 The red skin of a mild sunburn is an example of first degree burn. |
Burns and how to cure them are the hottest medical problem, thanks to the danger of A-bomb radiation added to the more peaceful accidents such as smoking in bed.
The best cure for burns is to prevent them. But if you are burned badly, the chances are you will get the best treatment the world has ever been able to give to burns.
Ugly, dangerous burns with the flesh literally cooked and charred and the skin totally destroyed are called third degree burns. The sign of a second degree burn is the blister, though you cannot always tell by this sign immediately, because the blisters may not form until hours or even a day later.
The first degree burn, unlike murder, is the least serious. The reddened skin of a mild wind or sunburn is an example of a first degree burn. The damage is confined to the most superficial layers of the skin which may "peel" in small powdery flakes. If you blistered after that day at the beach, however, you had a second degree burn. How sick you were depended on how much of your skin got seriously burned.
The amount of body surface burned as well as the degree of the burn plays a part in the severity of the burn. Up to the time of the second World War, first degree burns involving two-thirds of the body surface and, in adults, second-degree burns involving one-third of the body surface were generally fatal. But in 1945 a Navy surgeon could report the recovery and return to duty within three months of a young Marine who had second and third degree burns over 83% of his body.
To get such results requires practically the whole armory of medical weapons from gauze to vitamins and steaks and the surgeon's skin grafting instruments. And it requires also a corps of trained medical personnel. Because of the tremendous amount of material and equally large number of persons needed to care for a single badly burned patient, present medical research on burns is aimed partly at finding ways to cut these twin bottlenecks without sacrificing the patient's recovery.
In the decade before World War II, tannic acid was widely used to treat burns. It was used either alone or in combination with silver nitrate, a purple dye called gentian violet, or a so-called triple dye. The idea was to tan the skin and produce a protective scab, medically termed an eschar. These substances were sprayed on the skin until a good eschar was produced. Then the patient was put to bed and covered with a heat cradle. Burn ointments for home use had tannic acid put into them and people were even told that, if they could not get medical aid promptly, they might start the tanning process by applying strong tea to the burn.
The tanning treatment, however, had to go on over a prolonged period and the results were uncertain. Pus can collect, undetected, under a tanned scab and may destroy valuable bits of skin not killed outright by the burn. In second degree burns, even severe ones, many of the deeper parts of the skin are spared and can regenerate new skin. The tanning treatment too often destroyed these important surviving bits of skin tissue. The difficulty of removing the scab was another disadvantage of this method.
MODERATE TREATMENT
Successors to the tanning treatment were: 1. Use of a sulfa drug, sulfadiazine, in triethanolamine spray to form a transparent, pliable scab, or eschar, through which pus formation and other changes in the burned area could be seen. 2. Use of boric acid, in ointment or in fluid form under pressure dressings. This was abandoned when it was discovered that boric acid, previously considered a harmless, if weak antiseptic, could poison and even kill in some circumstances.
Discovery of the sulfa drugs and then of penicillin and other antibiotics has greatly aided the victims of severe burns. Infection has long been a major problem in burns, particularly those occurring in disasters in which the victims may have other wounds besides the burn. In the event of an atomic disaster, the infection problem is greater because radiation from the bomb reduces resistance to infection.
Medical scientists have not yet all agreed on the best method of fighting infection in burns. Some believe that sulfa drugs or penicillin or other antibiotics should be put directly onto the burn, usually in the form of an ointment, when the first dressing is put on. Others think it is better to put nothing on the burn itself except a sterile dressing or a sterile dressing impregnated with petrolatum. This group thinks the penicillin or other antiinfection drug should be given by hypodermic injection, as in the case of pneumonia or other infection, to be carried to the burned area and all other parts of the body by the blood stream. But, says the other side, this method of giving penicillin requires more trained personnel to give the hypodermic injections.
Both sides agree that when there are other wounds besides burns, as there are likely to be in the case of an atomic or other great disaster, "shots" of penicillin would have to be given to fight the danger of infection from the other wounds.
The solution may come, at least for atomic bomb burn victims, through aureomycin or some other antibiotic which is effective when given by mouth in pills or capsules.
One of the methods of treating burns now under trial in a couple of burn research centers, is the "exposure method." With this method, nothing is put on the burn. It is left completely exposed to the air, but the burned part is immobilized in some way. Good healing of superficial burns, without infection, in one to four weeks, has been reported with this method. Penicillin "shots" are given the patient as part of the treatment. How well this method works with deep burns that extend through all layers of skin tissue remains to be seen.
PRESSURE TREATMENT OF BURNS
Direct opposite of the exposure method is the pressure dressing which came into use during World War II and has continued in use since then. These are large pads of absorbent, resilient material bandaged on tightly and left in place for a week or 10 days. With this dressing pain is greatly relieved and almost all superficial burns, mild or deep, heal in one to four weeks if infection does not develop. Disadvantages, in case of disasters with mass casualties to be treated, are the amount of material and time and numbers of trained personnel needed to apply to dressings.
