Tony Blair is visiting a new hospital in Tyneside. He is ushered at speed from ward to ward; chatting to patients and exploiting the photo shoot opportunity. “And how have you benefited from New labours’ increased spending on health?” he asks one patient. The man looks at him and says “Some have meat and cannot eat and some lack meat that want it. But we have meat and we can eat and so the Lord be thankit”. “Er, quite”, says Blair feeling he may have missed something politically profound. He goes to the next bed and says to a man with his eyes bandaged “I’m Tony Blair, the prime minister, how…” and the man interrupts “Here’s to your honest sauncy face, great chieftain of the pudding race, weel are tha worthy of a grace as langs me arm” Thank you, says Blair, not sure if that is a compliment or what. He has hardly managed to finish “I hope you feel safe in the hands of new Labour” to the next man and he gets “poor, wee, sleekit timorous beastie, oh what a panics in thy brestie” So he turns to the doctor and says, what is this, the Psychiatric ward? And the doc says, “No sir, it’s the burns unit”.

In many countries burn wound care is considered so important that special hospital units are used for all serious burns. The outcome has improved by quantum leaps in the last 10 years, with massive improvement in survival, impressive decreases in scarring and a huge reduction in crippling injuries. Unfortunately in much of Africa burns are very common and most treated, or mistreated in the village with disastrous consequences.

Most of us will get a burn or a scald every year or so, most of them at home and mostly trivial. Sometimes children pour hot coffee over themselves and the burns may look really horrific and you rush off to a hospital. You may be quite amazed how quickly they heal, and perhaps be quite impressed with the dramatic and complicated treatment you received. If you have driven through far off villages you may have seen horribly crippled children crawling on the ground with limbs locked in full flexion by scar tissue joining the foot to the buttock and wondered what on earth went wrong. So what is the best first aid, what burns need to go to hospital and which victims need specialized treatment? And how do I try and make a controversial and difficult subject simple enough for even the Scots to understand?

The most important aspect of burn management is prevention. My new little friend Henry comes out with impressive ppff pfff noises every time he sees me drinking coffee. 1 year old and already he knows not to grab at something hot. It should be routine for all parents to teach tiny babies: Hot! Ffpf! No! Don’t touch! (OK how do you spell ppfff?) In Karamoja 20 years ago we were teaching women to make raised, fuel-saving cooking stoves out of mud. They work! Saves wood, prevents deforestation and global warming, and most important of all a child can’t crawl into the fire. Clever people the Karimojong.
The wiring in many homes in Uganda is appalling: I remember trying to simply change a bulb and getting a massive electric shock because the switch was on the neutral and the bulb holder broken. Switch off the switch the light went out. Should be safe. But not if the live simply earths through you instead. Think stoves, electricity, kettles, barbecues, and keep children at a distance.

First Aid

Simple! Pour cold water on it. Burns are caused by heat: in fact only 45 degrees centigrade is enough to cause continued damage to exposed flesh once the skin is burnt. Obviously drag the victim out of the fire, or away from the cable or out of the hot spring, roll them over and over to put out flames and remove burning clothes, then straight into water. If you don’t have water, anything to cool the area: fan it, blow on it, pee on it, even dirty water is safer than a burn. So THE priority: cool it.
Chemical burns such as acid again you cannot go wrong by pouring loads of water as fast as possible. They are often horrible, deep and difficult and require specialist care.
Assessment

How bad is it, how deep is it, and does it need medical attention?

Here are some basic rules of thumb.
Anything more than 15% total body surface area in a superficial dermal, i.e. a blistering burn, any deep skin burn, or any burn affecting deeper tissue needs special care.
Estimation of TBSA is easy. In adults it is the “rule of 9’s.” with children slightly different.
There are 11 nines. The head is one, the trunk front and back 2 each, the arms one each, the legs 2 each. The extra 1% is only in men. So 1 whole leg burnt is 18%. One arm and half the face and head is 9 + 4.5 = 13.5. Children are pretty much the same except the head is 2 nines and the legs 14 each. Didn’t realize a child’s head is a bigger surface area then a leg? You learn something new every day. So if it is over 15% you need medical care because the amount of fluid lost in the burn could be important. The reason why so many people die when 50% of the body is burnt is fluid and protein loss. So good rule: all burns drink a lot, over 15% TBSA look for medical care urgently.

Superficial, deep skin, full thickness or deep tissue?

Deep tissue
This is easy. You see no skin, and charred flesh, that is fat, muscle, tendons, bone; they are not usually painful, perhaps a bit uncomfortable, except round the edges where the burn is superficial. So if immediately you can see the burn is smoking, or charred, or after a few hours it is painless and you can see charred flesh, that is a deep tissue burn, what we used to call 3rd degree. Immediate care is the same: cool it down as fast as possible by pouring cold water on it.
These days all deep burns should be treated surgically, and usually within a few days. So you need to get to somewhere able to cut out dead charred flesh, repair what is missing and cover it with new tissue. Fortunately for Uganda there are many places in Kampala able to do that and increasing numbers of places up country.

Full thickness skin burns.

These are the same as above really, you can see the skin is gone, there is no pain, the wound is either charred or white, may be oozing but no blister, and in a few days lokos like leather. If it is more than a centimetre or 2 wide than it probably needs to have the dead tissue excised and the wound grafted, so as above, don’t try and treat it at home
Deep skin burns and superficial skin burns.

