The approach to care for the burned patient has undergone a change in focus over the past 20 years with optimal outcomes including not merely survival but global physical, emotional, mental, and social rehabilitation with increased emphasis on earlier re-entry into the previous social environment. The experiences of burn survivors provide unique opportunities for outreach and support of these patients. In 2001, a position on the Burn Team was developed by the Burn Center and a staff position created for a highly motivated, self-aware, and skilled burn survivor as a Burn Support Representative (BSR). Our regional burn center treats approximately 250 inpatients and 800 outpatients with 2200 patient visits per year. Our aggressive rehabilitation team and active social work program begin planning for social reintegration the day of admission. During treatment of burns, the care team must address the major psychological and social changes which the patient and his/her support structure experience. Our burn center director, the Burn Relations Representative, and a burn survivor active in the community with a background in counseling identified the need for a burn team member to interact with the patients and families. The goal was to offer emotional support and coaching, adaptation and

Palmar burn injuries cause scar contracture in patients requiring long term therapy and contracture release to achieve optimal outcome. Serial casting is employed at many burn centers as a method of preventing and correcting scar contractures, particularly at the elbow. At our regional burn center, we have used early serial casting for palmar burns to prevent palmar contractures. We have retrospectively reviewed the records of 64 patients with palmar burns requiring skin grafts (full and split thickness) admitted in the time period between Jan. 1999-Jan. 2005. Each of these patients underwent skin grafting and serial casting, with a long or short arm cast, and most patients were casted from the date of grafting until the graft was healed and the hypertrophic scar had started to mature. 64 patients, ages 5 months to 72 years, mean 9.8 years, underwent serial casting for palmar burns. Our population consisted of 21 females and...

Objective:To delineate blood transfusion practices and outcomes in patients with major burn injury. Context:Patients with major burn injury frequently require multiple blood transfusions; however, the effect of blood transfusion after major burn injury has had limited study. Design:Multicenter retrospective cohort analysis. Setting:Regional burn centers throughout the United States and Canada. Patient Population:Patients admitted to a participating burn center from January 1 through December 31, 2002, with acute burn injuries of ≥20% total body surface area. Outcomes Measured:Outcome measurements included mortality, number of infections, length of stay, units of blood transfused in and out of the operating room, number of operations, and anticoagulant use. Results:A total of 21 burn centers contributed data on 666 patients; 79% of patients survived and received a mean of 14 units of packed red blood cells during their hospitalization. Mortality was related to patient age, total body surface area burn, inhalation injury, number of units of blood transfused outside the operating room, and total number of transfusions. The number of infections per patient increased with each unit of blood transfused (odds ratio, 1.13; p < .001). Patients on anticoagulation during hospitalization received more blood than patients not on anticoagulation (16.3 ± 1.5 vs. 12.3 ± 1.5, p < .001). Conclusions:The number of transfusions received was associated with mortality and infectious episodes in patients with major burns even after factoring for indices of burn severity. The utilization of blood products in the treatment of major burn injury should be reserved for patients with a demonstrated physiologic need.

Telemedicine is a modality used to communicate with and evaluate patients in remote locations with limited access to healthcare. Teleconferencing is convenient for the patient but has proven to be costly for the centers involved. Digital photography offers quality superior to images on a television screen and is therefore better for wound and scar evaluation. Our Burn Center utilized telemedicine conferences for six years. The teleconferencing program was disabled owing to high costs and no return. Some evaluations were supplemented with transmission of information via JPEG file format. We investigated the cost-effectiveness of digital images for remote patient evaluation in telemedicine. We have retrospectively reviewed the medical records from 2000–2004 of patients who sent digital images to the Burn Center for evaluation of their wounds. We determined which of these patients also underwent teleconferencing, telephone communication, and clinic visits, thereby identified barriers and benefits to providing burn care with and...

Nicolau's syndrome, also called embolica cutis medicamentosa, is characterized by well- circumscribed livedoid dermatitis with aseptic necrosis after intramuscular injection. We report the case of a 45-year-old woman with severe necrosis of the thigh several days after a routine intramuscular injection of hydroxyzine who was transferred to and treated at our Regional Burn Center. Although there has been one case report and numerous voluntarily reported instances of intramuscular hydroxyzine-induced necrosis to the Food and Drug Administration Spontaneous Reporting System, this phenomenon is rare.

