Courtesy of Godoy Medical Forensics
Mr. John Smith, age 40, sustained multiple injuries when he jumped from the second story of a burning house. He was treated at the scene by emergency medical services and transported to the emergency department of the local medical center, where he was assessed and treated. It was estimated that burns covered 25 percent of his total body surface area (TBSA). He was also diagnosed with an inhalation injury. It was necessary to insert a breathing tube for mechanical ventilation. A central intravenous line was inserted for the administration of medication and fluid resuscitation. A urinary catheter was also inserted. Mr. Smith was then transferred to a regional burn center. Three primary medical issues were identified: second-degree burns of the face, upper extremities, head, and neck; respiratory injury; and a fracture of his right femur (leg bone). Three operative procedures were performed: a tracheostomy (an incision in the trachea that is made to accommodate a breathing tube), two procedures to debride and graft burn wounds, and a repair of the fracture of his right leg. He was hospitalized for one month and experienced complications of immobility, including weakness, pneumonia, and severe constipation leading to bowel blockage.
Mr. Smith was unable to function independently when he was discharged from the burn unit. He was transferred to a rehabilitation hospital for continued care. He received physical, occupational, and speech therapy. He was seen by a psychologist and was diagnosed with post-traumatic stress disorder (PTSD) related to the trauma of the fire. Mr. Smith was discharged after three weeks of treatment at the rehabilitation facility. He was not cleared to return to work and continued treatment as an outpatient at the burn center. His treatment consisted of moist heat, manual therapy for scar and edema management, and range of motion and strengthening exercises. He was medically cleared to return to work with restrictions after one month of outpatient treatment. A year after his initial injury, he was working full time without restriction and was taking medication to manage symptoms of anxiety and depression.
An investigation revealed that smoke detectors were installed in the home, but did not function. Mr. Smith retained an attorney to represent him in a civil case against the manufacturer of the smoke alarm. A legal nurse consultant assisted the attorney by organizing the medical records, providing a comprehensive medical chronology, and locating expert witnesses.
It is important to obtain and review medical records from the ambulance crew and emergency department in burn cases. The first responders will obtain information about the details of the fire, injuries, and medical history. This information is needed for management of the injuries. Demographic data such as height, weight, and age are important. The pre-burn weight is used to calculate fluid and medication doses. It may be documented in the medical record as “dry weight.” A detailed description of how and when the burn occurred and medical history should be documented. This information may be obtained from family members or witnesses, if the client is unable to speak or is confused.
Treatment in the first hours after a burn injury can mean the difference between life and death. It may be surprising to learn that treatment of the burns is not the first priority of care. Immediate care begins with the maintenance of respiratory function. In our case study, Mr. Smith was at risk for inhalation injury because the fire occurred indoors. Carbon monoxide is released in the process of combustion and leads to decreased oxygenation. If the neck or chest area is burned it can restrict the movement needed for breathing. Burns of the head, face, and neck are high risk injuries. Sometimes soot can be visualized in the oral/nasal passages or the client may be hoarse, indicating respiratory injury. Most clients are heavily sedated and intubated quickly when an inhalation injury is suspected before airway obstruction can occur. They are then connected to a mechanical ventilator and the oxygen level is monitored carefully. At this point, the client will be unable to speak and provide information.
Restoring fluid balance is the second priority of care because there is a massive capillary leak that occurs after major burns. This is sometimes referred to as “burn shock.” The rapid infusion of IV fluids is referred to as “fluid resuscitation.” The emergency personnel will try to establish IV access as quickly as possible. A urinary catheter is also placed to monitor urine output. The amount of fluid infused is calculated using a formula based on the client’s weight and percentage of body surface area burned. Baseline lab values will also be obtained in the initial stage of burn treatment and will be monitored throughout hospitalization. Nurses can help to interpret lab values and explain them to attorneys.
Pain management is the next priority of care if there is no blood loss. The pain experienced by burn clients is managed with medication, often narcotics initially. Wound care is not the first priority, but wounds are cleansed and covered to prevent infection until the patient is assessed by a specialist in burn care. In cases of extensive and severe burns, the patient will be transported to an American Burn Association-Verified Burn Center. The treatment of burns will be discussed in the following section.
