|MUMBAI NABICON RESEARCH AWARD 2012
|Year : 2013 | Volume
| Issue : 1 | Page : 3-7
Nothing glamorous about it!
Madhuri Anant Gore
Former Professor and Head & Chief of Burns, Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
|Date of Web Publication||22-Nov-2013|
Madhuri Anant Gore
20, Shreyas, Udayagiri CHS, V N Purav Marg, Deonar, Mumbai - 400 088, Maharashtra
Source of Support: None, Conflict of Interest: None
This article is based on the Mumbai NABICON Research Award 2012 oration which I delivered an oration at Vadodara in January 2013 during NABICON 2013. It traces my journey over about 25 years in the field of burn care. I have tried to share the thought process and the efforts involved in contributing meaningfully to some areas in this field. There is a lot more to be done to improve the quality of acute care of burnt patients in our country. With the large number of burnt patients that we still continue to face, it is a major challenge and I strongly feel that all the research and new developments in this field should henceforth be coming from us - Indians. I fervently hope that this article stimulates at least a few to think, innovate and apply and contribute to clinical research addressing our problems.
Keywords: Challenges, effect, innovations, research in burns, solutions
|How to cite this article:|
Gore MA. Nothing glamorous about it!. Indian J Burns 2013;21:3-7
| Introduction|| |
The burn injury is devastating for the victim - physically, psychologically and socially with prolonged hospitalization, repeated surgeries, altered body image and affected interpersonal relationships. It makes significant economic and physical demands on the family of the victim. The involved health-care professionals need to invest time and physical efforts and are affected psychologically too. The burn injury rarely affects the rich and famous and neither the injury nor the injured patient (even after wound healing) is glamorous by any stretch of the imagination. All these issues have resulted in a meager number of medical professionals getting interested in the field of burn care. My experience of about 25 years of my association with these patients has been an eye-opener in more than one way. There is a lot to be done in this field and this article is an effort to share my contribution and the thought process behind my actions. I had the opportunity to perform the work presented here at the burn unit at Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai.
| The beginning|| |
Though I was given the administrative responsibility of the burn unit in 1985, it was in 1989 that I obtained the complete authority to implement treatment decisions too for all the 800 patients with burn injury admitted every year. Nearly 70% of these were women and the average burn size was about 55% of total body surface area (TBSA). This meant a lot of work. High infection rate was causing delayed wound healing, long hospital stay, significant cost of treatment and high morbidity and mortality. The lethal area 50 (LA 50) at that time was 35% of TBSA. This situation was taking its toll and the health-care professionals in the burn unit experienced frustration, depression and lack of interest. I realized that I must inculcate qualities of team leader in myself with patience and persistence. Constant encouragement, education, empowerment paved the path of progress. Regular performance appraisal and interaction between team members strengthened the determination for further development.
| Infection control|| |
The first priority was to set up stringent measures for infection control with very valuable contribution from the microbiologist. Regular analysis of microbial flora and antibiotic sensitivity pattern guided the antibiotic policy and surface disinfection protocol. Provision of separate dressing drums and articles of personal use (bucket, mug, chair, bedpan etc.,) for each patient proved to a cheap and easy way to control cross infection and led to development of dressing protocol. Regular training and supervision of all health-care givers in the burn unit by the microbiologists ensured implementation of protocols, hand washing and surveillance of breakouts. This is an on-going process. Some modifications in the design of the burn unit, installation of air handling unit with 14 air changes/h, 55% humidity and temperature of 28 ± 2°C also contributed meaningfully towards the efforts to control infection. After some years, a study was conducted to detect fungal colonization of burn wounds and Candida and Aspergillus were detected most commonly. Several scientific articles including an editorial related to burn wound infection and infection control have been published until now. ,,,
| Nutrition|| |
Nutritional support is very vital for improvement in the survival of burnt patients. In collaboration with Department of Biochemistry and the dietician on burn team, studies were conducted to find the nitrogen balance and effect of suitable diet modifications in burnt patients. Dieticians developed diet plan using indigenous cereals and milk products. The diet in terms of calories and protein requirement was individualized according to the needs of every patient and daily optimal intake was ensured orally or through nasogastric/nasojejunal tube feeds. This not only augmented the wound healing, but also reduced the need for intravenous protein supplementation significantly. Nutritional support is an integral part of burn care today. One of the several studies about nitrogen balance has been published.  I must acknowledge with gratitude the financial support provided by Deonar Jyestha Nagarik Sangh toward high protein supplement for more than 12 years continuously.
