Burn victims need inner, outer healing

Maria Endah Hulupi, The Jakarta Post, Jakarta

The image of the resort island of Bali as the last safe haven for tourists in Indonesia was shattered by bomb explosions that destroyed two crowded nightspots in Kuta beach, claiming the lives of at least 184 people and injuring more than 300 others, mostly foreign vacationers.

Most of the surviving victims suffered burns and other trauma caused by debris thrown by the strong explosion.

A dermatologist with Siloam Gleneagles hospital in Tangerang, Hannah K. Damar, said that people with burn injuries should be rushed to burns units at hospitals to receive proper care under the supervision of experts, including dermatologists, surgeons, nutritionists and internists.

Burns cause intense pain and severe burns cases can be life threatening because of dehydration (that can lead to renal failure and in turn multi-organ failure), respiratory problems, shock and possible infection.

She said burn wounds, which can also be triggered by corrosive chemicals, electricity and radiation (like sunburn), can be divided into three degrees.

First degree burns were characterized by a reddish or grayish color in the burn area and some blistering. The pain could be eased by cooling off the burn area, she said.

Second degree burns usually affected the dermis, a deeper skin layer, and damage hair follicles, sweat and sebum glands. It caused blisters and intense pain as the nerve endings were left exposed.

Third degree burns also affected the underlying tissue but damaged the nerves so the victims did not experience pain. It required longer periods to heal and usually skin grafts.

"The degree of the burn, however, can increase because of a failure to cool off the affected area, enabling the heat to further damage the surrounding or the underlying tissue," she said.

Hannah said the area of the burn was assessed using the "rule of 9" for adults and "rule of 10" for children. Under these rules, each part of the body, like hands and legs, were given a specific percentage. The percentages of the affected areas were then added to count the total area of the wound.

She said giving first aid was important. People could help by: * Moving the victims to a safer place away from smoke and a panicked crowd to prevent other possible injuries like broken bones; * Take off removable clothing so the wound could be cleansed, and jewelry before a wound began to swell. * Try to cool the burn by dousing it with copious amounts of water for 10 to 20 minutes. Milk or other liquids at room temperature or colder can be used but don't use ice as it can lead to vaso constriction. * Cover the wound with a clean cloth (make sure the fabric's thread or fiber will not cling to the wound) or clean plastic. If the affected area involves the fingers, separate each finger.

"Do not use butter or toothpaste to cover the wound as it may trigger infection and delay further treatment because doctors will have to clean the wound first," Hannah warned.

She explained that serious fluid loss could occur because when the skin layer was damaged, body fluids evaporated quickly.

This condition, she added could also lead to infection because skin layers that protected the body were damaged and it prompted exudation of highly nutritious fluids for the wound's healing process, which also made the affected area a conducive living environment for bacteria like Staphylococcus aureus and Pseudomonas.

Other experts said that up to 75 percent of the patients that survived the initial period of treatment, but develop a wound infection, die as a result of sepsis.

Separately, a nutritionist with the Endang Darmoutomo Hospital said that burn victims needed immediate infusion to replace the loss of fluids and electrolytes.

Enteral feedings (given directly to the intestine) of high protein food to replace protein loss increased the patients' immune responses and supported the recovery process. "Enteral feeding also helps prevent translocation of bacteria in the intestines to the blood circulation," she said.

Superficial burn wounds could heal but Hannah said the blister, was best left the way it was, although in some cases doctors do remove it.

"The blister is a natural protection against infections and it helps hold the highly nutritious fluid for the reepithelization (the healing of the wound) in the next seven to 10 days."

But for deep burn wounds, she added, skin grafting from other body parts, from other people or cadavers could be performed.

Scarring may occur depend on the depth of the wound. The possibilities are keloid (thick, raised tissues that grow beyond the edges of the wound), hypertrophic (raised, red, thick scars that remain within the injury area) and atrophic scars.

Contracture, a permanent tightening of muscle, tendons, ligaments and skin that reduce the range of motion, can develop but it can be prevented by physical therapy.

Apart from leaving physical scars, the traumatic incident itself can also leave a psychological scar on victims.

This is why the hospital's psychiatrist, W.M. Roan, advised that vulnerable burn victims need calming words, consolation, attention and warmth to ease their confusion, panic or anxiety, while providing them with the initial treatment.

Physical damage after the incident can make them withdraw themselves from the public and to overcome this, cosmetic surgery could be performed, not only to improve the scar but also to help boost self-confidence, relieve depression and encourage victims to socialize.

"After the traumatic experience, survivors can also develop deep sadness, some may become angry and even seek revenge and some others may be grateful to be alive. It depends on the victim's personality," Roan said.

If consolation fails, he added, it was advisable to seek professional help to restore independency and improve their self- image. "The patients may be given anti-anxiety or anti-depression medication to help relieve their problem."