- Email: [email protected]
Logistic aids in treating massive burn casualties
146
Burns. 6, 146-l 46
Printedin Great Britain
Logistic aids in treating casualties
massive burn
D. Mahler and D. Hauben Department of Plastic Surgery and Burns Unit, Soroka Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheba, Israel Summary
The treatment ofmassive bum casualties admitted to a bums unit with short or no notice causes, apart from the medical problems, a severe logistic clumsiness. Some ideas about logistic aids in this aspect are discussed. Two instruments for improving the medical treatment are presented: an emergency bum kit, which aids the immediate, primary care of the bum patients on admission, and a working chart for improved orientation and proper handling of the multiple, various and repeated activities undertaken on a large number of bum patients during their entire hospitalization. INTRODUCTION
EVERY unit or surgical department admitting bum patients has its regulations and principles for their treatment. However, under the circumstances of sudden pressure of massive bum casualties arriving without or with only short notice, most of the routine becomes useless. The need for quick admission, diagnosis and primary care for a large number of patients, as well as a meticulous follow-up during the period of hospitalization, led to the search for some ad hoc resolutions to replace the useless routine of the past. Two such aids have been further developed to become an integral part in the treatment of massive bum casualties. Emergency
burn kit
There is always a shortage of nursing and surgical manpower during the first hours after admitting massive bum casualties. It appears, therefore, that the few who are on the spot can hardly cope with the large number of activities necessary while resuscitating all bum patients.
An emergency bum kit was developed (Figs. la and b) in order to enable each member of staff to work independently. The kit contains all necessary equipment for the required activities: general resuscitation tools (i.v. catheters, urinary catheters, etc.), instruments for escharotomy, bandaging, etc. (these can be changed or added to as required). The kit is prepared for use either in a horizontal position or when hanging vertically. Each department and unit has to calculate the number of kits needed as a stand-by reserve for emergency care. In our experience, 10 kits should be the minimum number in each burns unit. Working
chart
When adopting the aggressive treatment of bum patients by performing staged, tangential, early excision and grafting of the deep bums (Jackson and Stone, 1972; Mahler and Hirshowitz, 1975) one aims at a great number of overall activities, such as surgical procedures, changes of dressing, early physiotherapy, hydrotherapy and others. When applying this scheme to a great number of bum patients in a unit with a large number of staff members, it is not unusual to be confronted with obstacles, mistakes, forgetfulness, etc. These undesirable situations are enhanced by some more burdening conditions: (a) the surgical work on burn patients is often undertaken in more than one operating room where most of the surgeons work independently and cannot have a clear view of what is going on elsewhere; and (b) the number of patients per day undergoing any of the above procedures is large. No
Mahler and Hauben: Logistic Aids in Treating Casualties
one can remember all the details concerning the whole group of patients. Planning the activities to be done is thus difficult, and may lead to misunderstanding by the varied assisting and nursing staff. The proposed working chart aims to avoid pitfalls and to enable the achievement of the most important task of the early excision principle: quick healing of the patients with early ambulation. From the hospital point of view there is another aim: to cure and discharge the patients as quickly as possible in order to enable the hospital to function normally again.
hard paper, and hung in a central place in the unit. The first planning is made by a senior surgeon, who marks code letters for each patient for the first 24 h. The code letters and signs should, in practice, be marked in different colours, a special colour for each code letter, for a better orientation. After each procedure, the surgeon in charge is obliged to mark at least two codes: (a) to sign that the pre-planned procedure has in fact been undertaken. This is achieved by marking a circle around the code letter of the planned activity; and (6) to put down his instructions for what should be the next procedure, and when. In the case where a pre-planned procedure had to be postponed, or could not take place due to various reasons, the code letter has to be crossed through and a new code letter should stand for a new decision. A straight horizontal line is marked when no special activity is planned for that day. In this case, the surgeon should plan the following day’s schedule by a code letter representing his decision. Although each of the surgeons has to mark his own data and decisions: it is advocated that there will be one surgeon m charge of taking care of the proper completion of the chart. According to these principles, the treatment of the burn patient is meticulously monitored and preplanned.
