he was very reluctant to move his legs but we have given him stretches to do to try and overcome this and also we've treated him during his change of dressings, so when the bandages are off we've taken the opportunity to move his ankles and his knees as much as possible to get the fluid going in the joint and to really stretch the tissue out and that seems to have really helped and it actually took him quite a few weeks to get back to mobilising and he's still walking fairly slowly and it will take him a while before he can run and participate in sport again. But he's really improved which is really good and actually I think probably what I'd like to do with him soon is to get him on the bike, to get him on a static bike, so that he can really, really get that knee going and get some repetitive stretching of his soft tissue.
PORTER
Ben did all the right things. He got himself clear of the fire, tore off his smouldering tracksuit bottoms and ran for home where his mother put his leg in the bath to cool it down. All good basic first aid, as is keeping the burn or scald clean, and putting nothing on it until it has been seen by a doctor or nurse. If you need to cover a burn or scald before getting it checked, then wrap the affected area in Clingfilm.
Now, physio Elaine Yates wasn't the only person keeping a close eye on Ben. Dannie Winker is one of the occupational therapists at the centre.
WINKER
I get involved working quite heavily with the physios in range of movement and maintaining movement. In intensive care we do a lot of splinting, so that's actually to maintain the range sort of as a prolonged stretch really and I get a lot involved in the scar management when they go home, so looking at addressing really the visible appearance of their scars and also stopping those scars from restricting their movement later on in life.
PORTER
Now we're sitting next to a board here - and if you were in a surf shop they look like mini wetsuits almost for children, I mean very brightly coloured - but these are something very different, they're pressure garments I presume, that have come on a bit since I was working in hospital when they were all rather nasty sort of flesh coloured, these are quite exciting. What's the idea of these and how do they work?
WINKER
Pressure garments are made out of - this material here's called Powernet and sort of almost like a lycra stretchy material, it's fairly breathable because you can see it's got a few sort of very small holes in so the skin actually can breathe through them. And the idea is when you've had a burn you generally, if it's been grafted, will get a hypertrophic scar as a result from that.
PORTER
That's a thick prominent scar.
WINKER
It's a scar that gets almost - looks very lumpy and looks very red. And the reason for that is you've got a lot of blood and over production of collagen under the skin that pushes the skin up and makes it looks very lumpy and very, very aggressively red. And all pressure garments do is they press, literally, on top of the skin and they squash those collagen bundles to become flat and they also squash the blood that causes the redness out of them.
PORTER
So at what stage - I mean looking at here we've got little tiny - looks like a baby's or a toddler's booty here, we've got a little wrist splint up there, pair of shorts - at what stage of the burn management would they start to wear these?
WINKER
As soon as they're out of dressings. So once they've had - they've got no bandages on anymore. Generally we leave them, probably about two weeks after their bandages have come off - just to let the skin toughen up a bit - because obviously they're going directly on the skin and what we don't want is them to wear the skin away again really.
PORTER
And is it just for children who've had grafts or would you use them for other burns as well?
WINKER
We'd use them for anyone, I mean our scar management is for burns who've had grafts but sometimes children who haven't had a graft scar quite badly, so it's not only for children who've had grafts, it's for anybody whose scars are quite bad really.
PORTER
And how long would they be wearing an outfit like this for?
WINKER
Generally a year to 15 months sometimes, so it's quite a commitment and 24 hours a day.
PORTER
Yeah but that - it is quite a commitment but actually it's made a lot easier by the fact that they look quite good don't they, it must make a lot of difference.
WINKER
They look quite cool, I mean some of the kids, especially the boys, tend to go for the black with the blue and you can sell it to them that they're Ninjas or it's a new Power Range - they can be a black Power Ranger. And the girls often like it because it's almost like leotards and princesses and things like that. So you know it's a lot better than it used to be when it was purely skin coloured.
PORTER
And what happens once they're out of the garments, do you have an ongoing relationship with them after that?