| Inhalation injury|| |
Though more than 60% of our burnt patients had involvement of face, neck, upper trunk and upper extremities, there was no Indian data about the incidence of inhalation injury. In fact most of the senior burn specialists believed that inhalation injury was rare in our patient population. To me this appeared to be a myth and so in 1992 a study was undertaken in 30 patients with burn distribution suggestive of inhalation injury. Fiberoptic bronchoscopy was performed in each of these patients. Existence of inhalation injury was confirmed in 28 (93.3%) patients with 25 patients having upper airway involvement and three with affection of lower respiratory passage. Hence the clinical suspicion proved to be reliable. We decided to do early tracheal intubation, maintained a low threshold for tracheotomy. I succeeded in procuring ventilators and started organizing regular workshops for training the surgical residents in mechanical ventilation. Fiberoptic bronchoscopy has certain disadvantages as it's an invasive procedure, can cause hypoxia and does not permit visualization of airway beyond obstruction. So around 2002 a study was conducted in collaboration with Department of Radiology to evaluate the role of virtual bronchoscopy in diagnosis of inhalation injury using multi slice computed tomography scanner. This technique allows quick acquisition of images of complete tracheobronchial tree even beyond obstruction and is non-invasive. This study was published in international peer reviewed journal. 
| The cost of burn treatment|| |
Being a public institution; the nursing care, dressings, stay, consultant's visits, surgeries, food and most of the medicines were available free of charge to the patients. However, patients did have to purchase some of the medicines that were not available on hospital schedule. The relatives had to incur expenses for travel from home and food. Collection of data revealed that these expenses amounted to Rs 1000 for every % of burn extent. Majority of the patients came from families with per capita monthly income, which was less than Rs. 500 and these expenses were beyond their reach. Hence, the focus had to be on reducing the hospital stay by achieving early wound closure using simple and affordable ways.
| The burn wound care|| |
The aim was to achieve early healing of partial thickness wounds leading to effective reduction in burn extent and wound excision and closure of full thickness burns at the earliest. It was time to innovate. I think it is necessary to develop an insight into the problem at hand based on detailed information. Then total involvement, interaction with team members and fertile imagination can result in an innovation. I experienced this process while I developed banana leaf dressing [Figure 1] and conducted the clinical trials over a period of 4 years from 1995 to 1999. I chose the banana leaf due to its easy availability, non-adherent, waxy and large surface area and its cooling effect on the wound. All this allowed painless and quick dressing change procedure and effective healing of partial thickness burn wounds. I standardized the preparation process and the dressing procedure and trained the nurses and surgical residents. One of our recovered patients was employed to prepare the banana leaf dressings and was thus rehabilitated. A banana plantation was initiated in the hospital campus, but this concept failed due to utilization of leaves by other personnel in the hospital. A controlled trial was conducted using comparable body surface areas with partial thickness burns in the same patient to compare the boiled potato peel bandage (which was being used in the unit at that time) with banana leaf dressing. The banana leaf dressing was found to be effective, pain free and cheap with shorter preparation time and easier dressing change. Another clinical trial compared Vaseline gauze dressing with banana leaf dressing for skin graft donor areas. Banana leaf dressing was observed to provide superior pain relief and earlier epithelization, the difference being statistically significant. Research papers based on these trials have been published in the international journal. , Until today, banana leaf dressing continues to be the cheapest burn wound dressing in the world and is being routinely used at the burn unit and also at the burn care facilities at some other centers in India.
|Figure 2: Allograft stimulated epithelization with rejection of allografts|
Click here to view
After some years, I evaluated easily available polyethylene drape for dressing on skin graft donor areas and found it to be an easy, effective and cheap alternative.  This led to routine use of polyethylene drape dressing over burn wounds in mass casualty scenario.
My interest in burn wound care led to my collaboration with Bhabha Atomic Research Center for optimization and clinical trials of hydrogel dressing, which is now a commercially available wound care product. I also conducted clinical trials of indigenously developed topical agents and the results were encouraging.
Porcine xenografts are used routinely as burn wound cover and are known to provide good pain relief, infection control and promote epithelization thus reducing the autograft requirement. With significant efforts I started procuring porcine xenografts and got very positive results. Porcine xenografts provided excellent pain relief and infection control. It stimulated epithelization and led to good wound bed preparation for application of skin autografts. But with uncertain availability, routine use of porcine xenografts continues to elude the burn care professionals.
