- Email: [email protected]
ISBI extending burn education to developing countries
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Burns 3 3 S ( 2 0 0 7 ) S1–S172
Honorary Professor of Surgery, Buenos Aires University. President and Medical Director Benaim’s Burn Foundation, Alberti 1093, (1223) Buenos Aires, Argentina. 夽 Text
of the Plenary Conference to be presented on Thursday, 9/28/2006 at the XII Congress of the I.S.B.I.
doi:10.1016/j.burns.2006.10.376 ISBI extending burn education to developing countries Bringing basic burn care to Bhutan: An experimental model for the ISBI Heimbach David I.S.B.I. Past President, Seattle, WA, USA E-mail address: [email protected]. Hypothesis: The ISBI can have broad international impact in improving burn care in developing countries by hands on planning with the local government, hospital leaders, surgeons and other members of the burn team. Initial training of the national burn team can take place at selected international centers, and fulfillment of the program accomplished by on site education, Internet connections and a commitment to ongoing cooperation and education by the educating team, the developing nation team and the developing country ministers. Introduction: In my Presidential Address at the Seattle ISBI meeting in 1992, I challenged the ISBI to begin a program of helping developing countries to modernize their burn care. While the ‘visiting professor’ program to provide speakers for international and in-country medical meetings is well subscribed and gives good visibility of the ISBI, “State of the Art Lectures” probably have limited to no impact on subsequent burn care by the attendees of the lectures. There is often a language barrier, there is a definite scientific understanding barrier, and there is the constant realization that what the ‘professor’ preaches cannot be reproduced in day-to-day life back home. Marrying ISBI resources with existing philanthropic organizations seems an ideal way to accomplish this, given the limited financial resources of the ISBI. One such organization is The Global Burn Care and Reconstruction Foundation, which is based in the United States, with its president and founder, Margrit Elliott, living in Seattle. Mrs. Elliott has been involved in numerous developing countries (Nepal, Tibet, Bangladesh) in bringing teams of plastic surgeons to the country to provide plastic surgery (mostly cleft lip and palette repairs but also burn and other deformity reconstructions). For the past 8 years, her efforts have been focused on Bhutan. She has personally made 11 trips to Bhutan, and her team has been to all parts of the country, teaching the national surgeons, and performing hands-on surgery for about 100 patients at each visit. She feels the cleft palette program is now mature, and she wants to change the focus of the foundation from pure reconstruction to acute burn care. As a consequence, she had heard about my challenge to ISBI mission and contacted me to give an on-site evaluation of what could be done and what should be done in Bhutan (as an experimental model for other developing countries). As a major plus, she has become close friends of most of the Bhutan Ministers, including the Prime Minister of the country, thus opening many doors required for the accomplishment of our task. I) Bhutan (the country) A) It is a landlocked, very small, totally mountainous country quietly lying between India and Tibet. Population is about 700,000 and is fairly young. B) It is presently, and has been for 100 years, a Monarchy, but by the Centennial in 2007 there is hope it may become a constitutional Monarchy with a constitution already drafted, but currently being debated. C) It has few natural resources, with the largest, and essentially only, source of income selling hydroelectric power to India, and increasingly over the past few years tourism. Agriculture exports to India (rice, potatoes, legumes and fruits) make up a smaller source. D) The national airline (Druk {The Dragon}) has two Airbus 319 planes, which provide the only service to the only airport in the country (Paro). 1) There are flights most days from Bangkok via Calcutta. 2) The tower in Paro is VFR only (no radar), and the landing in the Paro valley requires a steep white-knuckle descent over mountain ridges. This is apparently particularly exciting on cloudy and rainy days. E) The Climax road in Bhutan is a one lane (3 m), bumpy, road with rocks on one side and 1000–2000 foot cliffs on the other. There is a small dirt shoulder on one side or the other, but no guardrails. The road is shared by cows, feral dogs (thousands), adult and children pedestrians, as well as by huge trucks from India. The trip from the airport to the capital city is 40 km, but took nearly 2.5 h. I am told that this road is the best in Bhutan. This has major implications for emergency transport to be discussed later. F) The country is mostly rural, and the people are incredibly friendly and courteous. Most still wear their traditional outfits (an woven ornamental wrapped dress) with long stockings. The school children all wear traditional costumes.
