Amanda Jane Wilde
South Africa has no national emergency plan for burn care, should a large number of victims require the very specific treatment needed for recovery. In fact, when it comes to burns, the levels of care in this country are well below international standards and very little national attention is being paid to improving treatment of these common and severe injuries.
After the fires that have raged in Cape Town, it is comforting to know that no human lives have been lost, although several burn injuries were suffered At the same time, the difficulty extinguishing the fires has shown how little control we do have over these raging acts of nature (or neglect), and that South Africa urgently needs a national plan for burn treatment, should a fire of this magnitude ever raze a densely populated urban area.
“We need to work towards a national disaster plan, because there isn’t one,” says Dr Nikki Allorto, a KwaZulu-Natal burns specialist and SA Burn Society president. “In the event of a national disaster, burns could be a large proportion of the injuries sustained, but there is no record of the hospitals with burn units or services, or the number of available beds around the country.”
This ties into the broader issue of burn treatments not being given appropriate attention in the South African context. According to Allorto, burns are extremely common injuries in South Africa. Every year, 3.2 percent of the population experiences a burn injury. Of these, 90 percent are minor burns that can be treated in a clinic or in a hospital as an outpatient. The remaining 10 percent are severe burns that need specialised care in a burn unit, burn service or ICU. “That equates to 268 patients who are severely burnt every month in South Africa,” she says.
Unfortunately, in South Africa the largest proportion of burn victims comes from low-income homes, where electricity and other heating mechanisms are not properly isolated because people are living in close quarters. “Burn injuries are a socio-economic disease,” says Dr Rachel Moore, a burns specialist in Gauteng. “Burn victims primarily come from informal settlements and shacks where there are unprotected electrical outlets, pots or kettles.”
And unfortunately, the public health-care infrastructure for these victims just isn’t there. Allorto explains that the international standard for burn care is that there should be one burn unit bed for every 50 000 of the population. In South Africa, there is a total of 200 burn beds, which is one per 245 000 of the population. This results in our higher incidence of burn mortality – 8.5 deaths per 100 000, compared to the international average of five per 100 000. In addition to the lack of space, burn care is also under-resourced.
“There is a severe lack of government attention, a low number of beds, and no specialised units or training for very specific care requirements,” says Allorto. These requirements include the ability to isolate the patients in smaller groups, dedicated nursing staff, available theatre time and blood for transfusions. Burn units also need to be kept at higher temperatures than most hospital wards because burn patients have trouble regulating their own body temperature.
Mistakes also occur at hospitals with no burn units or burn services, because there is no significant training in assessing the severity of a burn injury. This means that the first stage of treatment, when all the difference can be made, is often neglected.
“Because doctors don’t have burns experience, they don’t get that part right,” says Dr Janeshree Govindasamy, a burns specialist in KwaZulu-Natal. “By the time these people end up with a burns doctor, things have already gone wrong. Patients come to us complicated. These complications extend the length of their stay, and the resource requirements can triple or even go up to 10 times what we would have required, if we had started the correct treatment in the first hour.”
Few general practitioners and surgeons have burn training and experience, but even fewer desire that kind of specialisation. In fact, one of the greatest challenges facing burn care in South Africa – and globally – is that it is not a particularly appealing field of specialisation for healthcare workers.
“There is a lack of skilled professionals in burn care, so the people that are there are stretched,” says Amanda Jane Wilde, the managing director of Umsinsi Health Care, the local partner for ConvaTec Wound Care in South Africa. “Burn care is not as appealing as some other areas of health care, and relatively few health practitioners want to specialise in this field. Our burn dressings are helpful; however, it’s the doctors and nurses that make the biggest difference. It’s emotionally distressing to deal with children with burnt faces and adults are not much easier. It’s a long and demoralising process.”
Wilde says that more health practitioners need to take an interest in burn care, and likewise the government needs to provide better psychological care and counselling for those who work in the field and need to be supported while looking after burns patients.
“It’s emotionally exhausting stuff,” says Moore. “The patients look bad, they sound bad, they smell bad, and we’re working in temperatures of 30 to 32º. It’s hard work. Also, surgeons like to fix things and, for burn patients, there’s no quick fix.”
She acknowledges, though, that advances in burn care and dressings have made the field more appealing. “We’re not just slapping on cream any more. These innovative dressings do feed into the positive morale in our units. We get excited when we see wounds heal.”
The SA Burn Society is campaigning for action in all the areas in which burn care in South Africa is lacking. It is in the process of creating a network of practitioners around the country who can share support and best practice in this challenging field. Govindasamy is responsible for this outreach aspect of the society’s work.
“I am working to set up a hotline to integrate burn care across the country, so that a doctor in one small town can call the burns hotline and someone on the other end can take them through the assessment and treatment plan, and assist with the referral process,” she says.
Allorto is also pushing the government to establish national services like a national skin bank. “People sign up for organ donation, but only 1 percent of hospital deaths are actually suitable to donate. However, almost 100 percent of hospital deaths could be tissue donors, and one person’s skin could save over 50 burn victims. People – hospital workers and public – just don’t know enough to initiate the chain of events that would lead to the donation.”
It’s worth noting that the lack of skills, resources and a skin bank extends to patients in private health care as well, so the situation affects all South Africans, not just those of a low socio-economic standing. Although burns are not an appealing line of work, not well supported by the government or corporate sponsors, and terribly under-resourced in the South African context, where everyone is competing for resources, early and correct intervention and the right treatment throughout the process can radically improve the outcomes.
“It’s also important to remember that a burn injury that goes wrong takes away a portion of our able workforce,” says Govindasamy. “If treatment goes wrong, it can leave the patient with a major disability, taking them permanently out of the productivity pool. Because of this, if for no other reason, burn care should be a priority.”
While South Africa has a long way to go before its burn care compares to that in other countries, with health-care workers like these dedicated to improving the situation and lobbying for the government to take notice, there is hope huge advances will be made. Let us only hope it doesn’t take the unfolding of a major tragedy to get everyone to sit up and take notice.
l Wilde is the managing director for Umsinsi Health Care (Pty) Ltd