Bums (1992) 18, Supplement 2, 55 -5 6
Printedin Greaf&fain
ss
Preface: Organizational aspects of burn care in The Netherlands and some aspects of future burn care R. P. Hermans Beverwijk, The Netherlands
In the 1950s no dedicated bum facility existed in The Netherlands. Mostly patients were treated in a general surgical department or, if children were the bum victims, in a paediatric department. The treatment was conservative, usually with antibiotic creams. This type of treatment caused terrible pain to the patients and lead to a very slow healing process. The Red Cross Hospital in Beverwijk was near a steel factory. Serious bum patients were regularly admitted from this factory, and, as the university hospitals were not equipped to treat major bums, these patients had to stay in the Red Cross Hospital. Gradually, more and better skills were acquired, articles were published by the several researchers from Beverwijk and the hospital became known for its bum treatment. It became a referral centre and patients were admitted even from centres outside The Netherlands. When it was decided to build a new hospital in Beverwijk, it was clear that the building should include a dedicated bum care facility, which was opened in 1974 with a successful International Congress. Later, two more Dutch bum centres were opened, one in Groningen under the leadership of Professor Klasen and one in Rotterdam under the leadership of Dr Boxma. A close cooperation has always existed between the three centres. The latest development in the Beverwijk Centre has been the opening of a separate bums unit for children and the institution of four apartments, where families of the bum patient can be near to their relatives in a comfortable and affordable way.
The Dutch National
Skinbank
In 1971, the Dutch Bums Association was founded to coordinate bum research and prevention. Soon, research on donor skin started and the Dutch National Skinbank was founded under the auspices of the Dutch National Bums Association. Serving the entire country, the skinbank soon became one of the largest in the world. Initially liquid nitrogen was used as the storage medium. Hoekstra developed new ways of conserving donor skin, using 98 per cent glycerol. This method enabled the skinbank to operate in a more cost-effective way, and made distribution of the skin throughout Europe easier. Furthermore, glycerol has been shown to have antimicrobial effects. The extensive experience with allografts lead us to believe that the use of donor skin has caused one of the major changes in the treatment of partial thickness bums, in small children with scalds. Cosmetically particularly 4;) 1992 Butterworth-Heinemann 0305-4179/92/s20!?--02
Ltd
beautiful results could be achieved, and pain relief usually occurred instantaneously after the skin was applied to the wounds. Glycerolized donor skin is also used in the sandwich technique for the treatment of extensive full thickness bums (see pp. S19-S22).
The burn team Today, with all the modem facilities, it is very difficult to realize the problems that occurred in the early days of bum treatment. Shock prevention was very difficult to perform. Arterial punctures, central venous lines, etc. were virtually unheard of, and many diagnostic procedures that are now taken for granted were simply non-existent. Patients could not be fed with an intravenous line and ‘starvation’ was part of the therapy. Parenteral nutrition has been used extensively, but now there is a clear trend towards early enteral feeding. More important than technology, however, are the people. The treatment of bums is impossible without a dedicated team, consisting of anaesthetists, nurses, intensivists, physiotherapists, and many other specialists. A bum centre can only be successtul it it is run by a stable statt that have knowledge and experience in care and treatment and can cope with all the difficult problems that arise around a patient with a bum injury. All the work should be done in collaboration with all specialists concerned, and this includes the management of the hospital.
The burn triage teams The three Dutch bum centres have developed a countrywide system for triage of bum victims of a major disaster. Research has shown that, in such a disaster, a significant pattern can be recognized in most cases; usually a large percentage of all victims have very extensive or minor injuries and a relatively small percentage have bums of 30-70 per cent TBSA. Following disasters bum victims are referred to local hospitals. In these hospitals initial treatment is given according to standard protocols, and the B-team perform triage, to determine which patients should be transferred to the bum centres. This system avoids acute overload of the centres and provides a treatment scheme which is easier to coordinate and to apply.
