the pursuit of parkinson's - The University of Alabama at Birmingham

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Battling Burns and Winning Treatment Comes a Long Way By Roger Shuler James Cross, M.D., and Alan Dimick, M.D., along with many other physicians and staff, are part of the Burn Center’s ongoing commitment to burn care. When James Cross, M.D., is asked about progress made in the treatment of burns, he thinks about a scene from the 2001 film Pearl Harbor. “In the movie there is a scene where the Japanese have attacked, and the hospital is inundated with patients,” Cross says. “The doctors are triaging the patients, and when they have a burn patient, they say, ‘Put him over there under the tree.’ Back then, it was assumed that a patient with a severe burn was going to die.” That scene was set in 1941. Cross, director of the UAB Burn Center, says the medical approach to burns has changed dramatically since then. “Now we work under the premise that most burn patients are going to live,” Cross says. “We don’t save everyone. Patients with severe smoke-inhalation injuries, and those with burns over 60 to 70 percent of the body surface area—we have trouble saving them. But if the burn area is less than that, we work on the premise that we can save the patient.” Challenges and Complications Burns present some of the most difficult challenges in medicine. “With a severe burn, every single organ is affected,” Cross says. “Dealing with the burn to the skin is often the easy part. The difficult part comes when the lungs go bad, when the kidneys and the gastrointestinal tract aren’t working.” For example, a severe burn can cause swelling in the GI tract that makes it difficult for a patient to absorb nutrients. In fact, swelling in general is a major complication with burns. “When you get a bee sting, you have swelling right around the site,” Cross says. “A burn is like a total-body bee sting.” 12 For patients burned over more than 70 percent of their bodies, the mortality rate is very high. “Several things happen,” Cross says. “Often they don’t make it through the initial resuscitation effort; the insult to the body is so great that they just can’t tolerate it. If they get through that, they often succumb to other complications, such as infections or respiratory problems.” But because of progress in burn care, even severely burned patients can sometimes pull through. Alan Dimick, M.D., has seen the progress from the front lines. Dimick helped found the UAB Burn Center in 1970. He retired as burn center director in 1998, but he still serves as a consultant at Children’s Hospital and is a site reviewer for the American Burn Association’s verification program. “Before I retired, I had 15 patients walk out of the hospital after coming to us with 80- to 85-percent burns,” Dimick says. “If they were to walk into a room with their clothes on now, you couldn’t tell they had a burn.” Shortly after Dimick joined the UAB faculty in 1963, Chief of Surgery Champ Lyons, M.D., asked him to attend a meeting on burns in Galveston, Texas. “I saw how bad things were in burn care and how badly we needed to improve it,” Dimick says. A major step in that direction came when UAB hosted the first meeting of the American Burn Association (ABA) in 1967. “We had about 200 people at that first meeting,” Dimick says. “Now we have about 3,000 at the annual meeting.” Secrets of Survival UAB is one of 130 burn centers in the United States and admits about 250 burn patients a year. Another 150 burn patients are admitted each year at Children’s Hospital. A patient’s length of stay, which once was usually two to three months, now averages 21 to 28 days. But the hospital stay is just the beginning of the challenge. “We call burns a two-year disease,” Dimick says. “That’s how long it often takes to recover.” When Dimick began to oversee burn care at UAB, he did not have many competitors for the job. “Everyone was happy for me to take care of the burn patients,” he says. “You have patients with raw, open wounds, crying and smelling bad, hurting all the time. Nobody wanted to deal with them.” It didn’t help that outcomes often were not favorable. But gradually, that began to change. Early surgery for burn patients was a major step forward. “In the ’60s and ’70s, we used to wait until the burned tissue was completely off the patient before we did any skin grafting,” Dimick says. “Now we take them into the OR during the first couple of days. We now know that once you cut off the dead tissue and cover the burn with a skin graft or artificial skin, the patient gets much better.” The value of nutrition also became apparent. “When you sustain a burn, the body begins working overtime to heal the wounds,” Dimick says. “Your metabolic rate goes up 100 to 200 times. So we have to put a tube into the stomach and literally pump food into the patient.”
