Rousmaniere: Burn Care is Improving

America had a long and bloody history of injury carnage at work. The workers’ compensation system was created 100 years ago in part due to public concern about deaths and disabling injuries among rail, mine and manufacturing workers. We are, in effect, still responding to those concerns.

Although catastrophic injuries rarely occur today, it’s vital to understand them well. First, they demand from claims and medical people instant and on-going attention. Further, claims payers want to rise to the challenge of helping the most unfortunate.

Among all catastrophic injuries, such as brain, spinal cord, burns and multiple trauma, about one tenth occur at work. Contrast this with the tiny sliver – about 1% --- of total healthcare which workers’ comp accounts for. An important part of the funding of centers of excellence for trauma or rehabilitation care thus comes from the workers’ comp system. 

In the past 12 months I have described trends in treatment of spinal cord injuries (here) and brain injury (here). I queried complex case managers and administrators in leading rehab centers. And I spoke with expert clinicians who are medical directors of Paradigm. The firm has a bench of experts quite skilled at describing their field.

This past summer I conversed with Paradigm’s medical director for burns, Jeffrey R. Saffle. What is going on in burn care, I asked him?

First, some background. The frequency of burn cases in the U.S. has dropped by about half in the past 30 years. This is largely thanks to declines in home fires. Today, about 15,000 occupational burns occur annually involving a least one lost day. The most common work scenario is a cooking accident. There are also a lot of chemical burns in industry. Each year, very roughly 3,000 of burned workers are admitted to a hospital. And about 150 die from burns.

Saffle reports that treatment and outcomes improved markedly, particularly in the last decades of the 20^th Century, and further leaps in care are possible.

“Remarkably good outcomes,” he told me, “can be obtained for many patients even after very severe burn injuries.”

When one compares advances in burn treatment with brain and spinal cord injury treatment some common themes emerge:

One is the emergence of national networks of special treatment centers and clinicians. Around 1970, there were few such centers for any condition, and they were not well coordinated. Today there are 138 burn centers. Saffle said, “We now are in the third generation of doctors that went through fellowships in burn care. Regional burn centers have made it possible to collect staffs of specialized nurses, therapists, psychologists, and others who can focus primarily on burns as their major work.”

Another common trend for catastrophic care is the fine-tuning of Immediate response. The majority of hospital admissions for burns today are at one of the burn centers. Saffle said, “there are few EMT systems, and very few emergency physicians, who have not been exposed to training courses for emergency [burn] care.”

Third, across the spectrum of catastrophic injuries, more patients are surviving beyond the first hours and days after injury. This led to more attention on rehabilitation. Saffle said, “functionally excellent outcomes, and quality of survival, became major foci of burn treatment, and this led to a mini-revolution in our thinking about burn care, and devotion of much more resources to these goals.”

Fourth, improvements in diagnosis and treatment have altered the way we describe these injuries. For instance, there is a common misunderstanding about severe burns. The size of the burn (as in “60% of his body”) per se is not necessarily an accurate predictor of burn severity.  Even burns of limited size—a deep burn of the hand, for example, or an alkali injury to the eyes—can be devastating. This argues, per Saffle, for sending burn injuries to burn centers for care.

As is the case with other types of catastrophic injuries, the past few decades have seen relatively incremental improvement compared to leapfrogging gains of 1970-2000. What about the future?

Saffle sees three possible “game changers.”  First, burn centers will take over more acute burn care. They will need to continue to work at how they coordinate with rehabilitation centers.

Second, he says, “I think the role of telemedicine has received far too little attention in burn treatment. We now have the ability for experienced burn doctors to provide comprehensive visual assessment of burn injuries. Transfer decisions can be made much more appropriately.”

Third, the burn care community has worked for decades to develop an effective skin substitute.  “We’re not there yet,” he said, “but we’re getting closer. Within the next decade this could turn a 60% total body surface area burn into a three week rather than a three-month hospitalization, and permit much more effective rehab and return to a quality life.”

What is your story about a catastrophic work injury?  Can you in some way help the system improve our response further?

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