To cut this bottleneck, there is a new burn dressing consisting of fine mesh gauze next to the skin, a thick cellucotton pad and a tough outer layer of cotton. This all-in-one-section dressing can be put on quickly and its application should need only supervision by a doctor, thus freeing him to supervise treatment of large numbers of patients at one time. This dressing is now getting experimental trials in two large clinics where many burns patients are treated.
Nylon is also on trial as a burn dressing. English doctors have been trying Nylon bags to cover burned hands and pieces of Nylon to cover other burned areas. Advantages are that it can be put on fast, it can be sterilized in an autoclave, does not tear easily, is transparent in the form used so that the doctor can watch the progress of the burn without removing the dressing, allows unrestricted movement of the burned part, and should be cheap if mass-produced.
If fluid collects over the burn, the doctor can stick a sterile needle through the Nylon dressing or bag, suck out the fluid and seal the tiny needle hole instead of having to remove the entire dressing and put on a fresh one. Needed for more effective use of this dressing is a method of sealing the Nylon to the skin around the edges of the burn.
Regardless of what kind of dressings are used or whether none are used, good burn treatment dictates that everyone in attendance on the patient, from the surgeon who dresses the burn to the nurse or orderly who gives bedpans, should wear a mask. This is to cut down the chances of infection from germs that even healthy people may be carrying in their noses and throats.
PREVENTING PAIN
As everyone knows, burns are painful. Flash burns, such as come in atomic attacks and also in explosions, are superficial but extremely painful. Small doses of morphine or codeine do a good job of relieving pain in superficial burns, such as the flash burns of an atomic attack, and even in deep burns, especially when the burn is covered. The covering of the burn alone does much to relieve pain and this is one reason medical scientists have been working hard to find good simple ways o covering burns without contaminating them, for use in large scale disasters.
Morphine, however, may turn out to have another important value in treatment of burns besides that of relieving pain. It may reduce the swellings, from accumulations of fluid, known medically as edema, which come with severe burns. In studies with guinea pigs, scientists have found significant decreases in the swellings with increasing doses of morphine. In this study, the laboratory animals were all burned with a measured amount of heat so that all had the same kinds of burns and the effects of various treatments could be determined accurately by comparing treated with untreated but identically burned animals.
The morphine that reduced the swellings in these animals was given before the burn, so one of the big questions to be answered is whether it will be as effective for this purpose when given after the burn. The studies are still going on and it is not known yet whether the preliminary results will prove out, especially when applied to burned humans instead of burned guinea pigs.
Severely burned patients suffer shock, anemia and, if they survive, the first shock period, a kind of poisoning from the absorption of poison products from the burned tissues or from infection or both. Plasma, the fluid part of the blood, as well as red blood cells are lost from the blood stream into the burned tissues.
BLOOD TRANSFUSIONS
Plasma and blood albumin help fight the shock. But severely burned patients need whole blood as well. As one Army doctor puts it, burned patients "seem to burn up transfused blood." When a pint of whole blood is given to a burned patient, there is not the increase in red blood cells that would be expected and would come from transfusing a pint of whole blood to a patient sick with some other wound or illness. An A-bomb burn victim needs even more blood, because the radiation from the bomb damages the blood forming organs in his body. This makes him easier prey, also, to germs not only in the burn or other wounds but to those of pneumonia or strep sore throat or others which a previously healthy person could fight off easily with the aid of a sulfa drug or antibiotic such as penicillin. Atomic bomb burn victims need whole blood to save them until their own blood making organs have recovered and are on the job again.
 Steaks or their equivalent in protein are a must in the diet of the burn patient. |
Cortisone, adrenal gland hormone famous for its beneficial effects in arthritis, might become part of the future treatment for severely burned patients. Many doctors have already been using adrenal gland extracts, but recent experiments with guinea pigs show that the death rate can be halved if cortisone is given along with treatment for shock during the first critical days after the burn. The cortisone would tide the patient over the critical "toxic" period between the third and tenth days after the burn when some patients, even with no infection, who have survived the initial shock, still die. Whether cortisone is used for this purpose, of course, will depend on two things: 1. Whether the guinea pig results prove out in humans, and 2. Whether enough cortisone ever becomes available.
Steaks or their equivalent in good protein are a "must" in the diet of the burn patient. The protein ration should be at least 125 grams per day. That is four ounces or more, and the four ounces means protein, not just meat. It would take at least a pound of sirloin steak, weighed without the bone, to furnish four ounces of protein.
Because of the vast amounts of blood that would be needed to save victims of atomic attack, scientists are vigorously pushing research on blood substitutes. More correctly, these should be called plasma substitutes, because so far no one knows of any real substitute for whole blood. Of the plasma substitutes, useful for fighting shock and therefore important, dextran seems at present to hold most promise. This is a Swedish product developed, during World War II, from a byproduct of sugar manufacture.
Being pushed also, under the American Red Cross national blood program, is research into ways of keeping whole blood or red blood cells longer. At present, three weeks is the limit of the useful life of red blood cells and therefore of whole blood that has been drawn from the body. Any material extension of this time limit would make possible stockpiling of blood on a larger scale for use in case of large scale catastrophes.