“It ain’t over ‘til it’s over” Yogi Berra proclaimed in 1973 when the baseball team he was managing, the New York Mets, was nine games out of first place. Fans may remember that the Mets defied the odds and captured the pennant by defeating the Cincinnati Reds in the Championship Series. They eventually lost the World Series in seven games. “It ain’t over ‘til it’s over” can apply to many things. Although more commonly used during sporting events, it also rings true for the burn survivor’s struggle for reintegration into society. More accurately, for the survivor, it’s unlikely it’s ever over. For the Burn Team, when is it over? In his Presidential address to the International Society for Burn Injuries (August, 2002, Seattle, Washington), Dr. Heimbach asked, “Where have we been? Where can we go?” He challenged the world’s developing countries to adopt modern burn care. He pointed out the fact that burn injuries and burn fatalities in developing countries are a major cause of death and disability. Burn injuries and mortality rates, such as those experienced in developing countries, would not be tolerated in the United States or Canada. Modern burn care, including early excision and grafting, are almost unheard of in most developing countries. As Dr. Heimbach delineated, and subsequently discounted, there are a lot of arguments against adopting modern burn care in a developing country. The following statistics are taken from the World Health Organization Web site: 1) 29 countries have a life expectancy of less then 50 years; 2) more than one-fourth of the world’s countries have a life expectancy of less than 60 years; 3) Sierra Leone has the shortest life expectancy, 34 years (34 years is probably younger than the mean age of this audience!); 4) life expectancies in the United States, Canada, and Japan are 77, 80, and 82 years, respectively. More than half of the countries in the world spend less than $100 US per capita annually on healthcare. Compare this with Canada, where spending is more than $2,000 per capita. The United States leads the world in this arena, expending nearly $5,000 per capita annually on health care. Our healthcare per capita spending is more than 50 times the expenditures of half the countries of the world! We, the Burn Teams of the United States and Canada, have “done it all.” We can treat the majority of burns with relative ease; our burn surgeons can skillfully excise and graft burns of any body area in any age patient; our nurses can dress even the most difficult anatomic sites, and make the dressings stay in place; our burn therapists and social support staff can harangue even the most obstreperous patient into completing rehabilitation. So, what is the next challenge? Dr. Heimbach drew up a blueprint for bringing developing countries into an era of modern burn care. They cannot do it by themselves; the burn surgeons, nurses, therapists and support staff in these developing countries need teachers and mentors. You, members of the Burn Teams of the United States and Canada, can be the teachers and mentors. As an individual, consider doing what others have done: sharing your knowledge with others who are less fortunate and teaching them to provide modern burn and wound care. There are several areas to address before you jet off to another country to provide assistance in burn education. First, consider whether you wish to collaborate with a religious organization. Much of medical outreach is sponsored by and coordinated by religious organizations. Although these groups can greatly assist you in your efforts, the religious overtones can be fairly intrusive. Their requirements for involvement may conflict with your ethics, and it is best to identify what is required of you before jumping on board. Second, to have the Internal Revenue Service consider your expenses as tax-deductible contributions, the organization with which you affiliate must be nonprofit (and in the majority of circumstances, incorporated in the United States). Third, the ability to speak the native language is a genuine benefit. Whenever you use an interpreter, you miss a portion of the verbal interaction. This can be critical in the context of medical care. On the other hand, one should never be dissuaded from medical outreach based on language barriers. Fourth, you need to decide whether you are going as one or two individuals or as a team. There are pros and cons to either choice. Going as an individual requires less planning and coordination; however, a whole burn team provides for more complete education of the participants at the distant site. You also need to determine the desired skills your team will possess. Regardless of your skill set, there is a need for all disciplines. Fifth, preplanning with a thorough understanding of the facilities and equipment available at the distant site will make your trip more successful. Be prepared to hand carry necessary equipment. Shipping equipment may be unreliFrom the Regions Burn Center, St. Paul, MN. Presented at the 36th Annual Meeting of the American Burn Association, March 24–26, 2004, Vancouver, BC, Canada. Copyright © 2005 by the American Burn Association. 0273-8481/2005

This article presents the ABA Plan, developed by the Committee on Organization and Delivery of Burn Care and the Board of Trustees, for the management of mass burn casualties resulting from mass disasters and terrorist acts. Information is presented demonstrating the following: the extent of burn injuries in mass disasters and terrorist acts; the importance of appropriate triage and surge capacity policy; why treatment of burn patients in burn centers is preferable; the critical role that burn centers play in the local, regional, and federal response to mass burn casualty situations; and the important role of the ABA in interacting with federal agencies and other entities in mass burn casualty disaster preparedness.

Hydrofluoric acid (HF) is highly corrosive substance often used in industrial processes. HF burns to the skin cause local tissue injury. Systemic hypocalcemia may ensue, with the potential to produce life-threatening arrhythmias. Medical treatment consists of local application of topical calcium gels, subcutaneous injection of calcium gluconate, and intravenous or intra-arterial infusion of calcium gluconate. Calcium gluconate infusions have been used for HF burns on distal extremities and digits. We report a case of HF burn to the face that was treated by the use of calcium gluconate infusion via the external carotid artery.

Telemedicine is an evolving technology that is used for health education, health care administration, and health care distribution. The potential benefits of telemedicine include a decrease in travel expenses, improved continuity of care, and increased access to specialized consultants, thus meeting the needs of patients, practitioners, and communities. Telemedicine has many evolving applications, including improved access to health care in medically underserved and rural areas. Regions Burn Center assessed the efficacy and efficiency of burn visits via telemedicine and identified the barriers and benefits specific to burn care. Information regarding travel costs and financial data were evaluated from a total of 1000 burn follow-up visits with 294 patients via telemedicine during a 5-year interval. Our results indicate that telemedicine burn visits are a cost-effective clinical alternative for the patient. However, telemedicine can be a financial burden to health care systems and inefficient for health care providers.