Development of banana leaf dressing proved to be a boon for partial thickness burn wounds. However, full thickness wounds still posed a challenge as significant load of patients, paucity of blood and blood products, non-availability of OR time and uncertain supply of skin substitutes all contributed to the inability to perform early burn wound excision and wound closure. Hence, I decided to perform early wound excision in selected few and resorted to delayed wound excision starting from the 10 th post-burn day in most. I developed and evaluated standard operating procedure for split thickness skin grafting with the aim of minimizing graft loss. This approach resulted in significant improvement in the outcome despite the frequent change of surgical residents performing the procedure. 
| Supportive care|| |
Although focusing on burn wound care the supportive care was being provided with great involvement and enthusiasm by the members of the burn team. This led to the development of innovative and patient friendly leg supports, upper extremity supports, arm abduction and neck extension devices by the occupational therapists. Simple but effective equipments were fixed in the burn unit by the physical therapists to encourage active mobilization. We started providing regular scar care using thermoplastic material, compression garments and silica gel and most importantly patient education. All these measures improved our communication with patients and we realized that a significant number (15.15%) of female patients suffered from amenorrhea and/or galactorrhea in the post-burn period. However they were reluctant to volunteer the information unless specifically asked for and so continued to suffer silently. 
| Psycho-social problems|| |
That intentional burn injury is frequent in India is a common observation. In collaboration with Department of Preventive and Social Medicine, we collected data of 200 female patients. It revealed that 40% of them had suffered intentional burns-35% suicidal, 5% homicidal. Domestic violence, attention seeking and ignorance about the after effects of burn injury were commonly associated with suicidal attempt with burning. The homicidal incidents had dowry, suspicion about character, revenge or honor killing as the backdrop. Most important factor in my opinion was the failure of inter-personnel communication. Whatever reason, the burnt females have to face significant psychosocial issues. The relatives are often apathetic and reluctant to bear the expenses leading to non-compliance with treatment within the hospital as well as after discharge. The husband commonly deserts the disfigured burn victim often at the instance of other family members. The burn victim suffers as acceptance of altered body image is difficult for her and it is further accentuated as she also experiences non-acceptance and rejection from the society. In collaboration with the medical social worker department, we started a burn support group along with legal help for those in need. In my opinion making these females economically independent is an important step towards strengthening their confidence. Some have been employed within the hospital, some for making banana leaf dressing, some have been trained as patient helpers and some others work at sheltered workshops. I have observed that these earning women are often accepted back by the family too.
With focused efforts from every member of the burn team, by the year 1999 we had reached LA 50 level of 50% of TBSA burns. This was encouraging, but we needed to strive harder to progress on this path.
| Cadaver skin donation and skin bank|| |
Patients with more than 50% of TBSA burns needed skin substitute for salvage. Availability of porcine xenografts was uncertain and bio-synthetic skin substitutes were exorbitantly expensive and difficult to procure. I had used cultured autologous epithelia on a burn wound for the 1 st time in India in November 1995 and was convinced that it needed more research and was very fastidious and expensive for routine use. Hence, it was necessary to establish a skin bank with the capability to harvest and preserve cadaver skin allografts. With very valuable contribution from Dr. Daksha Pandit from Department of Microbiology and strong financial support from Sunday Friends (Non-Government Organization associated with the burn unit for several years) I was able to establish the first skin bank in India at Lokmanya Tilak Municipal Medical College and General Hospital on 24 th April 2000. This also marked the introduction of the concept of skin donation after death to Indian society. Being the first such facility in the country, I had the responsibility of establishing various protocols, ensure prompt response, evaluate the performance and supervise appropriate utilization. Creation of awareness about this new concept was a challenge and it needs to be an on-going program. I explored all the possible avenues - lectures, brochures, interviews, articles, short film. By 2006, the skin bank had received just about 60 donations from hospital based counseling of relatives of the deceased individual. The strategy needed a change. So in the year 2007 in close collaboration with Sunday Friends the focus was shifted to community based counseling done by general practitioners and non-medical volunteers. The response was amazing. Since the year 2007 the number of donations received has steadily and consistently increased from 70 in year 2007 to 180 in the year 2012. The Indian society has accepted this concept; we need to ask at the appropriate time. This experience of Lokmanya Tilak Municipal General Hospital (LTMGH) skin bank has broken the ice and has encouraged the establishment of three more skin banks in India - at Navi Mumbai, Indore and Pune. All are following the same model of community based counseling and are experiencing positive response. I am proud of the fact that LTMGH skin bank has paved the way for all the future skin banks in India. The skin bank team has shared its experience through several publications based on graft processing, response and utilization [Figure 2] of allografts. ,,
I am truly impressed by the prompt, dedicated response of the surgical residents for skin graft procurement at any time of the day or night. Their contribution to the success of skin bank is invaluable. I have experienced significant survival benefit with the use of skin allografts and salvage of patients with burn extent of 65%, 70% and 85% TBSA has been possible only because of the skin allografts.  I am convinced that we can do anything we want to, if we stick to it long enough!
