PERSONAL EXPERIENCE IN ESTABLISHING A BURN CARE FACILITY

Reda Mabrouk AW.

Burns and Plastic Surgery Unit, Helipolis, Cairo, Egypt

SUMMARY. The author describes the three phases of his experience in 25 years of managing burn patients in Military Service and National Health Organization Hospitals, i.e. the early sixties, the late sixties, and the early seventies. In this last period it was decided to build a Military Burns Centre which would also accept civilians and deal with mass casualties. An account is given of the basic criteria followed in the creation of the Centre, as well as a description of its actual functioning.

Returning from the United Kingdom in 1961 after training with the late Mr A.B. Wallace, I took the responsibility of treating burn injuries together with plastic surgery problems, both in the Egyptian Armed Forces and in some civilian hospitals run by the National Health Organization. The study of this experience of more than twenty-five years may be discussed as three periods in the development of burn care facilities:

1. The early sixties: during this period we had to deal with sporadic cases caused by what may be considered as civilian causes. The management required:

1. study of the aetiology, incidence and causes of burn injuries
2. personnel training: medical and nursing staff were chosen from junior staff and had to be honest, energetic, enthusiastic and interested.

Training was encouraged by adopting the team-work scheme, by giving the trainees the chance to practise plastic reconstructive surgery as well, and by giving them fulfilled promises for scholarships.
A small Burns Unit was established as a part of a general plastic reconstructive surgery department. Facilities for work included a separate dressing-room, but the same wards and the same operating theatre.
A standard treatment programme was agreed upon and adopted for each case.

2. The late sixties: starting from June 1967 a separate Burns Unit was established with:

• four intensive care beds
• four cubicles each of two beds.

Precautions were taken to guard against infection and cross-infection and to regulate the temperature by separate air-conditioning units. Facilities also included:

• a small laboratory
• two dressing-rooms: one for major injuries and the other for minor ones
• a separate theatre for grafting operations.
• Homografts were supplied by volunteers when needed. The medical staff shared their responsibilities in the management of burns with responsibilities in plastic reconstructive surgery in a rotatory scheme.

According to military orders injured soldiers must not leave hospital before complete cure. Patients were thus transferred to plastic surgery wards during the healing stage.

3. The early and mid-seventies: the mass casualties dealt with in June 1967 together with the good results achieved from our management helped us to persuade the authorities to let us have our own Military Burns Centre.
The design and study of the Centre took more than two years. The basis of our study was:

1. statistical data of aetiology of the burn cases admitted to the military hospitals during the previous fifteen years. The incidence of burns admitted to hospitals in the Cairo area was also considered: 13,765 cases were admitted during 1976;
2. detailed study of different Burns Centres and Units in other countries. The senior staff were granted scholarships to visit units in the UK, France, Sweden, Denmark, Belgium, Jugoslavia and the USA;
3. social and economical study of the Armed Forces and of our country.

Purpose of the Centre

1. Formation of team that can acquire knowledge and experience in the treatment of burns.
2. Treatment of military personnels, their dependents and referred civilians.
3. Education of medical and nursing professions.
4. Study of prevention of burns for public information.
5. Research work for improvement of management and for prevention.
6. Fulfilment of the Armed Forces orders in hospitalization of soldiers during convalescence and in preparedness to deal with mass casualties. This means having more beds than the internationally accepted numbers.

1. Economic problems:

1. High cost of establishing a highly sophisticated and expensive facility
2. High expenses of running and maintenance.

2. High possibility of sepsis in the event of inadequacy of precautions and with the admission of new patients with old septic burns.

3. Psychological Trauma:

• for the patient, who is isolated and allowed only strict visiting facilities
• for doctors, whose work is more or less monotonous. This could be overcome by their periodical sharing in plastic reconstructive surgery and by being given facilities for research work.

Principles in Construction and Running the Centre

1. The building is isolated, but attached to and dependent on a general hospital for food supply, laundry, main laboratory and other medical specialities, such as physiotherapy, orthopaedic surgery, ophthalmology, nephrology, etc.
2. The administration should be independent, with a separate budget. An experimental 6-month period of organization and administration is advised before establishing the administration rules. It is advisable to have a plastic surgeon as the Director.
3. The Centre should be a one-floor building, with plenty of storage places. Disposal of dirty dressing should be by a chute-system.
4. The out-patient department should be separate from the Centre, and facilities for follow-up and reception of old burns can be a part of the plastic surgery out-patient section.
5. The rule is to have one bed per 100,000 inhabitants, with a maximum of 20 beds. There is no objection to having more beds for convalescents in order to fulfil military orders. It was therefore agreed to have 4 beds for resuscitation, 10 for intensive care and the rest for convalescent patients (36 beds).
6. Air Control: the centre should be air locked. Temperature: for resuscitation and ICU, 24-30 Humidity: should be reduced to the accepted %. Air Pressure: highest in resuscitation, ICU and operating theatres. Not so high In isolation rooms; convalescent wards are not necessarily pressurized but should be air-conditioned. The Reception Room should be high-pressure with access to Resuscitation.
7. The Centre should be equipped with a mobile X-ray apparatus.
8. Personnel:

Nursing Staff (8-hour shifts):

6-8 for each patient in Resuscitation and ICU
6 Nurses for 12 patients in isolation cubicles
3 Nurses for 12 patients in convalescent wards
9. Miscellaneous:

During our study and construction of the centre, all the medical staff were granted scholarships abroad for 3-12 months to complete their training and to visit various Burns Centres and Units. Two senior nurses were each given the chance to train in France for a year.
Construction of the centre took about 3 years. All the above requirements were fulfilled. A second floor was added to the bulding to accommodate convalescent patients. The Centre is equipped with four fluidized beds and a skin bank.

RÉSUMÉ. L'Ameur décrit les trois phases de ses 25 ans d'expérience dans la gestion des patients brûlés chez les Hôpitaux du Service Militaire et du Service National de la Santé, c'est-à-dire pendant les premières années Soixante, les dernières années Soixante, et les premières années Soixante-dix. Dans cette dernière période, on a décidé de construire un Centre Militaire des Brûlés qui en outre accepterait les patients civils et pourrait être utilisé en cas de brûlures en masse. Les critères de base suivis pendant la construction du Centre sont définis, et il y a une description du fonctionnement actuel du Centre.

BIBLIOGRAPHY

1. Reda Mabrouk AW.: The causes and incidence of bums and factors in their prevention and management in the UAR. In: Wallace A.B. (Ed.): "Research in bums", E. & S. Livingstone, Edinburgh, 1966.
2. Feller 1, Crane K.H.: Planning and designing a burn care facility. Ann Arbor, Michigan, Institute for Burn Medicine, 1971.
3. Reda Mabrouk AW.: Bum injuries in Egypt. Incidence and management. Annals of the Mediterranean Bums Club, 1: 2 1-261988.