Question about Burns and EMS

[Cory]

Do most EMS services have to take a burn victim to a burn center, or can they be transported to a hospital that doesn't have a burn center?

And also, in your area is there a mobile burn unit that responds to medical emergences? I could be totaly wrong, but I think I remember hearing that in some places, there are special units sent out by burn centers to assist EMS in treatment.

Again, I could be wrong.

Now a BLS question that I am just going to put here: How exstensively does an EMT-B class teach about burn treatments? In all courses I have taken, I was taught almost nothing at all on the subject. So I wonder if that changes in EMT-B class.

 

[MrRevesz]

Since our burn center isn't too far away from our service area, we'll generally bring most burn victims there, not superficial though. As for a mobile burn unit, I'm not sure if we have one around here, could very well and I just don't know about it.

In my class, we talked about burns, treatments, the different degree of burns, and what makes them that. Overall basic burn management.

 

[EMT11KDL]

With EMT classes, it all depends on the instructors. Some instructors cover more in one area than another.

Also, some places do not have a "burn center" so they are transported to the ED where they are stabilized than usually transported to a burn center.

With burns, what is your agency having you do, wet dressings or dry. I have heard a lot different opinions on this.

 

[8jimi8]

rule of nines: adult/pedi, degrees of burns, how to treat each.


We responded to a burned pedi a few weeks back. By my estimation she had ~9% partial thickness burns that included her: left anterior thorax (no abdominal involvement) and the superior anterior portion of her left arm between the axilla and AC. The first layer of epidermis was sloughed, but not the dermis. The paramedic i was 3rd riding with is a new paramedic and he felt the need to call the helo. We were a 30 minute drive away from the nearest children's hospital and about 40 minutes out from Brooks Army Medical Center (humongous burn unit). With the response time of the helo, i think we could have gotten her to either facility in the same amount of time, had we just driven and not stayed on scene waiting for the the pickup. I haven't heard of any mobile burn unit.

 

[usafmedic45]

Do most EMS services have to take a burn victim to a burn center, or can they be transported to a hospital that doesn't have a burn center?

No, not unless the burn center is really close. It's not been a practice of any service I've ever dealt with to drive more than an extra 10 to 20 minutes for a patient that may not need the care and I'm certainly not going to call for a helicopter. They will go to the closest hospital for stabilization and then be shipped out as necessary. Most of the benefits of burn centers are in the tertiary phase of care and not in the immediate resuscitation phase where EMS decision making really plays a key role.

And also, in your area is there a mobile burn unit that responds to medical emergencies?

Never heard of it before, especially for scene response. Also, burn management is not as complicated in the initial phases as you seem to want to make it sound. It isn't something that is out of the scope of a competent team of EMS providers to handle. You seem to be envisioning it as something the requires a specialized team like some of the NICU/PICU transport teams used for interfacility transfer and that is simply not the case. The time delays and costs associated with operating such a team would be impractical. Usually if they're transferring them to the burn unit from an outlying hospital they go by helicopter if weather permits. If not a local paramedic unit is used for transport.

How extensively does an EMT-B class teach about burn treatments? In all courses I have taken, I was taught almost nothing at all on the subject. So I wonder if that changes in EMT-B class.

It's not exactly rocket science so what you get in the EMT course is sufficient: stop the burning process if it's still on going, keep the patient warm, keep the wound clean with dry sterile dressings (don't worry about fancy gel dressings or creams) and know when to recognize things that are likely to cause problems (signs of inhalation injury, circumferential deep burns of the chest, neck or extremities, etc). Honestly the only other things that play a role in burn management that can be done in the field are fluid resuscitation and pain management and both of those are ALS skills. If you really want the full spectrum of burn management from a primarily in-hospital perspective, you can always take the American Burn Association's Advanced Burn Life Support class which is a pretty good source of information but it's not something I would recommend as a standard course for EMS providers.

 

[Cory]

Never heard of it before, especially for scene response. Also, burn management is not as complicated in the initial phases as you seem to want to make it sound. It isn't something that is out of the scope of a competent team of EMS providers to handle. You seem to be envisioning it as something the requires a specialized team like some of the NICU/PICU transport teams used for interfacility transfer and that is simply not the case. The time delays and costs associated with operating such a team would be impractical. Usually if they're transferring them to the burn unit from an outlying hospital they go by helicopter if weather permits. If not a local paramedic unit is used for transport.

I realize that burns are treatable by EMS, but there are non-emergency phases to all serious burns. It is to my understanding that all bad enough burn victims, after initial sterilization and what not, have to be taken to the burn unit for things like skin graphs and those sorts of treatments.

I am guessing if a burn isn't to bad, they will clean it, wrap it, possibly medicate it, and then treat it like any cut, just keep it covered and clean?

 

[Mountain Res-Q]

Do most EMS services have to take a burn victim to a burn center, or can they be transported to a hospital that doesn't have a burn center?

I can only speak for my area. No Burn center nearby. Closest is 2-4 hours away by ground. (Anyone in NorCal... UCDavis closest Burn center to Yosemite right?) Hell, the closest Level 2 Trauma Center is 1.5 hours away from our little ER. So everything significant gets flown out.

