Annals of Burns and Fire Disasters - vol. XII - n° 2 - June 1999

NEVER TOO LATE? BURNS AND FUNDAMENTALISM

SUMMARY. This article considers how inadequate treatment may aggravate burn wounds. Two case histories are presented. Sometimes surgical treatment is recommended by a patient's physician but opposed by the family's religious adviser. It is recommended in such cases that there should be meetings with the counsellor so that the consequences of purely conservative treatment may be fully appreciated.

Introduction

Burn wounds can be aggravated by the wrong treatment, early hospital discharge, opposition to surgery in cases of deep burns, and treatment by inadequately trained personnel. Almost every month we face cases of patients who on the instructions of their religious advisers refuse to be treated in hospital or an out-patient clinic.
This article is dedicated to all burn patients - and their families - who owing to ignorance and the advice of nonmedical counsellors have suffered an aggravation of their injuries, i.e. patients whose treatment has been delayed, with an outcome that was less successful than might have been expected.
We present two extreme cases out of the many treated in our department.

Cases

A plastic surgeon usually treats a burn patient immediately after the burn event. In some cases there is a delay in the referral of a patient, who as a consequence arrives with advanced and neglected burns.

Case 1. R.S., an 8-year-old boy with 32% 2nd- and 3rd-degree burns, was admitted to the emergency room, after conservative treatment, with 13% open burn, hypergranulation, contracted scar in the knee (Fig. 1), and disturbed laboratory values: pt = 43%, inr = 2.73, vitamin k deficiency, leukoeytosis (23,500), thrombocytosis (902,000), hypoalburninaemia (21 g/1). The wound was infected with Candida albicans, Candida tropicalis, Pseudomonas, and Acinetobacter caluoace. Several days after hospitalization the patient developed a sepsis due to Candida infection. The child's hospitalization lasted 6 weeks, during which he twice underwent skin grafting.

Fig. 1 - Open wound in thigh and abdomen in child treated at home for 8 weeks.

Case 2. P.H., a 10-year-old girl, came to our out-patient clinic for consultation regarding a one-year old post-burn scar. The child had been hospitalized for a short term after the burn but left hospital without any surgical treatment.
The result of this second- intention healing scar is shown in Figs. 2 and 3. The patient underwent contracture release and skin grafting in the open wounds.

Fig. 2 - Second-intention healing after hot-water burn, with contracted scar permitting only 45° abduction movement of the shoulder. Fig. 3 - Same patient, anterior view.

Discussion

Deep burn wounds will create a scar following secondintention healing processes, but the deeper the burn the greater the chance of hypertrophic, keloid, and contracted scars.
Delay in wound healing can be due to systemic or localized conditions, and the best results are achieved through early detection of complications and early grafting of deep 2nd-degree burns.
For these reasons a follow-up by medical staff is mandatory.
We have witnessed cases in which an operation was recommended but the family's religious counsellor decided on conservative treatment, with disastrous results.
We therefore recommend meetings with such counsellors, if possible, in order to explain the possible consequences of delay or home treatment, using pictures of previous cases.
The most important thing for us is to disregard our ego and to understand that in all religions there are people who will obey their advisers and not our recommendations.
Nevertheless, always leave an open door for these patients so they will not be too embarrassed or afraid to return.

RESUME. Les Auteurs considèrent les conséquences négatives du traitement inadéquat des brûlures et présentent deux cas spécifiques.
Quelquefois le médecin conseille le traitement chirurgical, mais le conseiller religieux du patient s'y oppose. Dans ces cas il faut
organiser des rencontres avec le conseiller pour expliquer clairement toutes les conséquences possibles du traitement uniquement conservateur.

BIBLIOGRAPHY

1. Robson M.C., Barnett R.A., Leitch OW. et al.: Prevention and treatment of post-burn scars and contracture. World J. Surg., 16: 8796, 1992.
2. Robson M.C.: Disturbances of wound healing. Ann. Emerg. Med., 17: 1274-77, 1998. 3. Krizek T.J.,
3. Robson M.C., Kho E.: Bacterial growth and skin survival. Surg. Forum, 18: 518-20, 1967.
4. 4. Larson D.L., Abston S., Evans E.B. et al.: Techniques for decreasing scar formation and contractures in the burned patient. J. Trauma, 11: 807-23, 1971.