MANAGING BURNS & A LESSON IN MANAGEMENT

Dr Neeta Deshpande Senior AnaesthesiologistBoom!! A blast somewhere in the vicinity of Nagpur.. Sirens sounding… Fire brigade reaching the spot.. Ambulances being called immediately thereafter Patients taken to the nearby PHC..

A few hours later.Our hospital receives a phone call from the PHC and the Dept of Emergency medicine gears up for a mass inflow of burns patients. This is a regular phenomenon for our hospital, it being a tertiary care centre and as it boasts of an exemplary bums unit: Sometimes it’s a single patient, sometimes multiple. But the latest count was 20 patients coming from a single source. These 20 patients then get admitted in a ward specially readed for them, and a few in ICU. Which too is specially isolated for them. We have a team of 3 plastic surgeons, each one very good and unique in its own seme. So all the patients are divided between these 3 and after they are stabilized by the medical team, they are posted for alternate day dressings in the OT.  Managing bums is a team work in the wards no doubt, but managing them in the OT is a synergism or huge intensity!!  The Surgicall team includes the surgeon, the assisting nurse, the Of technician, the ayaa, the circulatory nurse, the nursing incharge, we the anesthesiologists, and of course the patient.

The patient is at the receiving end, while as every other member of the team thinks that the responsibility of curing the patient lies on his/her shoulders… even literally because many a times, they have to lift patient’s limbs and support them on their shoulders & to facilitate the dressing. We all work in unison, each person working on different parts of patient’s body simultaneously. So the arduous ordeal begins day by day bit by bit & facilitating the hearing of their burnt skins: Sometimes we lose the patient because the degree of burns is too much to make up for the last fluids secondary infections and failed organs. But majority of them get to go back to their own world after multiple dressings, skin graftings and at least a month long stay in the hospital. This whole process involving the whole team (we call it TEAM BURNS is not merely a surgical procedure but is a good lesson in Management, covering varied topics from leadership to problem solving to decision making to ethics to management competencies to team building to risk management to research and action and what not.

In this ocean of burns, even as the plastic surgeon is the captain of Team Burns and each plastic surgeon having his unique way of steering the ship through turbulent phases of patient healing every team member is no less than a Faculty for the varied topics in Management and what ensues thereafter is a funny but fruitful dialogue in patient care. What is unique about TEAM BURNS and does not happens with any other surgical case is that the whole procedure is an interactive session-No other surgery The surgeon explains the procedure to the whole team, and hence even the ayaa here has a vast therapeutic knowledge about burns!

Knowledge management

Burns is a learning module.. for the छोटी (the trainee or the junior most nurse) it’s like an internship of practical training. She gets her first posting in Burns OT and then she is judged and readied for more intense sessions in major OT’s.  She is marked as suitable for promotion when the shy to start with छोटी starts giving suggestions to the surgeon…

Planning and budgeting

By then little senior staff is at a higher level of exercising control over the surgeon-Nurse: Sir तुम्ही किती waste करता  bactigrass!!  उगीचच एवढं उघडून ठेवलं ना! आधी बघायचं नाही का? Surgeon: हो मॅडम परत नाही असं होऊ देणार….

Research and action
Still senior nurse: सर आपण आज तुमचं नेहमीचं ointment नाही लावू. ते दुसरे सर जे वापरतात ना ते लावू. त्यांनी जखम लवकर सुकते मी पाहिलंय… Surgeon : जशी आपली मर्जी…!!

Challenges

The Head nurse has special powers & she executes them perfectly. She can allocate extra staff in the Burns OT or else make us work with minimal workforce… There are other challenges as well like limited drapes, insufficient cotton roles, deficiency of dressing material etc and hence we all keep her calling continuously inside the OT. I often tell her तुम्हारा नाम दुर्गा राख देते है ..! atleast भगवान का जप तो हो जायेगा रोज..!

Assessment of situation

We all heavily depend on our OT technicians. They are anesthesia assistants, they monitor the actions of the छोटी, and they are the guide and right hand of the surgeons Surgeon: अरे हे हाताचे wounds सुकायला आलेत आता. Open ठेवू  कि close करू ? Technician: आज close करू न घा सर, नाहीतर physiotherapy नीट नाही होणार. पुटच्या वेळेस open ठेयू..  Surgeon: जी हुजूर !!! बरं मग हनुमान बनवून दे त्याला.. ‘हनुमान बनवून दे’ is a code word for applying Mercurochrome (an antiseptic which is red in colour) to the face wounds for accentuating epithelization. One more phrase commonly used in the Burns OT is ‘Change the gear’. While dressing the lower limb the technician raises and rests the limp up onto his shoulder and keeps changing the gear (position) for reaching difficult parts like perineum or medeal thigh. Sometimes these boys are responsible for some hilarious memories as well. I particularly remember a day about 20 years back. When the hospital along with the whole staff was in  infancy & Team burns enthusiastically dressed a 70% burns pt and the end result was  a fully bandaged patients in ‘flying bird pose’ The bandage was applied quite tight and hence both the arms couldn’t be fixed. We shifted the patient out from the broad doors of the OT But the ward boys couldn’t get the patient in the lift due to that flying bird pose. When I changed and left the OT half an hour later, the ward team was still there.. at the lift & contemplating going by the staircase in a hand stretcher. The patient was also fully awake by then. Hiding my laughter, I asked the patient to sit up, and rotated him 90 degree.  Now his arms were in the same axis as the stretcher. The whole team entered the lift laughing uncontrollabily and I joined them too.

Monitoring and evaluation

Coming to the anaesthesiologist, he/she is the Second Captain of the ship, but sometimes leads the leader too. Apart from their primary job, they give valuable tips to the surgeon Beware of this patient, his behaviour under anesthesia shows that he has internal burns, may require intubation in a day or 2 or this patient may have difficult intubation, go for an  elective tracheostomy etc.. Sometimes the dialogue is more about social awareness. Surgeon: Why don’t  these people pour water after burns? I always tell them. Me:You should take help of your society and put these Dos and Don’ts after burns on national channel- Your society should take help of celebrities like AB- लोग तुम्हारी नाही पर AB की बात तो मनोंगे ..!!

Entertainment

In the late phases of burn healing, the atmosphere in the OT is comparatively much more enthusiastic and sometimes even culminates into a musical morning, thanks in the singing capabilities of our surgeons…

Emotional quotient

Sometimes, there are true emotional moments in the OT. I remember, once there were mother and her 2 kids aged 6 years and 1.5 years admitted with burns .Though they were all discharged after healing the mother eventually died. When the 2 kids once came for follow up to the hospital they insisted on visiting the OT. And we could see how the elder sister was taking utmost care of her younger sister, she had grown up so prematurely.. had seen sooo much at the start of her life itself… She didn’t want her younger sister to have a scratch of the bitter memories on her mind… and we could the efforts… There are numerous such memories of the last 25 years that have been working in this hospital.. and I would like to admit that have immensely gained by the team spirit that we experience in our Burns OT. I am sure there would be another team in the wards or ICU who would like to add some valuable lessons to this book on management.

Dr Neeta Deshpande
Senior Anaesthesiologist