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G) Everyone that I met speaks reasonably good English. English is taught early in school, and subsequently all classes (math, etc.) are taught only in English. The native language is spoken at home, but most people are remarkably fluent in English. Although poor, they are a very enlightened and progressive society. H) The country is high. The Paro Valley is about 8000 ft, and the surrounding mountains go to 12–14,000 ft. Everyone in the country walks. School kids climb some 2000 ft from their homes by the river to the road, and then may walk as much as 12 km to school. Atherosclerotic heart disease is virtually unknown. As a sea level visitor, I certainly noticed the exertion climbing to the top of hills. I) It is really a tourist diamond. Written up extensively in high-end newspapers and travel magazines as a “High Value, Low Volume tourist destination”. Tourists must be part of an organized group (one or more travelers) with a guide and driver for all activities, and a visitor’s visa obtained from the travel service. Unaccompanied travel is not allowed. It does avoid the backpacker-leave-your-trash-on-the-trail-crowd that has become so prevalent in Nepal and Tibet. Many people come to trek in the mountains and the trails are apparently wonderful. II) Bhutan: medical care A) There are seven peripheral hospitals scattered around the country and one regional hospital in the capital (Thimphu). B) There are a total of eight general surgeons, four Bhutanese, four foreign. Most of the peripheral hospitals are staffed only by GPs and nurses. GPs do minor surgery, and bigger cases are referred to Thimphu or ignored. C) Rapid transport for critically ill or injured patients is essentially non-existent. Overland transport from far eastern Bhutan to Thimphu takes 3 days. There is no helicopter service, although distances are within helicopter range. D) The hospital in Paro (Airport city) is very primitive. One half is devoted to traditional herbal medicine, and the surgeon is Burmese, but he seemed pretty unenergetic and apparently does not attempt anything more complicated than hemorrhoids and appendectomies. There is limited laboratory support, and nothing but a basic X-ray unit. The hospital is old and everything within it could be considered outdated. There are two 20-bed wards, but there were few patients (only 2 on the surgical ward). Apparently visiting the other general hospitals would be very similar to the one in Paro, except they are even more primitive, since Paro and Thimphu are the largest population centers. In the other hospitals, patients sometimes must walk 3–5 days to reach the hospital, thus self triaging all the sick ones. E) The regional hospital in Thimphu is also old and outdated. This ‘jewel’ in the hospital crown has 100 beds, housed in 4 open rooms of 25 beds each. There are three intensive care beds in one room with partitions, but only one functional ventilator. Their general policy is not to admit anyone ‘real sick’ to the ICU because they will have such a long stay that others needing brief stays would not get care. As a result, most ‘real sick’ patients are given ‘comfort care’. They also have no CT scan, MRI or other modestly sophisticated diagnostic capability. F) Heart disease is rare. On the other hand, while making surgical rounds at the regional hospital, on the 20 bed surgical ward with about 15 patients, I saw three post-op stomach cancers, two huge hydatid cysts of the liver, one intestinal typhoid bowel obstruction and two patients with peritonitis from intestinal tuberculosis. The others had cholecystitis (3) urethral stones (2) and a urethral stricture, as well as two burn patients. G) On the bright side, a new hospital is under construction in Thimphu, and it is planned to open sometime in 2007. This will have 40 ICU beds, a burn unit, and should have much improved diagnostic and treatment capabilities. H) My personal opinion about the obvious foot-dragging acquisition of a helicopter is the major concern that if emergency ‘real sick’ patients were transported in minutes rather than hours or days, that there would not be the capability to take care of them once they arrived. So, there might be at least a small feeling, if they do not arrive alive, we do not have to keep them alive. This will surely change as time goes by and the new facility opens. III) Bhutan burn care A) Coordinated and organized burn care does not exist. 1) Serious burns are supposed to be filtered to Thimphu, but once they arrive there is no plan for their care. (a) One of the two patients in Poro was a man with a 50% burn who had been in bed for over 30 day, although his legs were unburned. He had had no supplemental nutrition, and he had signs of obvious muscle wasting. He underwent daily (sometimes) dressing changes and SSD. No surgery had been done and none was planned. He had had no PT or OT and was clearly getting severe limitation of both axillae and elbows. (b) He was covered with a mosquito net (perhaps to hide him from view) although it was not mosquito season. (c) When asked why the patient had not been transferred to Thimphu the Burmese surgeon said he saw no reason why he should do so. In his defense, the care would likely have been the same in Thimphu. 2) There are no even rudimentary burn trained nurses or therapists.