Bums (1992)Supplement
Sri
The future, what is to be expected care
in burn
The cosmetic results of bum treatment are typically not very acceptable. The physiology of the development of hypertrophic scarring and keloid formation is, at the moment, not fully understood, but reassuring work is being done. Once these processes have become clear, it is very likely that it will be possible to influence them by using topically administered new drugs, and/or mechanical devices and techniques. It is very likely that donor skin will remain the ‘golden standard for the temporary coverage of bum wounds in the near future, although some substitutes exist already (DuoDERM, Opsite) for the treatment of smaller partial skin thickness bums. Like donor skin, these materials can provide pain relief, fast healing, and, above all, a good quality scar. It is expected that real artificial skin will become available in the future. Better knowledge of the immunological processes in the bum patient will, without any doubt, lead to the development of new drugs and treatment regimens that will contribute to the survival chances for bum victims and, probably more important, to more acceptable scars. Selective decontamination of the digestive tract (SDD) has been used in Beverwijk for 3 years. The preliminary results show that SDD offers a very promising new means of controlling wound infection and sepsis. The possible consequences could be that local antimicrobial treatment, which is known to impair wound healing, would be less often necessary. Cultured keratinocytes, used as autografts or allografts, have gained a definite place in the treatment of large skin defects. A common problem with these sheets of cells, however, is their fragility; mechanical and chemical influences can destroy them very easily. It is very likely that a better understanding of the architecture and physiology of the dermis will lead to the production of a proper dermal component in conjunction with cultured keratinocytes; this will overcome the current drawbacks. General treatment possibilities, which already have reached such a high standard, may even become more developed to such an extent that survival rates for old and very young patients will become higher. Studies of the psychology of the bum victim is relatively new. Bum patients not only suffer from physical injuries, but very often also from major psychological trauma. Addressing these problems needs specialists in this field, and, fortunately, psychiatrists and psychologists have become more involved with the treatment of bum victims. In the western world, to a significant extent, and in the east (particularly India) to a greater extent, many patients admitted to bum centres inflicted the bums upon themselves in an attempt to commit suicide. The treatment of these patients raises major questions in some countries: ‘Does a bum team have the right to keep the patient alive using the sophisticated armoury that is now available if he or she really wants to die’, and ‘Does the attempt to commit suicide indicate a “death wish”, or is it a cry for attention or is it a “simple” means of fleeing from impossible circumstances of
2
living.’ The consequences of raising these questions should be very carefully addressed. In spite of the technical possibilities for treating patients with extensive bums, the majority of the world population cannot benefit from this technology. In many developing countries, modem equipment and techniques are simply not available. Therefore, the western world has the task to develop techniques that are less expensive and will still result in ‘proper bum care’. A programme, developed under the auspices of the International Society for Bum Injuries and the American Bum Association (ISBI/ABA), promises to take a leading role in the exchange of knowledge and treatment possibilities between the ‘Third World and ‘First World.
Acknowledgements It has been wonderful to have been in a position to experience and even help a little bit with the turbulent developments in bum treatment that have taken place during the last decades. From an underdeveloped country, Holland has become very well developed as far as bum treatment is concerned, with two more Dutch bum centres in addition to that in Beverwijk. The University of Amsterdam recognized the importance of care for bum victims and so I had the honour of becoming a Professor. I am very grateful to everyone with whom I have had the pleasure of working. Thanking everyone concerned is impossible; there are just too many of them. However, I would like to mention some people in particular:
-Dr
Schepel, who introduced me to early excision and grafting. - Dr Douglas Jackson, who taught me his techniques. -Dr C. Fox Jr, who was a very good friend and who, through his invention of silver sulphadiazine (SSD), has saved many thousands of lives. -Dr Huffstadt, who helped me, together with some captains of industry, to found the Dutch Bums Association. -Dr Spijker, who played a decisive role in the Red Cross Hospital in establishing a burn treatment facility. -Dr Kreis, who has contributed invaluably and in innumerable ways. - Dr Vloemans, who now runs the surgical part of the bum centre in collaboration with Dr Kreis. - Mrs van der Syde, who has so splendidly organized the Dutch National Skinbank. - Mrs Buur, with whom we formed the beginning of a bum team. -The many international bum friends who were willing to come to the opening symposium of the Beverwijk Bum Centre and who contributed to the success of the conference. -The friends from Denmark, the UK and some Eastern European countries with whom we founded the European Bums Association in the early 1980s.