And also, in your area is there a mobile burn unit that responds to medical emergences? I could be totaly wrong, but I think I remember hearing that in some places, there are special units sent out by burn centers to assist EMS in treatment.

Nope. Nothing in my area like that... in fact never heard of a special unit to handle these things.

Now a BLS question that I am just going to put here: How exstensively does an EMT-B class teach about burn treatments? In all courses I have taken, I was taught almost nothing at all on the subject. So I wonder if that changes in EMT-B class.

Like others said, EMT-Basic teaches you just that "BASIC Burn Management." Recognize what you got, stop the burning, sterile dressings, supporting BLS measures, get ALS, and transport... If we are talking serious burns, then what they really need is a Burn Center w/ people trained to give this person every fighting chance. Ambulance (bls, als, cct, or air) is just their to get them to the center ASAP and provide whatever supportive/pain management measures they can, which is realtively limited, but a vital first step.

 

[usafmedic45]

It is to my understanding that all bad enough burn victims, after initial sterilization and what not, have to be taken to the burn unit for things like skin graphs and those sorts of treatments.

As a general rule (at the risk of oversimplifying things), yes, that's basically correct. However, the point was that they can go either by a standard RN/EMT-P or dual RN or dual EMT-P HEMS crew or by ground ambulance. You don't need a special team for that. The primary reason I advocate against EMS triaging people to go to the burn center is that we do a downright piss poor job of triage as a whole and it gets even worse when you start applying it to low frequency events such as severe burns.

The only specialized burn transport team I am aware of is one operated by the US Army for mass casualty incidents and even with that, the majority of military burn victims still get flown by USAF Critical Care Air Transport Teams (at least they did as of late 2003 when I separated) which are generalist critical care teams akin to many civilian fixed wing aeromedical operations. Each team consists of a doc, preferably a critical care or EM doc or surgeon, but not always due to the hard time the military has recruiting and retaining them because of how bad the AF treats it's docs (I saw teams with family practice docs, oncologists, general pediatricians, etc) along with a a nurse (once again preferably an ED or ICU nurse) and a cardiopulmonary technician (respiratory therapist/echocardiographer/more or less de facto flight paramedic).

 

[Cory]

A local towhip FD every does a 2 day long demonstration for the public in the parking lot of a local mall (my county has a bit of a spending problem) it's kind of like an FD festival.

There was a mobile burn unit that was from a local university there believe it or not. I don't know if it was actually in service or not, it might have been experimental.

 

[Mountain Res-Q]

I realize that burns are treatable by EMS, but there are non-emergency phases to all serious burns. It is to my understanding that all bad enough burn victims, after initial sterilization and what not, have to be taken to the burn unit for things like skin graphs and those sorts of treatments.

I am guessing if a burn isn't to bad, they will clean it, wrap it, possibly medicate it, and then treat it like any cut, just keep it covered and clean?

If we are talking about minor (either in degree or surface area) can be treated at local hospitals or trauma centers. But if we are talking severe:

BASICS (maybe too basic): Skin is a giant organ that keeps things in (i.e. fluid) and things out (bacteria, etc...) That is why surface area of the burns are a big concern. The bigger the area burned… the harder it is for the body to keep stuff in and keep stuff out. The two biggest concerns are fluid loss (and subsequent metabolic shock) and infection. These kill people with severe burns. At the BLS level, sterile dressings are your only “skill” for warding off infection. Fluid loss… IVs… which you can’t do… so ALS is a big deal as is a Burn Center.

Of additional concern is hypothermia since the skin is a vital part of your thermoregulatory system. Also not to be overlooked is pain management.

All in all, at the BLS level, not much you can do with a severe burn with large surface area. Even at the ALS level, fluids, pain meds, and additional respiratory support is the extent (generally speaking), so a Burn Center is your best bet… and that usually means a helo if your closest one is hours and hours away.

Reminds me of a story… Was out camping 5 years ago with friends of my family (not mine) and a 13 year old touched a lamp… on purpose to see if it was hot… dolt!!! Burned his had pretty good… slight blistering. After laughing at him for being an idiot, I told him to stick his hand in cool water to stop the burning and relieve the pain before we addresses wrapping it. Next thing I know his mom grabs a tube of toothpaste and states slathering it on the hand! No, I have heard of some really strange home remedies for stuff before… but wouldn’t any paste help retain in heat? And what’s more… it is mentholated toothpaste, minty (as in, with a bite)!!! Ya, it started to hurt more the second he put that on. Anyone ever heard that one?

 

[Shishkabob]

We have Parkland hospital, which is a world renowned burn center, and where the "Parkland formula" for burn fluids was devised.


If there is a pt in Fort Worth that is a major burn victim, they get taken to the local Level 1 trauma center, which is JPS. From there, once "stabilized", they either get on a ground ambulance or CareFlight HEMS and flown to Parkland in Dallas, which is an hour away with no traffic.