Comments
Advantages
b
Fig. I The emergency bum kit: (a) the kit opened showing its various units; and (6) the kit as a closed sterile pack for storage.
and explanations
The chart (Fig 2) is drawn on a large piece of
1. Anyone
of this procedure
can easily have, at any time, an
Burns Vol. ~/NO. 3
148
1
M.G.
2
D.A.
3 4
A.0.
H 5
6
0 a
C.F.H.
B P
CH a -
L.V.B.
-
V.B.
# Fig. 2. The working chart for massive bum casualties. Code letters: R, resuscitation; S, surgical intervention; CH, change of dressings; PH, physiotherapy (active); B, bath/hydrotherapy; D, discharge from unit; and Ex, Exitus, Code signs: 0. the me-planned activity has been undertaken; /, the pre-planned activity has been cancelled; and -, no &cial activity planned. accurate picture of the situation as a whole, and of every patient in detail (Fig. 2). 2. One may learn what procedures are to be
undertaken on the following day, thus being able to prepare surgeons and necessary operating rooms, number of anaesthetics and anaesthetists, nursing manpower and equipment. (In Fig. 2 we can easily note that on 15 November for the next morning are scheduled three surgical while 2 patients still require procedures, resuscitation). 3. The chart easily presents the exact situation of every patient. Members of the staff are able to have all details regarding each patient at any time and be able to pre-plan the next steps needed accordingly. 4. When the whole treatment is terminated, the chart will serve as a basis for evaluating the
treatment aspects.
and its results from various possible
Acknowledgements
The authors wish to express their sincere thanks to the nurses, Miss Ahuva Fishgrund and Miss Ada Kuatrini, for their original thinking and assistance with the bums kit.
REFERENCES
Jackson D. M. and Stone B. S. (1972) Tangential excision and grafting of bums. Br. J. Plast. Surg. 25,461.
Mahler D. and Hirshowitz B. (1975) Tangential excision and grafting of bums of the hand. Br. J. Plast. Surg. 28, 189.
Paperaccepted 18 December 1978.
Requests for reprints should be addressed IO:Professor D. Mahler, Department of Plastic Surgery, Soroka University Hospital and Faculty ofsciences, Ben-Gurion University ofthe Negev, Beer-Sheba, Israel.
Burns. 6, 146-l 46
Printedin Great Britain
Logistic aids in treating casualties
massive burn
D. Mahler and D. Hauben Department of Plastic Surgery and Burns Unit, Soroka Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheba, Israel Summary
The treatment ofmassive bum casualties admitted to a bums unit with short or no notice causes, apart from the medical problems, a severe logistic clumsiness. Some ideas about logistic aids in this aspect are discussed. Two instruments for improving the medical treatment are presented: an emergency bum kit, which aids the immediate, primary care of the bum patients on admission, and a working chart for improved orientation and proper handling of the multiple, various and repeated activities undertaken on a large number of bum patients during their entire hospitalization. INTRODUCTION
EVERY unit or surgical department admitting bum patients has its regulations and principles for their treatment. However, under the circumstances of sudden pressure of massive bum casualties arriving without or with only short notice, most of the routine becomes useless. The need for quick admission, diagnosis and primary care for a large number of patients, as well as a meticulous follow-up during the period of hospitalization, led to the search for some ad hoc resolutions to replace the useless routine of the past. Two such aids have been further developed to become an integral part in the treatment of massive bum casualties. Emergency
burn kit
There is always a shortage of nursing and surgical manpower during the first hours after admitting massive bum casualties. It appears, therefore, that the few who are on the spot can hardly cope with the large number of activities necessary while resuscitating all bum patients.