WINKER
Well yes I mean children grow unfortunately and often scars that extend over any joints provide problems as they grow. So they will often come back, maybe two or three after I last saw them for further surgery and they need again further grafting and so will go into pressure garments again.
PORTER
Occupational therapist Dannie Winker. I am Dr Mark Porter and you are listening to a Case Notes special on burns, based at the new paediatric burn centre at Birmingham Children's Hospital.
There could be few things more distressing for a parent than having to deal with a badly burned child. And the injuries often look worse after they have been in hospital for a day or two. Burns surgeon Remo Pappini.
PAPPINI
When they first come in sometimes the burns may not look as frightening, although obviously losing the top layer of the skin can be a bit frightening to some parents, they think it's wrong that they've taken the clothes off because the skin's come away. And it would have done anyway and you have to explain that that's fine. And then as they get fluid - we're replacing the fluid they're losing of course they're swelling up, so I always tell the patients that have got facial burns, look by tomorrow morning he or she's going to look like the Michelin man and you have to prepare them for that. And of course there's a lot of exudate that comes off the surface and then - potentially it could dry on the surface and they look - they don't look very nice.
PORTER
They look worse.
PAPPINI
They look much worse and you have to say look don't worry in 48 hours it will start to go down and they'll start to look more normal and yes they will be able to open their eyes and be able to see and things.
PORTER
Are children better at healing than adults in that respect, do they heal more quickly? You often hear that said but for many other things, does it apply to burns?
PAPPINI
To a certain extent yes, unfortunately children are much more prone to what's called hypertrophic scarring, certainly the under fives it occurs in something like 60%. So ...
PORTER
That's an over compensation yeah.
PAPPINI
Exactly, that's where the scars actually become very florid and very red and raised. So yes they heal - they can potentially heal quicker but they can also produce very florid scars.
PORTER
So what would make you think that you need to intervene as a surgeon?
PAPPINI
If we thought that - well we may need to intervene in the first case when patients come in if they've got - if they have contaminated wounds. It doesn't sound like the surgery that you'd expect but we take them to theatre and we literally scrub them to get contaminants off the wound and to better assess them.
PORTER
Under anaesthetic of course, something you couldn't do in a normal ward setting.
PAPPINI
We would never, never do that without given them an anaesthetic. And then some patients have very deep burns that are around a limb or the chest, which can restrict breathing round the chest or can restrict the circulation. So they actually need to be divided to allow the circulation to continue to the distil limb, you know, when the limb swells up. So that's the early type of surgery. And then what we may do is we may remove some of the burned tissue, particularly with the larger burns the quicker we get all of the burn off the more chance they have of surviving the injury. What's made it much easier for us to do that now is the increasing availability now of skin substitutes, because getting the burn off was not necessarily an issue, although it has to be done in a safe manner and as quickly as possible, but we now need to be able to cover the wounds with something.
PORTER
When you say taking the burn off what you're actually doing is stripping out the burnt tissue completely.
PAPPINI
That's correct. And then of course you've got to replace it with something and obviously the ideal thing would be the patient's own skin. In a very large burn they don't have sufficient unburned skin to do that, so you have to use a skin substitute of some sort. We have our own skin culture laboratory here in Birmingham, we're one of only three skin culture laboratories in the countries, and we can grow some of the patient's own skin cells, so that helps us to supplement our wound cover.
PORTER
That sounds like a lengthy process, you're taking a sample from them is what you're saying and then putting it in - being very clever with it in the lab and actually getting it to divide and grow into skin?
PAPPINI
Yes, except that now - nowadays we don't tend to use skin in sheets, if you like. When this technique was first brought into play in the 1980s they used to take three to four weeks to grow sheets of skin in a dish. What we do now is we spray the skin cells on to the wound and allow the wound to act as a culture medium, if you like, to grow the rest of the skin. And that means that the skin cells are available much earlier, usually after about 7 to 10 days.