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3) The Thimphu general surgeon’s interest is in Oncology, and he has no expertise in modern burn care, aside from salve and non-aggressive surgery. Extremity burns are cared for by the Orthopedic surgeon, who also has little interest or expertise in acute burn management. B) Critical care skills and consultation are rudimentary at best. 1) The three critical care beds are used mostly by medical patients, or post-operative patients needing just a few hours of increased nursing. 2) There are no plastic surgeons in the country, and none of the eight general surgeons have any burn or critical care experience. 3) Anesthesia was not really investigated by me. There is apparently one anesthetist or nurse anesthetist per hospital if they have a surgeon. C) Current burn patient population 1) Young boy (perhaps 10 years) with a scald burn to the right thigh and calf. No debridement had been done in the first 5 days, and the surgeon had not seen the wounds at all. The wounds looked like mid-dermal burns, but without exercise and splinting and cleansing, it is likely that some will convert, and when healed will cause dysfunction. His hospital stay will likely be more than a month. 2) Six-month-old baby with contact burn from stove to whole right forearm. I did not see the wound (I suggested it would be painful without some pain control when they offered to take his dressings off). The surgeon had also not seen the wound since admission a week ago, but he said that he was told they would heal. No wound plans had been made. D) The burn problem in Bhutan 1) Burns are admittedly a major problem (Director of Medical Health, Director of Public Health). The incidence is not known precisely, as no records are kept. 2) Winter is ‘burn season’. Traditional homes in the countryside are not electrified, and candles, kerosene and kitchen wood stoves are the only source of heat. Usually, only the kitchen has heat in the winter, and the family gathers around the burning stove. Non-fatal burns are extremely common at this time. 3) There is a national rural electrification program, which will electrify 75% of the rural areas within the next few years. This will likely add the problem of electrical burns to that of thermal burns. 4) Scalds and flame burns occur throughout the year, and my pre-visit estimate of burns being 10% of hospital admissions (especially in winter) is likely correct. IV) Fact finding visit October 8–15, 2005 A) Finances 1) ISBI paid Heimbach round trip ticket to Bangkok from Seattle. 2) Global Burn Care and Reconstruction Foundation paid some Bangkok cost, airfare on Druk airlines to Paro, in-country costs (guide and driver are required of all visitors). 3) Heimbach paid Bangkok hotel, airport fees, and miscellaneous costs. B) Paro and Paro Hospital 1) Hospital tour with staff (doctors and nurses and hospital director). The District Director of Health accompanied us. 2) Patient rounds to see 50% burn patient described above. 3) Meeting with District Health Officer and Hospital Director (a) Discussed lack of equipment and staff to provide more than rudimentary care of any patients. (b) Discussed need for rapid transport system for critical illness. Emphasis on high likelihood of death during ground transport to Thimphu. (c) Not clear why burn patient had not been transferred to Thimphu. (d) They expressed gratitude for our visit, felt our project was worthwhile and very needed, and gave us their full support. C) Thimphu and the regional hospital
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1) Tour of Hospital, and rounds with Chief of Surgery, Chief of Orthopedics, Nursing Director, Physical Therapy director and Medical Director. 2) Patients as described above. Burn patient had dressings removed in a small, unlighted room without water or dressing table. My suggestion to debride some of the purulent blisters was greeted with enthusiasm. 3) Considerable discussion after rounds about real vs. perceived needs for equipment. Foundation had given a modern air dermatome, but they had to buy a nitrogen tank from India, and then go though enormous paperwork to get it approved, only to find an undependable nitrogen supply. They had not considered buying an inexpensive construction electric compressor, and making the appropriate adaptation for connecting the dermatome to the compressor cord. (I had never thought of it before either, but it immediately came as a quick idea when they described the problem—that is why on site visitation is crucial to local success). 4) There was great enthusiasm for the plan we proposed (see below). D) Meetings with officials in charge of health 1) Dinner meeting with Director of Medical Health for Bhutan, the Hospital Director in Thimphu and the Chief Surgeon in Thimphu. (a) Proposal (see below) avidly accepted and enthusiastically endorsed. (b) Discussion of helicopter transport did not lead to clear understanding of need versus expense for the service. (c) New hospital with 10-bed burn unit needs to be designed with 2007 needs, not 1999 needs (when plans were drawn). Agreement that I would review plans with my staff and make recommendations for a state of the art (at least by Bhutan standards) facility. 2) Meeting with Minister of Health and Prime Minister had to be postponed because they had a command performance to attend the wedding of the King’s Daughter. Mrs. Elliott will visit with them on her next Bhutan visit later this year. 3) Meeting with the Director of Public Health of Bhutan (a) Similar discussion and enthusiastic support of our proposal. (b) Discussion of public health issues and the need for bed allocation based on increasing public health needs. (i) (ii) (iii) (iv)
Diabetes Hypertension Psychiatric care Burns and trauma
(c) Agreed that a state of the art facility was needed. (d) Still an advocate that provincial hospitals should be trained and able to care for smaller burns. However, they currently have no plans to conduct the necessary training. V) Proposal to improve care A) Expert involvement in design of new hospital burn unit 1) 2) 3) 4) 5) 6)
Eliminate ward-of-many-beds concept, by partitioning unit into private or semiprivate cubicles. Have at least three beds ICU capable with full monitoring. Provide showers for burn washing, sinks for hand washing, and disinfectant dispensers. Spray table instead of very expensive Hubbard style tub. Agreement of the powers that be in implementing the expert’s suggestions. Repeated consultation as planning proceeds—www, e-mail.
