In medical school, Dr. Michael Smock, director of the Burn Center at Mercy Hospital St. Louis, wanted to be a plastic surgeon. "I thought I would primarily do reconstruction after cancer removal or injury," says Smock.
But before he could do specialized training in plastic surgery, he had to train in general surgery. As part of his rotation he went to the burn center. "It just really struck me," says Smock. "It was a very interesting combination of plastic surgery including those complex reconstruction problems that I could face in medicine along with critical care and the challenges of bringing patients through that early phase of a critical illness."
Plus, burn patients usually have to see their doctor for years, not weeks or months. So Dr. Smock is able to develop a long-term relationship with his patients, and most importantly, see them heal.
Where is the most dangerous area of the body to be burned?
The most concerning areas are the face and the hands. The face because it can have such a dramatic impact on one’s appearance and the hands because of the concern for functional recovery, and the problems that happen if scars are so thick and severe that they can impact the function of the hand.
What kind of burns do you see in children?
With children in particular the most common injuries are kitchen and tub hot-water scald burns. The kitchen and bath in particular are often places kids get burned. They’ll pull a put off the stove and get hot water poured down their body or grab some kind of grease fryer and spill that on themselves. Older kids who are trying to do some cooking on their own or care for themselves and pull things out of the microwave and then spill hot liquids on themselves. Those are the most common burns we see in kids.
How big does a burn have to be before a person’s hospitalized?
Well certainly if a burn exceeds 10 percent of the total skin surface area, they’ll need to be hospitalized. Some burns smaller than that may need hospitalization if they’re third-degree burns. They will need more intensive wound care or surgery for skin grafting. And burns smaller than 10 percent of the body surface area often will still be so intensely painful for the first several days that they’ll require hospitalization.
Is it more dangerous to inhale smoke than to get burned externally?
Yeah, a burn of an equivalent size, an equivalent total body surface area burn with smoke inhalation it’s more dangerous and associated with a higher degree of mortality than that same burn without smoke inhalation. Recovery is much longer and the risk of having complications up to and including death is higher.
When someone has been severely burned, I heard they're at risk for hypothermia.
Yes, it’s important to keep that person warm because the loss of a large portion of your skin makes it very difficult for your body to maintain temperature. So a person with a large surface area burn is at severe risk of developing hypothermia. That can be markedly worsened by now being doused with water and exposed in the open with a huge amount of skin pulled away. So it’s important that the paramedics and the ER staff keep the person warm while they’re assessing for the severity of the burn and assessing for any other injuries because this person may have been involved in an explosion, may have fallen, or sustained some other type of injury.
What is something people don't expect about burn recovery in the case of a severe burn [over 40% of the body]?
Burns affect much more than just the skin. In the first couple days there are tremendous shifts in a person’s fluid status. We have to give literally gallons of IV fluids in a couple days to replace all the fluid that seeps out through the burn wounds. So the fluid management is very critical that can then impact the respiratory function, their ability to breathe appropriately. It can impact heart function, blood pressure, kidney function. It’s a total body injury.
Also, the need for nutritional support is intensive throughout their hospital stay. The body literally has to regrow these large areas of skin and it requires a huge amount of calories and protein to maintain that healing process. So the care team that we have at the burn center really has to address all of those areas. We have a full team of specialized nurses, patient care technicians, occupational therapists, physical therapists, a dietician, social workers to help support patients and family as they progress through recovery, and physicians of other specialties are necessary. It’s really a very large specialized team.
How soon after the person comes in would you start doing the skin grafts?
Usually within the first few days, anywhere from one to four days. That may be a series of 10 or 15 operations for patients with larger burns.
How does the skin graft surgery work? I heard that you take a patch of skin but then you’ll stretch it?
Yes, that’s right, especially in a person with a large burn. So the basic concept is that where the skin has been destroyed by the burn has to be replaced with the person’s own skin from a healthy unburned area. We’re only able to use their own skin. We take a thin layer of skin, it’s about 100th of an inch thick from a part of their body that was not burned. That area where the skin comes from is called the donor site. Since we’ve only shaved the outer layers of skin off, the deep layers of skin remain, that skin can regenerate and heal back to a nearly normal state. Then we use a process called meshing where a series of little slits are cut into the skin so the skin can then be stretched or opened up in a net or a lattice type pattern. That skin can then stretch and cover a larger surface area than it would have originally and that’s how we can cover a large surface area burn without having to have an equivalently large size donor site. The downside of that meshing practice is that it does result in more scar tissue where the skin graft heals. In circumstances when we’re placing a skin graft on the face we don’t do that meshing procedure because the ultimate scar would really be unacceptable. So then we keep the skin graft as a complete sheet layer but to do that over the whole body in a person who has a very large surface-area burn would complicate their care and significantly increase the risk of wounds not healing as well.
I know that everybody’s different. Is there a ballpark for how long it takes for the person to get better?
The ballpark length of time that somebody will stay in the hospital is roughly one day per percent body surface area of their burn. So somebody with a 20-percent body surface-area burn will spend maybe 3 weeks in the hospital. Somebody with a 90-percent body surface-area burn, you wouldn’t expect them to be out before three months.
What happens after someone has recovered? They have scars even with skin grafts. Are there any concerns?
Yeah, there are some other problems or challenges that the burn survivor has to deal with. I think a lot of people don’t realize how much itching is involved during the recovery process and for months and months after recovery the scars can have an intense itching. So there are some treatments including some aspects of their physical therapy and occupational therapy that are done to address the itching plus some medication is also necessary for that. The skin is very sensitive to sun exposure so it’s very important in the first year after the burn that the person be careful to avoid sun exposure or very liberally apply 45 or stronger SPF sunblock throughout the day. They’ll often experience discomfort in cold or hot temperatures as the skin is just more sensitive. They’ll often have a prickly or a tingling or a stinging discomfort if they are exposed to cold temperatures or hot temperatures. The burn scar areas often don’t sweat like normal skin because the burn may have been all the way deep through the deeper layers of skin where the sweat glands are.
And then on the long-term, one of the potential dangers is a risk for skin cancer development. Fortunately it’s not a very common problem.