Printedin Greaf&fain
ss
Preface: Organizational aspects of burn care in The Netherlands and some aspects of future burn care R. P. Hermans Beverwijk, The Netherlands
In the 1950s no dedicated bum facility existed in The Netherlands. Mostly patients were treated in a general surgical department or, if children were the bum victims, in a paediatric department. The treatment was conservative, usually with antibiotic creams. This type of treatment caused terrible pain to the patients and lead to a very slow healing process. The Red Cross Hospital in Beverwijk was near a steel factory. Serious bum patients were regularly admitted from this factory, and, as the university hospitals were not equipped to treat major bums, these patients had to stay in the Red Cross Hospital. Gradually, more and better skills were acquired, articles were published by the several researchers from Beverwijk and the hospital became known for its bum treatment. It became a referral centre and patients were admitted even from centres outside The Netherlands. When it was decided to build a new hospital in Beverwijk, it was clear that the building should include a dedicated bum care facility, which was opened in 1974 with a successful International Congress. Later, two more Dutch bum centres were opened, one in Groningen under the leadership of Professor Klasen and one in Rotterdam under the leadership of Dr Boxma. A close cooperation has always existed between the three centres. The latest development in the Beverwijk Centre has been the opening of a separate bums unit for children and the institution of four apartments, where families of the bum patient can be near to their relatives in a comfortable and affordable way.
The Dutch National
Skinbank
In 1971, the Dutch Bums Association was founded to coordinate bum research and prevention. Soon, research on donor skin started and the Dutch National Skinbank was founded under the auspices of the Dutch National Bums Association. Serving the entire country, the skinbank soon became one of the largest in the world. Initially liquid nitrogen was used as the storage medium. Hoekstra developed new ways of conserving donor skin, using 98 per cent glycerol. This method enabled the skinbank to operate in a more cost-effective way, and made distribution of the skin throughout Europe easier. Furthermore, glycerol has been shown to have antimicrobial effects. The extensive experience with allografts lead us to believe that the use of donor skin has caused one of the major changes in the treatment of partial thickness bums, in small children with scalds. Cosmetically particularly 4;) 1992 Butterworth-Heinemann 0305-4179/92/s20!?--02
Ltd
beautiful results could be achieved, and pain relief usually occurred instantaneously after the skin was applied to the wounds. Glycerolized donor skin is also used in the sandwich technique for the treatment of extensive full thickness bums (see pp. S19-S22).
The burn team Today, with all the modem facilities, it is very difficult to realize the problems that occurred in the early days of bum treatment. Shock prevention was very difficult to perform. Arterial punctures, central venous lines, etc. were virtually unheard of, and many diagnostic procedures that are now taken for granted were simply non-existent. Patients could not be fed with an intravenous line and ‘starvation’ was part of the therapy. Parenteral nutrition has been used extensively, but now there is a clear trend towards early enteral feeding. More important than technology, however, are the people. The treatment of bums is impossible without a dedicated team, consisting of anaesthetists, nurses, intensivists, physiotherapists, and many other specialists. A bum centre can only be successtul it it is run by a stable statt that have knowledge and experience in care and treatment and can cope with all the difficult problems that arise around a patient with a bum injury. All the work should be done in collaboration with all specialists concerned, and this includes the management of the hospital.
The burn triage teams The three Dutch bum centres have developed a countrywide system for triage of bum victims of a major disaster. Research has shown that, in such a disaster, a significant pattern can be recognized in most cases; usually a large percentage of all victims have very extensive or minor injuries and a relatively small percentage have bums of 30-70 per cent TBSA. Following disasters bum victims are referred to local hospitals. In these hospitals initial treatment is given according to standard protocols, and the B-team perform triage, to determine which patients should be transferred to the bum centres. This system avoids acute overload of the centres and provides a treatment scheme which is easier to coordinate and to apply.