B) Educate a full burn team in burn physiology, and achievable wound care while the new burn center is being completed. Assumption: The Burn Center will be in Thimphu in the new hospital. 1) Identify long term potential team members (a) Identify at least one surgeon (Dr. Latay has already expressed an interest) who would be the leader of the team. (b) Identify three nurses (two have already volunteered). (c) Identify one therapist.
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2) Plan for their educational activity at a recognized burn center known for international education for an undefined period of time, but probably at least 1 month. I have volunteered the UW Burn Center at Harborview. (a) The problem is hugely aided by the ability of all the Bhutanese visitors to speak satisfactory English. Previous visitors spend half their time making themselves understood and understanding the teachers. (b) The team should come all at once, to maintain esprit and be sure that the same message is transmitted to all. (c) Group rates at local accommodations can be used. 3) Financial commitments (a) Bhutan will find replacements, maintain their benefits, and help with whatever funding, visa applications, etc., that will be required. (b) The Global Burn Foundation will have money to help pay the airfares and living expenses of the team in the USA. (c) The ISBI may be asked to help with airfares for some of the team under the visiting scholars program. (d) UW Burn center will contribute the considerable preceptorships, lectures, and other educational activities for the visitors. 4) Ongoing education will take place via e-mails, the Internet, and photo transmission to keep skills at good levels while awaiting increased census in the regional hospital. C) Continue to work on developing emergency transport system so that critical burns can be transported in a timely fashion. 1) The Ministers and Directors are aware of this, but will probably await some sort of state of the art facility before a helicopter system can be proven to be cost effective. D) Global Burn Care and Reconstruction Foundation will continue accumulating burn surgical instruments—a mesher, electrocautery, etc. E) Allow a ‘break in’ period as the new burn unit begins functioning. The team will identify particular problems, and may have their own unique solutions, but . . .. F) A burn team from Seattle (surgeon, nurse educator, and therapist) will return to Bhutan to help with growing pains, continuing education, and further discussion with the Ministers regarding the progress of the project. 1) This will likely be funded by the foundation, and in part asked of the ISBI. G) Country wide professional education and burn prevention is the next part of this project. It will likely be initiated and conducted by the trained burn team of Bhutanese doctor, nurses, and therapist. VI) Summary The site visit to Bhutan was highly successful. The need for a Burn Unit is clear and its construction is enthusiastically supported by all health ministers and the Hospital Directors. The site for the Burn Unit will be in the Capitol at the new referral hospital, scheduled to open in mid 2007. Burn Unit plans within the hospital will be reviewed frequently by Dr. Heimbach and the Seattle burn team. In the mean time, training will be undertaken at Harborview in Seattle for a core Bhutanese burn team (surgeon, three nurses and a therapist). Training will take place in summer 2006, as time will be consumed getting proper visas, etc. The Global Burn Care and Reconstruction Foundation will continue accumulating surgical supplies for the new Burn Unit. When the Burn Unit opens a small cadre of teaching burn team members will help establish protocols, guidelines, procedures, and provide ‘hands on’ teaching on site with the resources available locally.
doi:10.1016/j.burns.2006.10.377
Burns 3 3 S ( 2 0 0 7 ) S1–S172
Honorary Professor of Surgery, Buenos Aires University. President and Medical Director Benaim’s Burn Foundation, Alberti 1093, (1223) Buenos Aires, Argentina. 夽 Text
of the Plenary Conference to be presented on Thursday, 9/28/2006 at the XII Congress of the I.S.B.I.
doi:10.1016/j.burns.2006.10.376 ISBI extending burn education to developing countries Bringing basic burn care to Bhutan: An experimental model for the ISBI Heimbach David I.S.B.I. Past President, Seattle, WA, USA E-mail address: [email protected]. Hypothesis: The ISBI can have broad international impact in improving burn care in developing countries by hands on planning with the local government, hospital leaders, surgeons and other members of the burn team. Initial training of the national burn team can take place at selected international centers, and fulfillment of the program accomplished by on site education, Internet connections and a commitment to ongoing cooperation and education by the educating team, the developing nation team and the developing country ministers. Introduction: In my Presidential Address at the Seattle ISBI meeting in 1992, I challenged the ISBI to begin a program of helping developing countries to modernize their burn care. While the ‘visiting professor’ program to provide speakers for international and in-country medical meetings is well subscribed and gives good visibility of the ISBI, “State of the Art Lectures” probably have limited to no impact on subsequent burn care by the attendees of the lectures. There is often a language barrier, there is a definite scientific understanding barrier, and there is the constant realization that what the ‘professor’ preaches cannot be reproduced in day-to-day life back home. Marrying ISBI resources with existing philanthropic organizations seems an ideal way to accomplish this, given the limited financial resources of the ISBI. One such organization is The Global Burn Care and Reconstruction Foundation, which is based in the United States, with its president and founder, Margrit Elliott, living in Seattle. Mrs. Elliott has been involved in numerous developing countries (Nepal, Tibet, Bangladesh) in bringing teams of plastic surgeons to the country to provide plastic surgery (mostly cleft lip and palette repairs but also burn and other deformity reconstructions). For the past 8 years, her efforts have been focused on Bhutan. She has personally made 11 trips to Bhutan, and her team has been to all parts of the country, teaching the national surgeons, and performing hands-on surgery for about 100 patients at each visit. She feels the cleft palette program is now mature, and she wants to change the focus of the foundation from pure reconstruction to acute burn care. As a consequence, she had heard about my challenge to ISBI mission and contacted me to give an on-site evaluation of what could be done and what should be done in Bhutan (as an experimental model for other developing countries). As a major plus, she has become close friends of most of the Bhutan Ministers, including the Prime Minister of the country, thus opening many doors required for the accomplishment of our task. I) Bhutan (the country) A) It is a landlocked, very small, totally mountainous country quietly lying between India and Tibet. Population is about 700,000 and is fairly young. B) It is presently, and has been for 100 years, a Monarchy, but by the Centennial in 2007 there is hope it may become a constitutional Monarchy with a constitution already drafted, but currently being debated. C) It has few natural resources, with the largest, and essentially only, source of income selling hydroelectric power to India, and increasingly over the past few years tourism. Agriculture exports to India (rice, potatoes, legumes and fruits) make up a smaller source. D) The national airline (Druk {The Dragon}) has two Airbus 319 planes, which provide the only service to the only airport in the country (Paro). 1) There are flights most days from Bangkok via Calcutta. 2) The tower in Paro is VFR only (no radar), and the landing in the Paro valley requires a steep white-knuckle descent over mountain ridges. This is apparently particularly exciting on cloudy and rainy days. E) The Climax road in Bhutan is a one lane (3 m), bumpy, road with rocks on one side and 1000–2000 foot cliffs on the other. There is a small dirt shoulder on one side or the other, but no guardrails. The road is shared by cows, feral dogs (thousands), adult and children pedestrians, as well as by huge trucks from India. The trip from the airport to the capital city is 40 km, but took nearly 2.5 h. I am told that this road is the best in Bhutan. This has major implications for emergency transport to be discussed later. F) The country is mostly rural, and the people are incredibly friendly and courteous. Most still wear their traditional outfits (an woven ornamental wrapped dress) with long stockings. The school children all wear traditional costumes.
