Good morning, everyone. My name is Jamie Blackwell, and I am on the Education Committee for the Trauma Center Association of America. We are going to welcome today Dr. Jeffrey Carter. He's going to give us some education in regards to burns. And I know we had this scheduled a few weeks back, but due to a few travel issues that I'm sure Dr. Carter will talk about came into play, and so we had to reschedule. So we really appreciate everyone jumping on board. So before I turn it over to Dr. