|KNOW YOUR BURN UNIT
|Year : 2013 | Volume
| Issue : 1 | Page : 14-16
The burn unit: L T M medical college and general hospital
Madhuri Gore, Meena Kumar
Department of Surgery, L T M Medical College and Hospital, Sion, Mumbai, Maharashtra, India
|Date of Web Publication||22-Nov-2013|
Shreyas, 20, Udayagiri CHS, V. N. Purav Marg, Deonar, Mumbai - 400 088, Maharashtra
Source of Support: None, Conflict of Interest: None
The burn unit at Lokmanya Tilak Municipal Medical College and General Hospital was established in 1983 and since then continues to be an integral part of the Department of General Surgery. It has been recognized as the center of excellence in western region of India by The Association of American Physicians from India and it has several firsts to its credit and has undergone some metamorphosis over the years. The focus has always been to provide comprehensive, quality-of-care to the burn victims.
Keywords: Burn team, burn unit, design, progress, training
|How to cite this article:|
Gore M, Kumar M. The burn unit: L T M medical college and general hospital. Indian J Burns 2013;21:14-6
| Introduction|| |
The need to have a dedicated unit for providing comprehensive care to the burnt patients was first perceived in 1983 by the then Head of the Department of Surgery, Dr. S.V. Nadkarni. He procured and refurbished an available space in the hospital and established the burn unit (the first amongst the three municipal medical colleges in Mumbai) with 16 beds. This is one of the very few units in our country that is being spearheaded by Department of General Surgery. Over the years, it has emerged as one of the best centers in the country and has gained reputation for the research and innovations and the quality-of-care provided at the burn unit. This article is an attempt to share the process of evolution that has occurred at the burn unit over last 30 years.
| The Initial Period|| |
The burn unit has a central open space [Figure 1] with nurses' station and is surrounded by the patient rooms. Initially, the 16 bedded burn unit had seven pediatric beds accommodated in two rooms, five isolation rooms and four beds in shared rooms for adult patients. The unit had a dressing room with facility to administer sedation during the dressing changes. A pantry and a bathing area with toilet facility completed the unit.
The admission to the burn unit was restricted to children and adult females with burn extent up to 40% of total body surface area (TBSA). All males and females with larger than 40% of TBSA burns were admitted in the general wards. This policy was based on the facts that females far outnumbered the males and patients with more than 40% of TBSA burns almost always succumbed to their injuries. The average number of children with burns was 250 every year and all the seven beds were occupied most of the times. Patients were looked after by respective general surgical unit and received treatment according to the practice followed by that unit. In 1985, Dr. Madhuri Gore was instructed to take the administrative responsibility of the burn unit. However, the patient care continued under the guidance of respective unit chiefs and so it was not possible to implement any specific protocol. The burn surgeries were scheduled last on the operation list of respective unit and were often postponed due to lack of time.
| The Change|| |
In 1989, Dr. S.V. Nadkarni (who was then The Dean of the Institution) allotted dedicated time in the operation theatre for the performance of burn surgeries 3 times a week. This brought about a major change. The complete care of all the patients was now the responsibility of the burn team under the leadership of Dr. Madhuri Gore. The burn team consisted of Dr. Gore, Microbiologist Dr. Pandit, a surgical assistant professor, three burn residents and the nursing and labor staff of the unit. A physiotherapist, an occupational therapist, a dietician and a medical social worker complete the team until today. The anesthetist, physician and pediatrician as well as obstetrician join the team as and when required. Detailed patient evaluation by the whole team once a week provides the opportunity to interact and plan the future course of treatment. These discussions help sharing of ideas and suggestions and have resulted in many innovations in every aspect of burn care. Development of a cohesive and committed team has improved the quality-of-care and the patient outcome. Another activity that has augmented the patient care to a great extent is regular interaction between the chief of burns and the nursing staff. This helps in educating and encouraging this very valuable group to become proactive in patient management and to share their observations and suggestions. Development of infection control policy, antibiotic protocol, nutritional support, timely surgeries - all have contributed to the consistent improvement in the survival of patients. This further encourages the team to achieve more.
| Infrastructure Changes|| |
Over next 10 years, some structural changes were made in the burn unit. As the number of children with burns decreased from 250/year to about 100/year, the number of pediatric beds was reduced to three and the total number of beds to 14. The walls of all the rooms and rest of the unit were tiled from floor to ceiling. This made the cleaning more effective and improved infection control. The bathing area was suitably modified to facilitate the bathing process. Procurement of vacuum cleaner and washing machine made these jobs easier and better. Installation of the air handling unit with 14-16 air changes/h, humidity of 55% and temperature of 28C and movement of air from rooms to central hall was possible due to a generous donation. The supervision of efficacy and frequency of filter cleaning is the responsibility of the sister in charge of the unit. This installation has augmented the infection control remarkably. Structural alterations have also been incorporated to permit unidirectional movement of soiled linen and dressing material.
Each room is equipped with intensive care bed with motorized air mattress, central oxygen supply and central suction equipment. Procurement of infusion pumps, monitors and ventilators has made care of critically ill-patients possible. Hence, the burn unit is now the burn intensive care area. A room in the male surgical general ward has been identified as male burn room and is equipped with appropriate gadgets for four patients. The total number of dedicated burn beds is now 24-14 in burn unit, six in female general ward and four in male general ward.
| Admission Policy|| |
Initially, only the patients who were admitted in the burn unit were treated by the burn team. However since 1995, all patients with burn injury in the burn unit as well as in general wards are being managed by the burn team. As the survival probability improved from lethal area 50 of 35% TBSA burns in 1989-50% TBSA burns by 1999, a change in the admission policy was implemented. Now, besides children and adult females, adult males also had access to the intensive burn care area. The general ward beds are mainly used as convalescent area. The total number of burn admissions was about 800 at that time. Timely performance of wound closure procedures has reduced the hospital stay with rapid turnover. Today the extent of burn or the sex of the patient does not decide the entry into the intensive burn care area. The requirement of patient and availability of bed are the deciding factors. The total number of burn patients treated by the burn team in a year has gradually reduced to about 650 by the year 2003 and it continues to remain so until today. The LA 50 was 65% of TBSA burns in 2009.
| Supportive Care|| |
Over the years supportive care has developed significantly and has contributed toward making burn care more comprehensive. Ready availability of innovative splints in the burn unit contributes to control of deformities. Follow-up clinic conducted along with the occupational therapists helps in scar care using the pressure garments, silica gel and thermoplastic materials. Conduct of regular patient education program during the hospital stay has improved the patient compliance with scar care protocol. The burn support group activity initiated some years back is no longer active. However, the medical social worker on the burn team conducts personal counseling sessions and helps in employment and job training. Legal help is also provided to those in need.
| Training|| |
Knowledge generates confidence to deal with any exigencies. Hence training of all the categories of personnel forming a burn team is essential. Conduct of burn updates, on-site short talks with resident doctors, nurses and ward attendants, analysis of mortality, discussion about patient care plan and regular appraisal of the performance of the unit - all contribute to augmentation of knowledge and strengthening of experience. Regular rotation of general surgical residents has made the surgeons trained in LTMGH confident of treating a burn victim efficiently. This practice also provides a very able work force in burn mass casualty situation. Several overseas medical graduates have chosen this burn unit for the elective posting to gain valuable experience.
| Research|| |
The burn unit at LTMGH is recognized for extensive research work conducted by its team. These research projects have stimulated collaboration with different departments such as microbiology, biochemistry, preventive and social medicine, obstetrics and gynecology, anesthesiology. This synergy has been very rewarding. Development of banana leaf dressing, optimization of Hydrogel in collaboration with BARC, evaluation of indigenous topical agents like Panchvalkal, study of psychosocial problems in burnt females and many more projects have opened new vistas. The members of burn team have contributed significant number of original articles to peer reviewed national and international journals, have prepared manuals and written chapters on topic related to burn care.
Establishment of the first skin bank in India in April 2000, with the capacity to procure skin donation after death is certainly a feather in the cap. The credit for introducing the concept of skin donation after death to the Indian society goes to this enthusiastic and illustrious team. This has paved the way for establishment of other skin banks in India. Active skin bank has given the unit the strength to salvage extensively burnt patients even in mass casualty situations.
| The Future|| |
Dr. Gore shouldered the responsibility of the burn unit continuously for 25 years. She was ably supported by series of assistant professors from the Department of Surgery and sincere and committed surgical residents. After the superannuation of Dr. Gore in 2010, Dr. Meena Kumar has taken over the mantle with sincerity and commitment. The skin bank is making good progress under her leadership. Development of acellular allogenic dermis may well be the next research project. For further improvement in the quality-of-care, the intensive burn care area needs to be augmented with appropriately equipped and staffed step down unit and convalescent care area. A rehabilitation center would be a very valuable addition to bring the burn victims back into the mainstream of the society.
The majority of the burn victims belong to young and productive age group and are free of comorbid conditions. If they receive comprehensive quality-of-care at the appropriate time, they can contribute to society and their family very meaningfully for many more years. There is nothing more satisfying than a completely rehabilitated burn victim.