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G) Everyone that I met speaks reasonably good English. English is taught early in school, and subsequently all classes (math, etc.) are taught only in English. The native language is spoken at home, but most people are remarkably fluent in English. Although poor, they are a very enlightened and progressive society. H) The country is high. The Paro Valley is about 8000 ft, and the surrounding mountains go to 12–14,000 ft. Everyone in the country walks. School kids climb some 2000 ft from their homes by the river to the road, and then may walk as much as 12 km to school. Atherosclerotic heart disease is virtually unknown. As a sea level visitor, I certainly noticed the exertion climbing to the top of hills. I) It is really a tourist diamond. Written up extensively in high-end newspapers and travel magazines as a “High Value, Low Volume tourist destination”. Tourists must be part of an organized group (one or more travelers) with a guide and driver for all activities, and a visitor’s visa obtained from the travel service. Unaccompanied travel is not allowed. It does avoid the backpacker-leave-your-trash-on-the-trail-crowd that has become so prevalent in Nepal and Tibet. Many people come to trek in the mountains and the trails are apparently wonderful. II) Bhutan: medical care A) There are seven peripheral hospitals scattered around the country and one regional hospital in the capital (Thimphu). B) There are a total of eight general surgeons, four Bhutanese, four foreign. Most of the peripheral hospitals are staffed only by GPs and nurses. GPs do minor surgery, and bigger cases are referred to Thimphu or ignored. C) Rapid transport for critically ill or injured patients is essentially non-existent. Overland transport from far eastern Bhutan to Thimphu takes 3 days. There is no helicopter service, although distances are within helicopter range. D) The hospital in Paro (Airport city) is very primitive. One half is devoted to traditional herbal medicine, and the surgeon is Burmese, but he seemed pretty unenergetic and apparently does not attempt anything more complicated than hemorrhoids and appendectomies. There is limited laboratory support, and nothing but a basic X-ray unit. The hospital is old and everything within it could be considered outdated. There are two 20-bed wards, but there were few patients (only 2 on the surgical ward). Apparently visiting the other general hospitals would be very similar to the one in Paro, except they are even more primitive, since Paro and Thimphu are the largest population centers. In the other hospitals, patients sometimes must walk 3–5 days to reach the hospital, thus self triaging all the sick ones. E) The regional hospital in Thimphu is also old and outdated. This ‘jewel’ in the hospital crown has 100 beds, housed in 4 open rooms of 25 beds each. There are three intensive care beds in one room with partitions, but only one functional ventilator. Their general policy is not to admit anyone ‘real sick’ to the ICU because they will have such a long stay that others needing brief stays would not get care. As a result, most ‘real sick’ patients are given ‘comfort care’. They also have no CT scan, MRI or other modestly sophisticated diagnostic capability. F) Heart disease is rare. On the other hand, while making surgical rounds at the regional hospital, on the 20 bed surgical ward with about 15 patients, I saw three post-op stomach cancers, two huge hydatid cysts of the liver, one intestinal typhoid bowel obstruction and two patients with peritonitis from intestinal tuberculosis. The others had cholecystitis (3) urethral stones (2) and a urethral stricture, as well as two burn patients. G) On the bright side, a new hospital is under construction in Thimphu, and it is planned to open sometime in 2007. This will have 40 ICU beds, a burn unit, and should have much improved diagnostic and treatment capabilities. H) My personal opinion about the obvious foot-dragging acquisition of a helicopter is the major concern that if emergency ‘real sick’ patients were transported in minutes rather than hours or days, that there would not be the capability to take care of them once they arrived. So, there might be at least a small feeling, if they do not arrive alive, we do not have to keep them alive. This will surely change as time goes by and the new facility opens. III) Bhutan burn care A) Coordinated and organized burn care does not exist. 1) Serious burns are supposed to be filtered to Thimphu, but once they arrive there is no plan for their care. (a) One of the two patients in Poro was a man with a 50% burn who had been in bed for over 30 day, although his legs were unburned. He had had no supplemental nutrition, and he had signs of obvious muscle wasting. He underwent daily (sometimes) dressing changes and SSD. No surgery had been done and none was planned. He had had no PT or OT and was clearly getting severe limitation of both axillae and elbows. (b) He was covered with a mosquito net (perhaps to hide him from view) although it was not mosquito season. (c) When asked why the patient had not been transferred to Thimphu the Burmese surgeon said he saw no reason why he should do so. In his defense, the care would likely have been the same in Thimphu. 2) There are no even rudimentary burn trained nurses or therapists.