The client with severe burns will be hospitalized for weeks or months. Burn wounds often require painful dressing changes, surgery, and grafting. Preservation of function and prevention of complications are the priorities of care. A multidisciplinary team will care for the burn patient. The team may consist of nursing staff who provide 24-hour care, case management, pulmonary specialists, medical providers, surgeons, physical therapists, occupational therapists, nutritional specialists, and spiritual care providers. The documentation can be overwhelming and legal nurse consultants can help to organize and interpret the medical records.
Treatment of burn injury is dependent on the type of injury to the skin and underlying tissue. The skin consists of two layers. The upper layer of skin is the epidermis; the deeper layer is the dermis. Burn injuries are classified according to depth.
During hospitalization, burn wounds are measured and assessed daily. Restoring the skin by natural healing or grafting starts with the removal of dead skin (called eschar). The damaged skin may be removed by the application of topical enzymes, hydrotherapy, or surgical debridement. Patients who require surgery are usually taken to the operating room within the first five days after injury. This reduces the risk of infection. If skin grafting is required, it may be from the patient’s unburned skin (called an autograft) or from a tissue bank (called an allograph). Dressings are applied post-op and changed according to protocol.
The client with burn injuries will be discharged from the acute care hospital when life threatening complications have resolved and wounds are almost completely healed. Additional treatment at a rehabilitation hospital may be needed for weeks or months. A multidisciplinary team is needed, just as in the acute care hospital. Physical and occupational therapy will be provided to help the client achieve as much function as possible and adapt to changes in lifestyle. Following discharge, pressure dressings and garments may be worn on an outpatient basis to prevent contractures and minimize scarring. Reconstructive and cosmetic surgery may be performed many years after the initial injury. Attorneys may find that their client has unrealistic expectations about their appearance or health. The client may never return to their pre-injury status. They can be physically disabled. Psychological support may be needed for years to help the client cope with their stress and trauma.
We have reviewed medical records from clients with burn injuries that have more than 20 diagnoses documented. This is because of the numerous complications associated with severe burns. The skin is the largest organ of the body. Damage to the skin from a burn affects multiple body systems and it is impossible to identify every complication that may occur. In this newsletter, we will identify some of the complications from burn injury that we have observed from clinical work and consulting. It is not a comprehensive list.
The skin acts as a barrier to protect us from infection. The risk for infection after a burn injury is high. Hospital-acquired infections, such as methicillin-resistant Staphylococcus aureus (MRSA), can occur. The risk of infection is also increased when the client has an IV line, breathing tube, feeding tube, or urinary catheter. These provide portals of entry for infectious organisms. If a client is on bedrest for an extended period of time, the risk for pneumonia increases.
There are other complications of bedrest—such as blood clots, skin breakdown, and muscle weakness—that can occur. Burn injuries can cause severe pain and clients may require heavy sedation for routine nursing care such as bed making, bathing, or repositioning. Narcotic pain medication is addicting and we have seen clients experience mental status changes, such as delirium, when the dose is decreased and they are weaned off the medication.
Burn injuries cause significant swelling and fractures may be undiagnosed until the swelling is reduced, causing a delay in treatment. Healing of the fracture is prolonged or impaired.
A fluid shift occurs as part of the physiological response to a burn injury. Fluid resuscitation is an important aspect of treatment. Changes in fluids and electrolytes such as sodium and potassium can affect the heart and other organs such as the kidney. We have worked with clients who have experienced congestive heart failure and renal failure after a burn injury.
Bowel function is disrupted when narcotics that slow intestinal motility are administered, the client is on bedrest or the client is not consuming a full diet. Intestinal obstruction is a complication that has occurred. This may require a surgical procedure to correct. It is also extremely painful.
The client with a respiratory injury from burns is at risk for respiratory failure. If mechanical ventilation is required for an extended period of time, a surgical procedure called a tracheostomy is performed. The client is at risk for infection, as noted above. We have worked with a client who experienced vocal cord paralysis after a tracheostomy.
Clients who are burned can develop mental and emotional complications that are just as devastating as their physical injuries. They can experience acute and chronic grief secondary to the losses experienced, including health, job, home, and other material possessions, and a sense of safety and security. Anxiety disorders, such as phobias and PTSD, are common. Symptoms of depression can be experienced and require treatment. Treatment for mental illness may be short-term or the client may require medication and therapy for the rest of his or her life. Since physical and mental disability can be permanent, a life care planner may be helpful to the attorney in estimating costs.