The U.S. experience with burn care in Iraq and Afghanistan, and from the 9/11 attacks and recent natural disasters, has accelerated improvements in burn care in both the civilian and military spheres of medicine. The experience has often been a symbiotic one. Civilian physicians are deployed, and re-deployed, as military reservists, or participate in 2-4 week tours at the U.S. military’s Regional Medical Center in Landstuhl, Germany, where they learn by participating in the care of severely injured soldiers and assist in the education of clinical staff. In addition, the Department of Defense has opened trauma training sites where military surgeons are exposed to cutting-edge civilian concepts in trauma care. These programs have facilitated a dialogue between military and civilian trauma surgeons and burn specialists, and are helping: (a) to improve clinical outcomes in burn management during the ongoing wars in Iraq and Afghanistan; and (b) to sharpen the nation’s community planning for civilian mass-casualty programs.
Historically, 10-25 percent of all casualties inflicted during a military conflict involve burns of some type. Of these, nearly 20 percent are categorized as severe and/or involve greater than 20 percent of the patient’s total body surface area (TBSA). As in civilian burn care, the strategic priority for military burn management is the early evacuation to a facility that specializes in burn management, careful management of acute resuscitation, and the early excision of burn wounds and definitive coverage with auto-graft.
To prevent organ failure and death, optimal resuscitation while avoiding over-resuscitation morbidity is critical in the first 24 hours post-burn. Burn patients injured in the continental United States generally experience triage and early resuscitation efforts by a team of emergency medical technicians, followed by transportation to a definitive care facility, within several hours after injury. Military burn casualties injured in the Middle East, though, are rapidly evacuated, not across town, but across three continents, to the U.S. Army’s Institute of Surgical Research Burn Center (Army Burn Center) in San Antonio, Texas. Transport times average 3-6 days versus the several weeks it took to transport burn casualties injured during the Vietnam War.
From the Battlefield to Balad to Landstuhl to Brooke
In the current conflicts in Iraq and Afghanistan, the typical soldier or marine victim has been injured by an improvised explosive device (IED) that has caused a combination of blunt and penetrating injuries and burns. The patient receives first aid from a medic and is then transported by helicopter to trauma facilities in the combat zone, where initial decontamination, débridement, and abbreviated operations (damage-control surgery) are carried out. Within a few hours after being injured, the patient is transported by helicopter to the next level of care (at Baghdad or Balad in Iraq, and at Bagram in Afghanistan), where more definitive care – including fasciotomies, escharotomies, and burn débridement – is provided.
These severely injured patients are then transported by the Air Force’s Critical Care Air Transport Teams (CCATTs) in large, fixed-winged planes to Landstuhl, where they typically arrive within 24 to 36 hours after being injured. The receiving teams at the trauma center at Landstuhl usually receive eight hours notice of incoming patients and, by using the Web-based Joint Patient Tracking Application, can preview each patient’s case (including injuries sustained, operations performed, blood products received, and medications administered) even before the patient arrives at Landstuhl. Computed tomographic scans and the results of other radiographic assessments also are available on this Web-based registry. In addition, burn teams from Brooke Army Medical Center in Texas have frequently flown to Germany both to assist in the early management of major burns and to accompany patients back to Brooke to facilitate continuity of the care provided.
To ensure high quality and consistent care, and because of the high turnover rate of deployed nurses and physicians, standardized treatment guidelines have been implemented and rigidly adhered to. The National Institutes of Health developed intensive-care protocols for burn management. In response to an increased incidence of over-resuscitated patients, burn-resuscitation guidelines (BRGs) were developed and promulgated, along with a burn flow sheet (BFS) to better document the resuscitation efforts carried out during the evacuation. Use of the BRG and BFS has been extremely effective in improving the documentation and standardization of care.
Team Efforts, Rapid Treatment, High-Speed Transportation
These initiatives at standardizing burn management during evacuation and in intensive care were often team efforts that included civilian consulting surgeons as members of the team. The application of these standard operating procedures to civilian burn management is expected to be equally beneficial, because the procedures address problems common to both the civilian and military medical communities: communication and documentation deficiencies; the care delivered by personnel possessing different levels of specialization; and frequent staff turnover.
Rapid treatment and critical-care transportation capabilities remain vital to the survival of burn casualties who may have been injured thousands of miles away from medical centers where definitive care can be provided. Early consultation, both remotely and in-theater, and early communication between deployed providers caring for the burn casualty and the burn center staff are essential. Special training – such as that provided through the CCATT and Joint Combat Predeployment courses – serves as a core curriculum that inculcates standardized protocols and a common clinical language, both of which facilitate uniform and continuous care, the protocol-driven in-flight management of burn and trauma patients, and uniform documentation requirements.
The Advanced Burn Life Support Course at the U.S. Army Institute of Surgical Research at Fort Sam Houston, Texas, has been used to train military physicians and nurses for more than 16 years. While preparing for the hostilities in Iraq, the faculty developed several add-on modules, including specialized segments on: (a) the treatment of white phosphorus burns; (b) the treatment for mustard gas exposure; (c) the long-range aeromedical transfer of burn patients; (d) the management of burn patients beyond the first 24 hours; and (e) the delivery of burn care in austere environments. These new modules are also applicable to many if not all civilian terrorist or mass-casualty situations.
