Deep Burns: Comparing the Developed and Developing World

We dedicate this editorial to the victims of the horrific fires in California and to the heroic efforts of the firefighters, first responders, and healthcare professionals helping those in need. In this issue of Advances, Dr Michael Hermans’ continuing education article documents the incidence of burn injuries in the United States. In a developed country of 329 million persons, there are an estimated 40,000 burn injury hospitalizations annually; 60% of these patients receive care in specialized burn centers.1 It is important that proper wound care is delivered to minimize painful disfiguring sequelae. Deep partial-thickness burns benefit from early excisional surgery after patients have been stabilized medically. In all populations, young children and older adults are at the greatest risk of burn-associated morbidity and mortality. In the US, one civilian fire death occurs every 2 hours 41 minutes and the odds of an American dying from exposure to fire, flames, or smoke are 1 in 1,442.1 That said, the survival rate based on data from the National Burn Repository for 2015 is 96.8%. Most burns occur at home (73%), and 68% of burn victims are male. The cause of on patients admitted to the hospital are: 43% fire/flame, 34% hot liquid scald, 9% contact with a hot solid surface, 4% electrical, 3% chemical, and 7% other.1 The same statistics are very different in the developing world. India has a population that is three times that of the United States, with around 1 billion persons as of 2004.2 That year, there were an estimated 700,000 to 800,000 individuals hospitalized for serious burns,2 or up to 20 times the number of hospitalizations in the United States! The World Health Organization reports that in Bangladesh almost 173,000 children are moderately or severely burned every year.3 Seventeen percent of children with burns in Bangladesh, Columbia, Egypt, and Pakistan incur a temporary disability, and 18% experience a permanent disability.3 Under poor socioeconomic conditions, burn care is often delayed and too expensive for many victims to receive treatment. There is also an additional high-risk Indian population of young females between the ages of 16 and 35 years who cook over open flames at floor level, often with faulty equipment and loose clothing susceptible to catching fire.2 To help address these unfortunate conditions, providers can access guidelines for burn care under austere conditions.4 The economic burden of burns in the developing world can be overcome with an integrated care plan mapped out with the Porter Model of Healthcare.5 This model emphasizes value for the healthcare dollar without a higher cost. To put the problem in perspective, the economic impact of burns was greater than $211 million for children in the United States in 2000, greater than $10.5 million in Norway for hospital burn management in 2007, and $26 million for burn care after kerosene cookstove incidents in South Africa every year.3 The principles of cost-effective burn management can be simplified using the “5 P’s” format, introduced in our December 2018 editorial:5Patients need improved education to overcome illiteracy and superstitions to receive proper medical treatment and institute safety measures in the home. Professionals need to develop dedicated expertise in burn care. Payers need improved infrastructure for disaster plans and implementation strategies to coordinate care in difficult situations. Policy makers need to facilitate the development of burn registries, centers of excellence, and a system change to link these centers at all levels of the healthcare system. Politicians need to pass legislation for adequate safety regulations and healthcare reforms supporting efficient systems that avoid delayed, siloed, and substandard care. If stakeholders work together to combine education, expertise, and efficiency, we can create a coordinated and integrated system to improve outcomes for patients with burns.FigureR. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JMFigureElizabeth A. Ayello, PhD, RN, CWON, ETN, MAPWCA, FAAN

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