Skin Grafts: A Tale of Twins Small Burns, Big Impacts Burn care requires a multidisciplinary approach, and that is why most burn centers are in large health-care facilities. “What I do is not an isolated thing,” Cross says. “I couldn’t do what I do in a small-hospital setting, without the physical and occupational therapy, the burn-dressing team, the specialists in nutrition, pain control, psychiatry, plastic surgery, and ophthalmology. All of these people work together on our burn patients at UAB.” The ABA has developed criteria for physicians to use in referring patients to burn centers. The idea, Cross says, is to let physicians know that burn centers are not just for patients with large burns. “Patients with burns greater than 20 percent are going to come here anyway because those are impressive burns,” Cross says. “But it’s also the small burn on the back of the hand that might affect several fingers, or the burn across the neck or face or a major joint—those are the ones we also need to see. “I couldn’t do what I do in a small-hospital setting, without the physical and occupational therapy, the burn-dressing team, the specialists in nutrition, pain control, psychiatry, plastic surgery, and ophthalmology. All of these people work together on our burn patients at UAB.” — James Cross, M.D. If a burn has the potential to affect a person’s function or appearance for the rest of his life, he should be sent to a burn center.” Assisting the loved ones of burn patients is another part of the equation. A support group called B.U.R.N.S. (Burns Understanding Resources Needs Support) meets once a month at UAB Hospital. And Dimick has long been involved in burn-prevention efforts. “Burns are always going to be with us,” he says. “As long as we have industry and transportation, as long as we have drugs and alcohol, we will have burns. That’s why we need people who will continue to be on the cutting edge of caring for burns.” William Hardin, M.D., examined the six-year-old girl with burns over more than 80 percent of her body and knew it was going to be a difficult case. “After the initial evaluation, I told her mother that the burns were severe and things didn’t look good,” Hardin says. “The mother was distraught and said this was going to devastate the little girl’s twin sister. The implications of her comment were enormous.” The mother’s comment touched off a medical, legal, and ethical story that has attracted national attention. Thankfully, the story has a happy ending. Jenny with a UAB staff member during a recent appointment at the hospital. Jenny Cowan was badly burned in early December 2002 after a fireplace explosion at the family’s home in Lynn Haven, Florida, near Panama City. She was transferred to Children’s Hospital in Birmingham with burns everywhere but on her head, her hands, behind her knees, and under her arms. She was on a ventilator for five days and in desperate need of skin grafts. Doctors put her chance of survival at 50 percent. Those chances improved when Hardin learned about Jenny’s twin sister, Sydney. “We know, from our experience with transplants, that the absolutely best match for any organ is an identical twin,” Hardin says. “But there were ethical and legal issues to be considered. Can you take skin from a normal child to benefit a sibling? Do you ask the child? Can a six-year-old consent? Who decides?” Hardin consulted experts nationwide, and the Cowan twin operation was approved by a medical ethics committee. The family went before a probate judge, who appointed attorneys for both children and conducted a hearing. The judge expressed “significant concerns,” Hardin said, but approved the grafts. Skin was taken from Sydney’s back, scalp, and bottom and successfully grafted onto Jenny. “Both girls are back in school, and the burned child is now in gymnastics class,” Hardin says. “They both are doing beautifully.” ABC’s 20/20 has filmed interviews for a segment about the Cowan twins. For Hardin, the ethical questions linger, and he recently made a Grand Rounds presentation about the case. “I posed the question: How much does the outcome influence perception of what we did? It was wildly successful from a medical perspective, but what if it had gone badly? We would be called to account for that. “Is the correctness of this, in terms of ethics, determined by the clinical outcome? I’ve had people say they can view the two separately. But I’m not sure I buy that.” Sydney (left) and Jenny Cowan. Sydney and Jenny (L and R, with an unidentified friend) recently celebrated their seventh birthday. 13
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