Bums (1992)Supplement
Sri
The future, what is to be expected care
in burn
The cosmetic results of bum treatment are typically not very acceptable. The physiology of the development of hypertrophic scarring and keloid formation is, at the moment, not fully understood, but reassuring work is being done. Once these processes have become clear, it is very likely that it will be possible to influence them by using topically administered new drugs, and/or mechanical devices and techniques. It is very likely that donor skin will remain the ‘golden standard for the temporary coverage of bum wounds in the near future, although some substitutes exist already (DuoDERM, Opsite) for the treatment of smaller partial skin thickness bums. Like donor skin, these materials can provide pain relief, fast healing, and, above all, a good quality scar. It is expected that real artificial skin will become available in the future. Better knowledge of the immunological processes in the bum patient will, without any doubt, lead to the development of new drugs and treatment regimens that will contribute to the survival chances for bum victims and, probably more important, to more acceptable scars. Selective decontamination of the digestive tract (SDD) has been used in Beverwijk for 3 years. The preliminary results show that SDD offers a very promising new means of controlling wound infection and sepsis. The possible consequences could be that local antimicrobial treatment, which is known to impair wound healing, would be less often necessary. Cultured keratinocytes, used as autografts or allografts, have gained a definite place in the treatment of large skin defects. A common problem with these sheets of cells, however, is their fragility; mechanical and chemical influences can destroy them very easily. It is very likely that a better understanding of the architecture and physiology of the dermis will lead to the production of a proper dermal component in conjunction with cultured keratinocytes; this will overcome the current drawbacks. General treatment possibilities, which already have reached such a high standard, may even become more developed to such an extent that survival rates for old and very young patients will become higher. Studies of the psychology of the bum victim is relatively new. Bum patients not only suffer from physical injuries, but very often also from major psychological trauma. Addressing these problems needs specialists in this field, and, fortunately, psychiatrists and psychologists have become more involved with the treatment of bum victims. In the western world, to a significant extent, and in the east (particularly India) to a greater extent, many patients admitted to bum centres inflicted the bums upon themselves in an attempt to commit suicide. The treatment of these patients raises major questions in some countries: ‘Does a bum team have the right to keep the patient alive using the sophisticated armoury that is now available if he or she really wants to die’, and ‘Does the attempt to commit suicide indicate a “death wish”, or is it a cry for attention or is it a “simple” means of fleeing from impossible circumstances of
2
living.’ The consequences of raising these questions should be very carefully addressed. In spite of the technical possibilities for treating patients with extensive bums, the majority of the world population cannot benefit from this technology. In many developing countries, modem equipment and techniques are simply not available. Therefore, the western world has the task to develop techniques that are less expensive and will still result in ‘proper bum care’. A programme, developed under the auspices of the International Society for Bum Injuries and the American Bum Association (ISBI/ABA), promises to take a leading role in the exchange of knowledge and treatment possibilities between the ‘Third World and ‘First World.
Acknowledgements It has been wonderful to have been in a position to experience and even help a little bit with the turbulent developments in bum treatment that have taken place during the last decades. From an underdeveloped country, Holland has become very well developed as far as bum treatment is concerned, with two more Dutch bum centres in addition to that in Beverwijk. The University of Amsterdam recognized the importance of care for bum victims and so I had the honour of becoming a Professor. I am very grateful to everyone with whom I have had the pleasure of working. Thanking everyone concerned is impossible; there are just too many of them. However, I would like to mention some people in particular:
-Dr
Schepel, who introduced me to early excision and grafting. - Dr Douglas Jackson, who taught me his techniques. -Dr C. Fox Jr, who was a very good friend and who, through his invention of silver sulphadiazine (SSD), has saved many thousands of lives. -Dr Huffstadt, who helped me, together with some captains of industry, to found the Dutch Bums Association. -Dr Spijker, who played a decisive role in the Red Cross Hospital in establishing a burn treatment facility. -Dr Kreis, who has contributed invaluably and in innumerable ways. - Dr Vloemans, who now runs the surgical part of the bum centre in collaboration with Dr Kreis. - Mrs van der Syde, who has so splendidly organized the Dutch National Skinbank. - Mrs Buur, with whom we formed the beginning of a bum team. -The many international bum friends who were willing to come to the opening symposium of the Beverwijk Bum Centre and who contributed to the success of the conference. -The friends from Denmark, the UK and some Eastern European countries with whom we founded the European Bums Association in the early 1980s.