Psychological Responses to Burn Injuries
Psychological problems are a frequent component of the response to burn injury. Burn victims often display symptoms that can impede recovery, a problem that can cause severe long-term impairment, both physical and psychological. Among the psychiatric problems frequently seen in burn patients are depression and post-traumatic stress disorder (PTSD), usually characterized by a fear reaction during the trauma and subsequent intrusions, avoidance, and hyperarousal. The PTSD rate of burn victims varies between 9 percent and 35 percent at 2 to 4 months after the burn injury. Unfortunately, the extent to which psychological factors such as coping style predict the psychological outcome for burn patients is not yet well understood. The true incidence of post-traumatic stress disorder after a combat burn injury – and how best to prevent or treat it – also remains an important unresolved issue.
A study of the burn support received by 38 burned service members from Operation Iraqi Freedom determined that 44.7 percent of them had core symptoms of anxiety, and 26.3 percent had core symptoms of depression. Careful consideration must be given to each diagnosis when evaluating service members exposed to explosions – who also may be suffering from minimal brain trauma, which has overlapping symptoms with PTSD. The need to provide psychological care for the burn victim’s family, and for the treating team, also has received belated attention.
The experience at burn centers has confirmed the value of certain services. It is important, for example, to provide families with free lodgings near the burn-care facility. Soldiers also should be supported by events such as award ceremonies and visits by military leaders and other dignitaries. Having the burn-service members grouped in one location facilitates this type of support and improves morale.
Prevention Strategies Plus Protective Clothing
The civilian experience in the primary prevention of burns has assisted military efforts to develop barriers to burn injury. New developments in weapons seek to exploit the vulnerability of the serviceman and servicewoman to burn injury. Clothing can be a barrier to some types of burn, not only inherently in the properties of the material but also by trapping air between layers of clothing.
Conversely, ignition of the clothing may exacerbate a burn. Even relatively lightweight combat clothing can offer significant protection to skin from short-duration flash burns; the most vulnerable areas are the parts of the body that are not covered – i.e., the face and hands. In one study, 98 percent of tank crewmen who had sustained burn injuries were found to have been wearing fireproof suits at the time they were burned. The wearing of protective suits: (a) increased the percentage of minor burns from 21 percent to 51 percent; and (b) reduced, from 29 percent to 18 percent, the percentage of burns greater than 40 percent TBSA. Only 12 percent of the victims studied had sustained abdominal burns, whereas 77 percent had facial burns (in large part because none of them were wearing fireproof masks).
On the other hand, only 9 percent of the soldiers burned who wore fireproof gloves sustained hand burns, compared with 75 percent of those who were not wearing the gloves. The Army alone has issued almost two million pairs of FR-rated gloves to its combat personnel. However, simply because gloves (or any other types of protective gear) have been issued does not guarantee they will be used. Numerous studies have reinforced the importance of continuous supervision to optimize and maintain compliance with the requirement to wear preventive clothing.
Dwindling Capacity and Other Problems
Burn-care capacity in the United States has decreased significantly during the last decade. In the 12-year interval between the two desert wars, the number of burn beds in the United States, according to the ABA Burn Care Resources Guide, has decreased from 1,966 beds to 1,897 beds. In the same time frame, 16 burn centers have closed, and several others (including the Army Burn Center) have downsized. The remaining burn centers have lost at least some of their surge capacity.
Burn care beds and nurse specialists are suffering critical shortages. As one author described it, changes in inventory management to “just in time” delivery means that the hospital warehouse now probably stores only a one-week supply of silver sulfadiazine instead of the several months’ stock of supplies usually maintained only a few years ago. At the same time, the possibility of a civilian burn mass-casualty incident producing hundreds of patients has become more real in the post-9/11 era. At least one strategy – based on a system already in place for military mass-casualty situations – has been described for the regional and national distribution of burn patients resulting from a mass-casualty incident.
To conclude: Burn care is a complex, resource-intensive, multidisciplinary team process. Current care standards require a coordinated capacity for rapid assessment, acute and ongoing resuscitation, and critical care transport to definitive care facilities. The civilian experience in the initial assessment, resuscitation, and transportation of casualties to designated burn centers has informed the basic approach to military burn-care management. Civilian clinical outcomes may be affected by a more decentralized health care system, less well developed communication channels, and the daunting economics of maintaining burn centers and the life–long care of severely burned and disabled victims.
Conversely, the military experience – characterized by complicated burn injuries, logistical challenges, and critical care transportation, inter-echelon communication, definitive care at the Army Burn Center, integrated education and training programs, emphasis on preventive barriers, and attention to the psychological dimensions of burn care – has highlighted some of the many problems that have been addressed, with numerous applications to civilian planning for terrorist or natural disasters. Other important issues, such as the economics of burn-care management, casualty estimates and medical planning for surge capacity, and the limited availability of trained and experienced medical burn practitioners, remain daunting challenges.
Dr. Christopher S. Holland is an assistant professor of preventive medicine and biostatistics at the Uniformed Services University in Bethesda, Maryland. He is board-certified in occupational, emergency, and general preventive medicine and public health, and fellowship-trained in both undersea and hyperbaric medicine as well as occupational dermatology. A graduate of the New York Medical College and a captain in the U.S. Naval Reserve, he is now serving as a consultant in occupational medicine at the Uniformed Services University, at Bethesda Naval Hospital, and for the U.S. Public Health Service.