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FOREWORD The history of treating the burn-injured person in Victoria is closely associated with the development of, and continuing changes in, the Royal Jubilee Hospital's Burn Unit. Those of us, who have knowledge of present care of the burn injury in the Third World and the comparable treatment in the Western World prior to the advent of a specialized Unit, know first hand of the dramatic changes. The history of our Burn Unit mirrors, on a very small scale, what has happened with the treatment of burns in the Western World. I have been intimately involved in this change and so have attempted to document some of the dates and events of these parallel changes over a period of 35 years of burn-injury treatment. It is to be hoped that this brief History will be reviewed in the future and the story continued by another. I am grateful to the following
for their help in establishing the events accurately, recording
the anecdotes and in the production of the final draft: Mrs. Ethel
Jordan, Mrs. Bea Sinclair, Mrs. Joanne Pillar, Ms Kathie Johnson,
Dr. Embert Van Tilburg, Mr. Gerry Lister and Ms. Alison Gareau.
As well, I acknowledge my surgical colleagues, who are mentioned
little in the story but who have been at the center of the treatment
of the burn injured patient. |
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The treatment of the burn-injured person changed very little historically until this century. The Second World War and later the war in Viet Nam gave impetus to improvement. In WW II, the experience of surgeons in Britain, when so many air personnel were burned, resulted in studies that promoted new understanding and treatment. Four Plastic Surgery Units were established in Britain to meet the demand, with one surgeon at the Queen Victoria Hospital in East Grinstead, Sussex, doing more than any other to promote both early treatment and rehabilitation. Sir Archibald McIndoe was acknowledged as a superior technician, but more than that, he was an innovator. He popularized the saline tank for treatment, and developed many surgical techniques for the burned face and hand; yet he also understood the need for long-term rehabilitation as opposed to purely surgical repair. East Grinstead was an ideally chosen location for treating these large numbers of burn victims, as the pleasant country surroundings, a world away from the bombed cities and industrial areas, lent it to the long term rehabilitation required. Indeed, part of the patient's treatment was to face the outside community in shops, cinema etc. and here the small market town played a major role by readily accepting the many patients who were so badly deformed. The American experience during the Viet Nam war added even more to the knowledge and understanding of the burn injury, particularly when large numbers of patients were involved and equipment and facilities were strained. Most of the knowledge gained, was learned from thermal burns but the treatment of chemical, electrical and radiation burns also benefited since they all have some common characteristics. Prior to the 1960's, burn injuries were treated throughout Canada, and in fact the world, on general surgical and occasionally medical wards, alongside all other injuries and illnesses. Sometimes patients were even assigned to isolation wards where they were treated amongst extremely infectious patients, the rationale being, that all burn patients inevitably became infected and were therefore a hazard to others. In the evolution of treatment approaching the 1960's, this understanding changed and there was recognition that the burn patient did not necessarily need to become infected and in fact, they were the ones needing protection. Only later was it further appreciated that one common source of patient infection was the patient's own organisms. In the meantime, separation of the particularly vulnerable burn-injured from the rest of the hospital population was introduced, using private or even corner rooms, where a certain amount of traffic control could be achieved. From that point, it was a minor step to advocate a separate ward for this injury, namely a Burn Unit, with a dedicated staff as well as environmental control. (In this context, "dedicated" refers not just to motivation, but also to a staff who have specialized training in Burn Care and confine themselves to treating these patients.) This was a major advance and probably accounts for more of the progress in the treatment of burns than any other single item, including all the support technology and antibiotics. Unfortunately, in the Third World this understanding and the many other improvements seen in this century have yet to be achieved. In fact, over the last 20 years, one has had to travel well outside the Western World to see examples of the type of burn complications which were once commonplace here. VICTORIA: BEFORE THE BURN UNIT With the help of others, and particularly Dr. Embert Van Tilburg, Mrs. Ethel Jordan, Mrs. Bea Sinclair, and Ms. Kathie Johnson, I will relate the essential facts regarding our present Burn Unit. It was in England, in East Grinstead, long after the war where I met Alastair Baird and where we finished