Walking Through the Ashes: A Resource for Burn Trauma Survivors Get access C. M. Gilyard, MA, C. M. Gilyard, MA 1Regions Hospital, Clear Lake, MN; Regions Hospital Burn Center, St. Paul, MN Search for other works by this author on: Oxford Academic Google Scholar L. D. Solem, MD, FACS, L. D. Solem, MD, FACS 1Regions Hospital, Clear Lake, MN; Regions Hospital Burn Center, St. Paul, MN Search for other works by this author on: Oxford Academic Google Scholar D. H. Ahrenholz, MD, FACS, D. H. Ahrenholz, MD, FACS 1Regions Hospital, Clear Lake, MN; Regions Hospital Burn Center, St. Paul, MN Search for other works by this author on: Oxford Academic Google Scholar W. Mohr, MD W. Mohr, MD 1Regions Hospital, Clear Lake, MN; Regions Hospital Burn Center, St. Paul, MN Search for other works by this author on: Oxford Academic Google Scholar The Journal of Burn Care & Rehabilitation, Volume 24, Issue suppl_2, March-April 2003, Page S163, https://doi.org/10.1097/00004630-200303002-00242 Published: 01 March 2003

Journal Article COX-2 Expression by Fibroblasts and Vascular Endothelial Cells in Healed Burn Wound Tissue Get access R. D. Nelson, PhD, R. D. Nelson, PhD 1Regions Hospital, St. Paul, MN2Pharmacia Corporation, St. Louis, MO Search for other works by this author on: Oxford Academic Google Scholar J. M. Harmon, BS, J. M. Harmon, BS 1Regions Hospital, St. Paul, MN2Pharmacia Corporation, St. Louis, MO Search for other works by this author on: Oxford Academic Google Scholar D. H. Ahrenholz, MD, D. H. Ahrenholz, MD 1Regions Hospital, St. Paul, MN2Pharmacia Corporation, St. Louis, MO Search for other works by this author on: Oxford Academic Google Scholar L. D. Solem, MD, L. D. Solem, MD 1Regions Hospital, St. Paul, MN2Pharmacia Corporation, St. Louis, MO Search for other works by this author on: Oxford Academic Google Scholar A. T. Koki, PhD A. T. Koki, PhD 1Regions Hospital, St. Paul, MN2Pharmacia Corporation, St. Louis, MO Search for other works by this author on: Oxford Academic Google Scholar The Journal of Burn Care & Rehabilitation, Volume 23, Issue suppl_2, March-April 2002, Page S129, https://doi.org/10.1097/00004630-200203002-00174 Published: 01 March 2002

Paraquat is a bipyridyl compound widely used as a contact herbicide. Since its introduction in 1962, hundreds of deaths have occurred, usually after suicidal or accidental ingestion. Death after dermal absorption of paraquat is uncommon, but has occurred after either contact with undiluted paraquat, disruption of skin integrity, or prolonged exposure. It is the purpose of this case report to describe a patient who had fatal dermal paraquat absorption after a crop-dusting accident in which he sustained 37% TBSA burns. After 9.5 hours of cutaneous exposure, a paraquat level of 0.169 mg/ml was obtained at 20 hours, the standard lethal dose at 16 hours being 0.16 mg/ml. In light of the apparently irreversible pathophysiology of paraquat poisoning with plasma levels as low as 3 mg/L, prevention and early intervention are the best treatments. Our patient may have survived an otherwise routine thermal injury had his wounds been aggressively irrigated in the field.

The Baxter formula is commonly used to calculate fluid requirements. Baxter reported that 12% of patients would require more than 4.3 mL/kg per percentage of total body surface area (%TBSA). We anecdotally observed that we frequently exceeded the predictions of the formula, and we wondered if this was unique to our practice. We studied our last 11 burn-related resuscitations and collected fluid resuscitation data from US burn centers. Twenty-eight centers were queried, and 6 centers shared data. We were therefore able to study the resuscitation data of 50 adult patients. For 29 patients (58%), 4.3 mL/kg/%TBSA was exceeded compared with the 12% reported by Baxter. These findings suggest that in actual practice, fluid volumes administered are larger than the Baxter formula predicts. This survey does not explain why. Possible reasons for the larger fluid volumes are as follows: (1) the sample is not representative; (2) the formula is used improperly; (3) burns have changed and require more fluids; (4) burn care has changed.

We assessed the efficiency and effectiveness of burn consultations via telemedicine. The Regions Hospital Burn Center completed 87 follow-up visits with 40 patients via telemedicine from March 1997 to August 1998. These consultations involved burn physicians, occupational therapists and a clinical psychologist. Patients were seen at 15 telemedicine sites in six states (Minnesota, Iowa, Montana, North and South Dakota, and Wisconsin). Telemedicine burn consultations were cost-effective for the patient, but were more time consuming for the physician and therapist. As remote sites become more familiar with preparing patients for teleconsultations, telemedicine will become more efficient for the physician while remaining cost-effective for the patient.