PORTER
Remo Pappini.
Researchers are trying to understand more about the body's response to burns in an attempt to discover ways of accelerating healing and reducing scarring. Gus McGrouther is Professor of Plastic and Reconstructive Surgery at the University of Manchester and joint director of research at the charity Restore.
MCGROUTHER
I think we've always thought that the damage from a burn is caused by heat and that's true but the heat goes away fairly quickly but the damage continues. And the damage is caused by the body's own inflammatory response. The same sort of thing you get if you drop a heavy weight on your toe - it's red and painful and sore and that happens with a burn. So in fact much of the tissue damage is actually caused by inflammation.
PORTER
Gus, can the body actually differentiate between different types of injury? Does it know, for instance, whether it's been burnt or cut?
MCGROUTHER
I think the differences in response to these insults are really in gradation, rather than in kind. The body really is a little bit silly - it really has one way of responding. I think it's the way we've evolved. In nature if you don't heal before the next meal you are the next meal. And so we haven't got an evolutionary response to burns.
PORTER
So the healing process isn't just a solution, it's actually part of the problem too?
MCGROUTHER
Yes very much, I think the body reacts very vigorously to a burn and we're beginning to think now that you can actually lessen the damage by slowing the body's response down.
PORTER
So with a better understanding of that response could we actually manipulate it?
MCGROUTHER
The response initially is an inflammation and then it's followed by the healing response and the charity Restore has done a lot of work on this and what they've shown is that you start off by getting an inflammatory response and then the healing is done not just by the local tissues, we've always thought if you damage your skin the skin heals, it does to some extent but it depends very much on recruiting stem cells from other parts of your body. We have within our body stem cells, they're in our bone marrow, they're in peripheral tissues - we have some in the skin, we have them in the hair follicles - and the body recruits these stem cells from other sites to do the healing.
PORTER
Okay but how can we influence the whole process to improve healing?
MCGROUTHER
We have the potential to manipulate the whole process first of all by dampening inflammation and then by manipulating the stem cells in the right sort of way. We think that the stem cells are important in healing and it may be that in fact that they at a certain stage contribute to the wound healing but at a later stage they may be contributing to scarring. So it may be that if we can understand exactly what's happening with these stem cells, because as the stem cells arrive in the wound they almost certainly change their nature and become different sorts of cells. So it may be that altering the timing of when they arrive could be quite significant in determining the final outcome.
PORTER
The ultimate aim presumably being to reduce scarring?
MCGROUTHER
What we need to do is to get a much better form of healing. We know that primitive creatures like, for example, a salamander, can re-grow whole parts of its body, it can re-grow a limb, a tadpole can re-grow a tail. We've got the same sort of genetic mechanism but then all of our immune mechanisms on top of that seem to stop it happening. And I think at some point in the future we'll have a potential to be able to get much better quality healing.
PORTER
Professor Gus McGrouther.
Back at the burns centre in Birmingham Children's Hospital, Ben has seen Elaine the physio and is off home. Before he goes, I ask his father Tim what impact he thinks the bonfire accident will have on the rest of Ben's life?
TIM
It's the mental - what the scarring's going to do and all the rest of it, name calling and all the rest of it.
PORTER
Were you worried that his mates at school might tease him about the fact that he's got scars on his leg?
TIM
He will get some kind of teasing later on, it just depends how he handles it, that's where your character's got to kick in.
PORTER
He seems a pretty sparky lad, it doesn't seem to have knocked him back. What was he like in the first few days afterwards?
TIM
He's been pretty chirpy all the way through to be fair. The initial shock I think has already hit him, I'm not sure. Maybe when he gets the bandages off and is back to normality is probably when the shock will actually kick in, the actual reality of it all.
PORTER
And he's banned from stomping round in bonfires now is he?
TIM
Well he's certainly not going out on November 5th.
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