our training together before returning to Canada to practice. He went to Winnipeg and I came to Victoria in 1962. I was then the only Plastic Surgeon on Vancouver Island until 1969 when Dr. Baird joined me in practice. Dr. John Wellman joined us on the staff in1970. The first Head Nurse through this difficult pre-Burn Unit period, was Mrs. Ethel Jordan who continued on when the Burn Unit first opened. She was Head Nurse of Ward 3C-East at St. Joseph's Hospital in Victoria, where burn-related adults were admitted during the 1960's. (Children were treated on the pediatric ward.) Mrs. Jordan vividly remembers a time "when we worked in the crudest of pre-Burn Unit environments She states that "the patients were treated in a private room on Ward 3C-East - no screens and no sinks, so we had basins of water to wash our hands. I remember the first burn patient we had - he had 60% of his body burnt - 1st, 2nd, and 3rd degree burns. Our knowledge of nursing burn patients was very limited. We did the best we knew how - basically following Dr.'s orders - but it was not enough to save the patient". Mrs. Jordan's recollections include the advent of silver nitrate compresses for dressings. It had been discovered that gram-negative organisms were particularly sensitive to silver nitrate. Later this was incorporated into creams, but originally a very messy dressing procedure was involved, which resulted in the silver solution of the compresses staining everything black. One patient, presumably establishing an independence not otherwise available, took to throwing the compresses about the room spattering walls, floor, furniture, not to mention innocent nurses, coloring all with a splashy black decoration. Not only the staff but also the Laundry Department complained mightily, and one result was that the linen for such patients was kept separate from the linen used for the rest of the Hospital. One of the measures taken by the nurses to protect themselves from the discoloration of their clothing was that of winding perforated naso-gastric tubes into the dressings. The silver nitrate solution could then be flushed through the tube and would keep the compresses moist without necessitating such frequent dressing changes. She goes on to say "we learned from our experiences, daily. As well, we attended courses and perhaps increased our reading of contemporary scientific literature." I was no exception, and learned lessons continually in this atmosphere. For instance, I had read about people who were unable to sweat after very extensive skin grafting but it took me some time to appreciate the symptoms a patient complained of long after he was discharged and attempting to work, namely: dizziness, marked suffering of heat and headaches accompanying exertion of any sort. He had been so badly burned and had required so much skin grafting, that as his temperature rose his body was unable to respond normally (as grafts do not sweat). There are many other such incidents, which the nurses and I remember. In order to introduce hydrotherapy for the burned patient, use of the Hubbard tank in the Physiotherapy Department three floors away, had to be scheduled. This was extremely difficult, not only because of time constraints, but also the resistance of some, because of the perceived potential contamination from burn patients. Mrs. Jordan also recalls that transverse the distance involved was both draughty and painful for the patients. Another problem arose when our time honored and natural ventilation system (of opening a window), had the unfortunate result of maggots being found on a patient. This upset patient and staff alike. (Our aesthetic sense does not usually allow the benefits offered by such crawlies to be appreciated.) The fact is however that maggots only devour dead tissue and if allowed, would clean up such a wound beautifully. An occasional visit to the
morgue was not unusual in order to harvest homologous skin for grafting
the severely injured (which became a necessity, when a patient did
not have enough unburned donor surface him/herself). In those days
mortality rates quoted in the literature were very high by the standards
we know today. For instance, a third degree burn of over 40% of
the body area had associated with it a 50% mortality rate. Today,
this has been greatly reduced. Infection, the major cause of death
after a burn injury, could not be adequately controlled in the rudimentary
working surroundings that the nurses endured. They deserve credit
as well, for putting up with, what in retrospect, has to be seen
as crude treatment modalities. Pain was not as well controlled as
it is today, and consequently, both debriding (removing dead tissue/skin)
and dressing techniques were much more difficult. Because there
was no separate treatment room, which therefore necessitated changing
dressings in bed rooms, and because the exposure method of treatment
was being used more frequently, the rooms had to be kept very warm;
uncomfortably so for the staff. In spite of the difficulties, a
dedicated nucleus of nurses became expert in burn care, but it was
nonetheless becoming more and more apparent that a formal Burn Unit
was required. |
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