Third degree burns, in which all the skin is destroyed, are the ones in which skin grafting is needed unless the burn is small in area. These also are the burns with ugly scars that contract as they heal, pulling flesh out of shape and, when they cross joints, making movement difficult or impossible. Burns of the neck, hands, elbows and other jointed parts of the body are therefore given special care to prevent these often crippling contractures. Early skin grafting is usually done for this purpose.
Another class of burns are chemical burns. First step in treatment of these consists in washing off the chemical with large quantities of water. If the burn was from an acid, an alkaline solution, such as soda in water, if available, would be useful because it would counteract the acid.
While the treatment of burns is enormously complicated, burns are burns, whether they come from an atom bomb, the sun's rays on the beach, a chemical, or the steam from the tea kettle on the stove.
FIRST AID FOR BURNS
In case of burns, the first aider's duties "are to relieve pain, prevent infection and treat shock."
Those directions, from the American Red Cross First Aid Textbook, will be especially important for you to remember if you are called on to give first aid in case of an atomic bomb attack in your community.
Burns are expected to make up anywhere from one-fifth to one-half the casualties in such an attack. Estimates based on the Japanese experience may be too high, because with any warning of the attack, large numbers of people should be able to find shelter from the heat flash accompanying the bomb burst. If fire-fighting plans now being made are carried out, it should be possible to reduce the number of burn casualties still further, because many of these were caused by uncontrolled fires after the atom bombing in Japan.
Several thousand severe burn casualties, however, can be expected in any community that is atom bombed. It is to care for these, as well as for the victims with serious bleeding, broken bones and torn and mangled flesh, that 20,000,000 lay persons must be trained in first aid.
Treatment of patients with severe burns requires morphine, bandages, penicillin, blood, blood plasma and plasma substitutes, salt and fluid replacement and special diets. But except for the bandages, these measures all will have to be given in hospitals or burn stations by doctors, nurses and other specially trained personnel. Some of you may through your local civil defense organization be called to take this special training for work on a burn team. But everyone can learn the simple, immediate first aid treatment for burns, whether caused by atom bombs or an upset pot of boiling liquid on the kitchen stove.
The first thing to remember about a burn, no matter how severe or slight, or what the cause, is to keep it from getting infected. In other words, keep germs out, just as you are careful to keep germs out of an open cut or other wound.
You might think that a burn would be sterile, all the germs killed by the heat that seared the flesh. Hospital experience, however, shows that this is not the case. Patients arriving in hospitals for burn treatment almost always have some infection in the burn. Penicillin and other modern germ-fighting drugs play a tremendous part today in saving the victims of burns. But these drugs are for use by doctors, not first aiders.
Your role as a first aider treating a burned patient is to keep any more germs from getting into or onto the burn. If you can get the patient to a doctor, hospital or burn station quickly, you do not need to put anything on the burn. Watch to see that clothing does not brush against it, and that no one coughs, sneezes or weeps into or onto the burn.
 Keep any more germs from getting into or onto the burn. |
The sterile dressing will help ease the pain. Any covering over a burn helps to stop the pain, but do not use just any covering. At Hiroshima people put rice flour, raw ground potato and cucumber juice on burns. This, one burn authority says, "undoubtedly accounted for the widespread subsequent infection" though these substances apparently did relieve pain.
If you have not sterile dressings at hand, use the very cleanest cloth you have. Ironing the cloth or heating it in an oven will make it more nearly sterile and germ-free. Be careful when you put the dressing on and bandage it in place to avoid touching the burn or coughing or sneezing near it. Nurses and doctors in hospitals wear face masks, you know, when dressing a burn to keep germs from their breath getting into the burn.
 Ironing the cloth will make it more nearly sterile. |
You can reassure a burn victim who complains of the pain by telling him that the painful burns are not the serious ones. This is because in serious burns, the nerve endings are destroyed and the patient does not feel any pain. Do not, however, tell this to the burn victim if he does not complain of pain.
Many people have a tube or jar of medicated burn ointment in the home medicine chest or first aid kit. Tannic acid was once widely used by doctors to treat burns and ointments containing it were widely sold. Later, doctors found that tannic acid was not good medicine for burns and now they do not advise it. Some burn ointments have medicines in them to relieve the pain. Most authorities now, however, advise that if you do use an ointment, you use a bland petrolatum ointment or jelly, such as Vaseline petroleum jelly.
If you are giving first aid to a burn victim who wants you to put an ointment on, you should ask whether he is willing to take a chance on having the germs in the burn sealed in by the ointment. You might point out that use of the ointment may mean a longer stay in the hospital because of the danger of more severe infection. If you can calm him and relieve some of his anxiety, you will do much to relieve the pain, too, because fear is a large component of pain.
Shock, the third thing the first aider must be prepared to handle in burn cases, is a subject for a lesson in itself, particularly since shock is something to consider in any major injury.