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3) The Thimphu general surgeon’s interest is in Oncology, and he has no expertise in modern burn care, aside from salve and non-aggressive surgery. Extremity burns are cared for by the Orthopedic surgeon, who also has little interest or expertise in acute burn management. B) Critical care skills and consultation are rudimentary at best. 1) The three critical care beds are used mostly by medical patients, or post-operative patients needing just a few hours of increased nursing. 2) There are no plastic surgeons in the country, and none of the eight general surgeons have any burn or critical care experience. 3) Anesthesia was not really investigated by me. There is apparently one anesthetist or nurse anesthetist per hospital if they have a surgeon. C) Current burn patient population 1) Young boy (perhaps 10 years) with a scald burn to the right thigh and calf. No debridement had been done in the first 5 days, and the surgeon had not seen the wounds at all. The wounds looked like mid-dermal burns, but without exercise and splinting and cleansing, it is likely that some will convert, and when healed will cause dysfunction. His hospital stay will likely be more than a month. 2) Six-month-old baby with contact burn from stove to whole right forearm. I did not see the wound (I suggested it would be painful without some pain control when they offered to take his dressings off). The surgeon had also not seen the wound since admission a week ago, but he said that he was told they would heal. No wound plans had been made. D) The burn problem in Bhutan 1) Burns are admittedly a major problem (Director of Medical Health, Director of Public Health). The incidence is not known precisely, as no records are kept. 2) Winter is ‘burn season’. Traditional homes in the countryside are not electrified, and candles, kerosene and kitchen wood stoves are the only source of heat. Usually, only the kitchen has heat in the winter, and the family gathers around the burning stove. Non-fatal burns are extremely common at this time. 3) There is a national rural electrification program, which will electrify 75% of the rural areas within the next few years. This will likely add the problem of electrical burns to that of thermal burns. 4) Scalds and flame burns occur throughout the year, and my pre-visit estimate of burns being 10% of hospital admissions (especially in winter) is likely correct. IV) Fact finding visit October 8–15, 2005 A) Finances 1) ISBI paid Heimbach round trip ticket to Bangkok from Seattle. 2) Global Burn Care and Reconstruction Foundation paid some Bangkok cost, airfare on Druk airlines to Paro, in-country costs (guide and driver are required of all visitors). 3) Heimbach paid Bangkok hotel, airport fees, and miscellaneous costs. B) Paro and Paro Hospital 1) Hospital tour with staff (doctors and nurses and hospital director). The District Director of Health accompanied us. 2) Patient rounds to see 50% burn patient described above. 3) Meeting with District Health Officer and Hospital Director (a) Discussed lack of equipment and staff to provide more than rudimentary care of any patients. (b) Discussed need for rapid transport system for critical illness. Emphasis on high likelihood of death during ground transport to Thimphu. (c) Not clear why burn patient had not been transferred to Thimphu. (d) They expressed gratitude for our visit, felt our project was worthwhile and very needed, and gave us their full support. C) Thimphu and the regional hospital
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1) Tour of Hospital, and rounds with Chief of Surgery, Chief of Orthopedics, Nursing Director, Physical Therapy director and Medical Director. 2) Patients as described above. Burn patient had dressings removed in a small, unlighted room without water or dressing table. My suggestion to debride some of the purulent blisters was greeted with enthusiasm. 3) Considerable discussion after rounds about real vs. perceived needs for equipment. Foundation had given a modern air dermatome, but they had to buy a nitrogen tank from India, and then go though enormous paperwork to get it approved, only to find an undependable nitrogen supply. They had not considered buying an inexpensive construction electric compressor, and making the appropriate adaptation for connecting the dermatome to the compressor cord. (I had never thought of it before either, but it immediately came as a quick idea when they described the problem—that is why on site visitation is crucial to local success). 4) There was great enthusiasm for the plan we proposed (see below). D) Meetings with officials in charge of health 1) Dinner meeting with Director of Medical Health for Bhutan, the Hospital Director in Thimphu and the Chief Surgeon in Thimphu. (a) Proposal (see below) avidly accepted and enthusiastically endorsed. (b) Discussion of helicopter transport did not lead to clear understanding of need versus expense for the service. (c) New hospital with 10-bed burn unit needs to be designed with 2007 needs, not 1999 needs (when plans were drawn). Agreement that I would review plans with my staff and make recommendations for a state of the art (at least by Bhutan standards) facility. 2) Meeting with Minister of Health and Prime Minister had to be postponed because they had a command performance to attend the wedding of the King’s Daughter. Mrs. Elliott will visit with them on her next Bhutan visit later this year. 3) Meeting with the Director of Public Health of Bhutan (a) Similar discussion and enthusiastic support of our proposal. (b) Discussion of public health issues and the need for bed allocation based on increasing public health needs. (i) (ii) (iii) (iv)
Diabetes Hypertension Psychiatric care Burns and trauma
(c) Agreed that a state of the art facility was needed. (d) Still an advocate that provincial hospitals should be trained and able to care for smaller burns. However, they currently have no plans to conduct the necessary training. V) Proposal to improve care A) Expert involvement in design of new hospital burn unit 1) 2) 3) 4) 5) 6)
Eliminate ward-of-many-beds concept, by partitioning unit into private or semiprivate cubicles. Have at least three beds ICU capable with full monitoring. Provide showers for burn washing, sinks for hand washing, and disinfectant dispensers. Spray table instead of very expensive Hubbard style tub. Agreement of the powers that be in implementing the expert’s suggestions. Repeated consultation as planning proceeds—www, e-mail.