 

[fast65]

Like everyone else here said, it really depends upon the proximity of the burn center and severity of the patient. Our closest burn center is Emanuel up in Portland so that's a good 3 or 4 hour drive, so burn patients will get stabilized in the ER,which is a level 2 trauma center, and then taken to the burn center if the situation dictates.

I've never heard of a mobile burn unit either, seems like a waste of money to me.

In my EMT-B class we spend about a day (3 hours) covering burns, so I guess we spent a pretty average amount of time on them. Stop the burning, cover with a dry sterile dressing, provide basic supportive care, get ALS, and transport.

 

[VentMedic]

I can only speak for my area. No Burn center nearby. Closest is 2-4 hours away by ground. (Anyone in NorCal... UCDavis closest Burn center to Yosemite right?) Hell, the closest Level 2 Trauma Center is 1.5 hours away from our little ER. So everything significant gets flown out.

St. Francis in San Francisco is one of the first burn units to be established in the West. It also takes the Pedi cases and Oakland Children's Hospital does not. The biggest disadvantage in SF is there are no helipads at the hospitals to fly in patients.

http://www.saintfrancismemorial.org/Medical_Services/195214

The next burn center is Santa Clara Valley Medical Center which also does Peds.

http://www.sccgov.org/portal/site/s...DEP)/Programs & Services/Burn Center/Services

Since burns are a specialty, it is rare to find a children's hospital that has a burn unit as they are very expensive to staff and equip. The burn centers mentioned are often self contained with their own OR.

These burn centers may have the burn team respond to the ED. We have a fiber Optic scope to assist in establishing an airway and recording the extent of injury on DVD as we are putting the tube in. As well a trach may also be placed in the patient patient immediately but if possible we wait until they are in the burn OR. Escharotomies will also be performed, preferably in the burn unit, to relieve compartment syndrome of extremities and abdomen as well as the chest. Thus, the patient spends very little time in an ED if taken the burn center. The sooner they can actually be inside the burn unit the better to start the stabilization and surgical processes.

The local EDs will often call the burn center to make sure they are following the correct protocols for resuscitation, especially fluid, of the burn patient. As well, it is vital they have a secure airway for the aggressive resuscitation and the appropriate ventilator with the right protocols in place. That doesn't mean just a recipe for what knob to turn but what corrections to do with fluids and meds if permissive hypercapnia is allowed and to stabilize the hypotension on in some cases hypertension.

 

[EDAC]

I can only speak for my area. No Burn center nearby. Closest is 2-4 hours away by ground. (Anyone in NorCal... UCDavis closest Burn center to Yosemite right?)

RMC in Fresno has a Burn Center.

 

[JB42]

Closest burn centers for us are in Boston. We transport to any of the local level 2 trauma centers for stabilization and patients are transferred as appropriate.

 

[Mountain Res-Q]

Thanx Vent & EDAC... All I know is that severe burns in my area always get flown out to UCDavis... but never stopped to consider what (if any other) burn centers are in relative proximety to me. Since I am just north of Yosemite, Fresno is a little further off for us, but anything in the central valley (sac) or the bay are usually used.

For anything flown (last I checked): Usually Modesto (2 Level 2 Trauma Centers)
Cath Lab: Modesto
Burns: UCDavis
Peds: Oakland or Madera

 

[VentMedic]

For anything flown (last I checked): Usually Modesto (2 Level 2 Trauma Centers)
Cath Lab: Modesto
Burns: UCDavis
Peds: Oakland or Madera

You've got one more specialty that you should be aware of: Microsurgery and replantation.

The Buncke Clinic at California Pacific Medical Center (Davies Campus) in San Francisco receives patients from all parts of California and other states 24/7 for limb reattachment and reconstruction like from the various animal attack or industrial accidents.

 

[Mountain Res-Q]

You've got one more specialty that you should be aware of: Microsurgery and replantation.

The Buncke Clinic at California Pacific Medical Center (Davies Campus) in San Francisco receives patients from all parts of California and other states 24/7 for limb reattachment and reconstruction like from the various animal attack or industrial accidents.

Thanx good to know.

 

[ResTech]

The destination decision will be based on a few things... one is the overall priority of the patient... two is how much is burned, what degree, and where. Also, age is a factor. Certain body regions burned earn a higher priority on the criteria for burn center transport.... Burns to parts of the body that are critical to daily functioning need to go to a burn center.. for example burns to hands, face, feet, and genitals.

If its a critical burn patient they can most certainly be flown to a burn center. Being in the city with a short ETA, were most likely going direct to the local hospital which is a Level III trauma center. Further out though, aviation would be a wise choice. Our closest burn center is Bayview Burn Center in Baltimore, MD.

And I have no idea what a specialty mobile burn unit would do... burn patients in the field need fluids, analgesics, and burns kept clean from contamination. And airway management if airway burns present.

 

[usafmedic45]

the various animal attack

Not to come across as snide or anything but is this really that big of a problem in California? I mean I know there are mountain lions, great white sharks (not that you recover anything they take off), grizzly bears (up north from what I've heard) and dogs, but is it really THAT common? I mean we have a problem with packs of roving dogs here, but it's not very common that someone winds up that badly mauled that they need limbs or skin flaps reattached. How common is it out there?