An emergency bum kit was developed (Figs. la and b) in order to enable each member of staff to work independently. The kit contains all necessary equipment for the required activities: general resuscitation tools (i.v. catheters, urinary catheters, etc.), instruments for escharotomy, bandaging, etc. (these can be changed or added to as required). The kit is prepared for use either in a horizontal position or when hanging vertically. Each department and unit has to calculate the number of kits needed as a stand-by reserve for emergency care. In our experience, 10 kits should be the minimum number in each burns unit. Working
chart
When adopting the aggressive treatment of bum patients by performing staged, tangential, early excision and grafting of the deep bums (Jackson and Stone, 1972; Mahler and Hirshowitz, 1975) one aims at a great number of overall activities, such as surgical procedures, changes of dressing, early physiotherapy, hydrotherapy and others. When applying this scheme to a great number of bum patients in a unit with a large number of staff members, it is not unusual to be confronted with obstacles, mistakes, forgetfulness, etc. These undesirable situations are enhanced by some more burdening conditions: (a) the surgical work on burn patients is often undertaken in more than one operating room where most of the surgeons work independently and cannot have a clear view of what is going on elsewhere; and (b) the number of patients per day undergoing any of the above procedures is large. No
Mahler and Hauben: Logistic Aids in Treating Casualties
one can remember all the details concerning the whole group of patients. Planning the activities to be done is thus difficult, and may lead to misunderstanding by the varied assisting and nursing staff. The proposed working chart aims to avoid pitfalls and to enable the achievement of the most important task of the early excision principle: quick healing of the patients with early ambulation. From the hospital point of view there is another aim: to cure and discharge the patients as quickly as possible in order to enable the hospital to function normally again.
hard paper, and hung in a central place in the unit. The first planning is made by a senior surgeon, who marks code letters for each patient for the first 24 h. The code letters and signs should, in practice, be marked in different colours, a special colour for each code letter, for a better orientation. After each procedure, the surgeon in charge is obliged to mark at least two codes: (a) to sign that the pre-planned procedure has in fact been undertaken. This is achieved by marking a circle around the code letter of the planned activity; and (6) to put down his instructions for what should be the next procedure, and when. In the case where a pre-planned procedure had to be postponed, or could not take place due to various reasons, the code letter has to be crossed through and a new code letter should stand for a new decision. A straight horizontal line is marked when no special activity is planned for that day. In this case, the surgeon should plan the following day’s schedule by a code letter representing his decision. Although each of the surgeons has to mark his own data and decisions: it is advocated that there will be one surgeon m charge of taking care of the proper completion of the chart. According to these principles, the treatment of the burn patient is meticulously monitored and preplanned.
Comments
Advantages
b
Fig. I The emergency bum kit: (a) the kit opened showing its various units; and (6) the kit as a closed sterile pack for storage.
and explanations
The chart (Fig 2) is drawn on a large piece of
1. Anyone
of this procedure
can easily have, at any time, an
Burns Vol. ~/NO. 3
148
1
M.G.
2
D.A.
3 4
A.0.
H 5
6
0 a
C.F.H.
B P
CH a -
L.V.B.
-
V.B.
# Fig. 2. The working chart for massive bum casualties. Code letters: R, resuscitation; S, surgical intervention; CH, change of dressings; PH, physiotherapy (active); B, bath/hydrotherapy; D, discharge from unit; and Ex, Exitus, Code signs: 0. the me-planned activity has been undertaken; /, the pre-planned activity has been cancelled; and -, no &cial activity planned. accurate picture of the situation as a whole, and of every patient in detail (Fig. 2). 2. One may learn what procedures are to be
undertaken on the following day, thus being able to prepare surgeons and necessary operating rooms, number of anaesthetics and anaesthetists, nursing manpower and equipment. (In Fig. 2 we can easily note that on 15 November for the next morning are scheduled three surgical while 2 patients still require procedures, resuscitation). 3. The chart easily presents the exact situation of every patient. Members of the staff are able to have all details regarding each patient at any time and be able to pre-plan the next steps needed accordingly. 4. When the whole treatment is terminated, the chart will serve as a basis for evaluating the
treatment aspects.
and its results from various possible
Acknowledgements
The authors wish to express their sincere thanks to the nurses, Miss Ahuva Fishgrund and Miss Ada Kuatrini, for their original thinking and assistance with the bums kit.
REFERENCES
Jackson D. M. and Stone B. S. (1972) Tangential excision and grafting of bums. Br. J. Plast. Surg. 25,461.
Mahler D. and Hirshowitz B. (1975) Tangential excision and grafting of bums of the hand. Br. J. Plast. Surg. 28, 189.
Paperaccepted 18 December 1978.
Requests for reprints should be addressed IO:Professor D. Mahler, Department of Plastic Surgery, Soroka University Hospital and Faculty ofsciences, Ben-Gurion University ofthe Negev, Beer-Sheba, Israel.