B) Educate a full burn team in burn physiology, and achievable wound care while the new burn center is being completed. Assumption: The Burn Center will be in Thimphu in the new hospital. 1) Identify long term potential team members (a) Identify at least one surgeon (Dr. Latay has already expressed an interest) who would be the leader of the team. (b) Identify three nurses (two have already volunteered). (c) Identify one therapist.
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Burns 3 3 S ( 2 0 0 7 ) S1–S172
2) Plan for their educational activity at a recognized burn center known for international education for an undefined period of time, but probably at least 1 month. I have volunteered the UW Burn Center at Harborview. (a) The problem is hugely aided by the ability of all the Bhutanese visitors to speak satisfactory English. Previous visitors spend half their time making themselves understood and understanding the teachers. (b) The team should come all at once, to maintain esprit and be sure that the same message is transmitted to all. (c) Group rates at local accommodations can be used. 3) Financial commitments (a) Bhutan will find replacements, maintain their benefits, and help with whatever funding, visa applications, etc., that will be required. (b) The Global Burn Foundation will have money to help pay the airfares and living expenses of the team in the USA. (c) The ISBI may be asked to help with airfares for some of the team under the visiting scholars program. (d) UW Burn center will contribute the considerable preceptorships, lectures, and other educational activities for the visitors. 4) Ongoing education will take place via e-mails, the Internet, and photo transmission to keep skills at good levels while awaiting increased census in the regional hospital. C) Continue to work on developing emergency transport system so that critical burns can be transported in a timely fashion. 1) The Ministers and Directors are aware of this, but will probably await some sort of state of the art facility before a helicopter system can be proven to be cost effective. D) Global Burn Care and Reconstruction Foundation will continue accumulating burn surgical instruments—a mesher, electrocautery, etc. E) Allow a ‘break in’ period as the new burn unit begins functioning. The team will identify particular problems, and may have their own unique solutions, but . . .. F) A burn team from Seattle (surgeon, nurse educator, and therapist) will return to Bhutan to help with growing pains, continuing education, and further discussion with the Ministers regarding the progress of the project. 1) This will likely be funded by the foundation, and in part asked of the ISBI. G) Country wide professional education and burn prevention is the next part of this project. It will likely be initiated and conducted by the trained burn team of Bhutanese doctor, nurses, and therapist. VI) Summary The site visit to Bhutan was highly successful. The need for a Burn Unit is clear and its construction is enthusiastically supported by all health ministers and the Hospital Directors. The site for the Burn Unit will be in the Capitol at the new referral hospital, scheduled to open in mid 2007. Burn Unit plans within the hospital will be reviewed frequently by Dr. Heimbach and the Seattle burn team. In the mean time, training will be undertaken at Harborview in Seattle for a core Bhutanese burn team (surgeon, three nurses and a therapist). Training will take place in summer 2006, as time will be consumed getting proper visas, etc. The Global Burn Care and Reconstruction Foundation will continue accumulating surgical supplies for the new Burn Unit. When the Burn Unit opens a small cadre of teaching burn team members will help establish protocols, guidelines, procedures, and provide ‘hands on’ teaching on site with the resources available locally.
doi:10.1016/j.burns.2006.10.377