In the year 2009, we reached LA 50 level of 65% TBSA burn. We still have a long way to go, but we are on the right path.
| Capacity building|| |
The large number of burn victims demands more number of trained health-care professionals. Hence, capacity building is an important responsibility that we all must share. The experience and training in the field of burn care accrued by each surgical resident has given them the confidence of treating a burn patient after they qualify. This force gave us the strength to deal with burn mass casualties efficiently and with excellent outcome. With my leadership the burn team did the tremendous task of providing training in burn care to 80 surgeons from district hospitals under the Maharashtra health systems development project.
Conduct of several clinical trials and collaborative research resulted in widening of the horizons. Sharing of experience at scientific forums and through articles, contribution of chapters to several books devoted to burn management and preparation of burn care manual - all have been very enriching experiences for me.
| Pillars of strength|| |
All this and some more could be achieved only because of very strong supports. Despite of working in a public institution, I never lacked funds for any new venture or research project as donations from individuals and organizations were always available. I am convinced that if you have the purpose (and the sincerity and transparency) the means would always follow! My team was my greatest strength. Though the team members changed, each one made a valuable contribution while on the team. We trusted, respected and appreciated each other and everyone from the consultant to the ward boy had the freedom to express his/her views and ideas. The contribution of the nursing staff to the whole process of evolution was particularly noteworthy. I was fortunate to have some senior and very wise guides and friends with whom I could discuss my thoughts. I would always be indebted to late Dr. M. H. Keswani, Dr. John and Mary Davies, Dr. Mariella and Pankaja Hanumadass, Dr. Snehlata Deshmukh and Dr. Arun Chaukar as they have influenced my thoughts and actions positively at one time or other. Without the encouragement and understanding from my family, nothing would have been possible.
| Clinical research and clinical practice|| |
In my opinion research and practice must go hand in hand for any progress to occur. One must identify and acknowledge the existence of a problem and find its cause. This should stimulate the thought process leading to a possible solution, which needs to be implemented. If the evaluation of outcome is satisfactory then the solution should become an integral component of clinical practice. This whole process must be shared with the fraternity as without it we are depriving the patients from receiving the benefits of our experience.
| References|| |
|1.||Pandit DV, Gore MA, Saileshwar N, Deodhar LP. Laboratory data from the surveillance of a burns ward for the detection of hospital infection. Burns 1993;19:52-5. |
|2.||Pandit DV, Gore MA. Nosocomial infections in patients with thermal injury and measures taken for prevention. Bombay Hosp J 1997;39:59-63. |
|3.||Gore MA. Infection in burnt patients - Editorial. Indian Pract 2003. |
|4.||Goyal NK, Gore MA, Goyal RS. Fungal colonisation in burn wounds: An Indian scenerio. Indian J Surg 2010;72:49-52. |
|5.||Phadke MS, Sameer M, Gore MA. Study of nitrogen balance in thermally injured patients. Internet J Emerg Intensive Care Med 2007;11: 1. |
|6.||Gore MA, Joshi AR, Nagarajan G, Iyer SP, Kulkarni T, Khandelwal A. Virtual bronchoscopy for diagnosis of inhalation injury in burnt patients. Burns 2004;30:165-8. |
|7.||Gore MA, Akolekar D. Banana leaf dressing for skin graft donor areas. Burns 2003;29:483-6. |
|8.||Gore MA, Akolekar D. Evaluation of banana leaf dressing for partial thickness burn wounds. Burns 2003;29:487-92. |
|9.||Gore MA, Umakumar K, Iyer SP. Polyethylene surgical drape dressing for split thickness skin graft donor areas. In: Gore MA, editor. Skin Grafts. 1 St ed. Croatia: InTech; 2013. p. 85-96. |
|10.||Gore MA, Gadhire MA, Jain S. Evaluation of skin grafting procedure in burnt patients. In: Gore MA, editor. Skin Grafts. 1 St ed. Croatia: InTech; 2013. p. 17-25. |
|11.||Goyal N, Gore MA, Shankar R. Galactorrhea and amenorrhea in burn patients. Burns 2008;34:825-8. |
|12.||Mathur M, De A, Gore M. Microbiological assessment of cadaver skin grafts received in a Skin Bank. Burns 2009;35:104-6. |
|13.||De A, Mathur M, Gore MA. Viability of cadaver skin grafts stored in skin bank at two different temperatures. Indian J Med Res 2008;128:769-71. |
|14.||Gore MA, De AS. Deceased donor skin allograft banking: Response and utilization. Indian J Plast Surg 2010;43:S114-20. |
[Figure 1], [Figure 2]