Superficial means affecting only the first layer of skin, the epidermis. These are like sunburn, do not blister and can be ignored. Deeper burns affecting the lower layer of skin, called the dermis, are of two types, superficial dermal and deep dermal. It doesn’t matter much as early care is the same. Cool it then assess it. If it is painful that is good news, it is probably mostly superficial, deeper burns are less painful. If it blisters with a big raised tense blister that is good, superficial burns blister the most and the fastest. Deep dermal burns blister less, and are less painful and are often rather blotchy white. Many burns are mixed, especially the common hot water scald in children, perhaps mostly superficial dermal with a few deep dermal areas. After a few days the deep skin burns are usually pale pink or white, the superficial pink to red. Pressure makes the superficial burn blanche, then go red again, the deeper ones do not change colour when pressed. The important difference is that superficial burns require no treatment and heal in about 2 weeks; the deep skin ones will also heal but take longer. In both there should be no scar. If the dermis is destroyed, that is a full thickness burn, it needs grafting unless it is smaller than a few centimetres.

Pain.

Burns are painful. The best treatment is cold water. Keep it in cold water for hours if needed. Swallow some brufen or panadol. Don’t panic, it makes pain worse. Screaming kids can be held under water, (you know what I mean!) and if necessary 1 tab of valium for each 10kg will make everyone a lot happier ( and give some to the child, too)

Home treatment

Only for small areas, less than 10% TBSA or up to 15% if it is all superficial dermal.
Pain. As above
Assess. As above
Drink a lot.

Dressing of superficial and deep skin burns
Superficial burns require no dressing at all. Faces definitely nothing. If it is a large area on the trunk a good treatment is a cradle to keep the bed clothes off, let it dry, and leave it alone. If there are blisters leave them alone until they reabsorb on their own usually within a week. If it is a small area on an active child, or on the limbs, or an adult who wants to work, a thick cotton gauze dressing wrapped not too tight protects it from being knocked and lets it heal. Leave it there until it is either messy or for 4 or 5 days. Then soak it in water or hydrogen peroxide and let it float off on its own very slowly. Unwrapping a dry stuck dressing is painful and will pull off all the lovely new healing skin tissue. Take your time, soak it for an hour if you have to, and let it float away.

When you take off the first dressing, assess it again for depth: pain, colour, and does it blanche on pressure. You will probably find that some superficial burns have a few areas that are now clearly deep dermal. If they are small, it doesn’t matter, dress it again and leave it alone for another 5 days. If any areas are hard, look like leather, with a dried up shell called an eschar with no feeling at all, that is full thickness. It needs surgery so go somewhere where good surgery is available.

Dressing material
For blistered wounds simple dry cotton gauze many layers thick is fine. When the blisters burst or are burnt off and there is wet oozing wounds, then keeping them wet makes them heal faster. Everyone has their favourite dressing, and most research shows that most are no better than nothing, some are definitely worse, and none are significantly any better than any other!!

Antiseptics are OUT. They delay healing.
Simple paraffin gauze is fine. Personally I find it sticks and is painful to remove so I don’t like it.

Most ointments are messy, may delay healing, if they contain antibiotics they encourage yeast infection, and personally I never use them
Silver sulphadiazine ointment is as good as anything, often cheap and easily available so it is widely used. It is antibacterial and antifungal. Stick a good thick smear of it all over the wound, or on the gauze and slap it on, bandage it on firmly but not tight, and leave it alone until it is either messy or 5 days. Then soak it off with diluted hydrogen peroxide.

My favourite dressing is honey. It is antiseptic but does not delay healing; it does not stick so the dressings float off easily, and it also prevents yeast and fungi growing, and is cheap and available. A lot of good research has been published on honey on all wounds including burns. Some have even shown that certain species of flower or tree are better for certain infections! The best is the local runny honey with dead bees floating in it. We get through bottles and bottles of it. Pour it all over the wound, slap on the gauze, good thick layer and leave it 2 to 5 days. We find most dressings get a bit messy after 3 days so 5 days may work for some people but not for your average active 2 year old.

Quick note: this “leave it for 5 days” business is for recent burns seen in a few hours, not the stinking, festering, infected horrors from neglected wounds inappropriately treated for a week that we see all the time. Those we dress twice a day until they are clean. If you look after a burn properly from the outset, it will never go like that and either nothing or a dressing change every 3 to 5 days is fine.

Infection

Superficial burns left alone to dry, blisters left alone or dressed with a thick layer of gauze, do not get infected. Giving antibiotics is wrong. Antibiotics do not prevent infection and do more harm than good. It simply encourages yeast, fungi and resistant bacteria. Even the deep wounds with an eschar treated in hospitals do not require systemic antibiotics. When they do get infected, that is when good antibiotic treatment is necessary. The first sign may be a bit of redness around the edge, perhaps a slightly manky wound, and then antibiotic dressings are probably the best. When there is fever, red, swollen tissue and spreading infection in the surrounding tissue, then systemic antibiotics are needed.

Outcome.

Superficial dermal burns should heal in 2 weeks without a scar, deep dermal burns in 3 or 4 weeks with maybe some discolouration but no real scar, and all other wounds probably require surgery. If it looks as if it isn’t healing in that sort of timetable than it must be reassessed. See a doctor; it may require excision and grafting, and these days earlier rather than later.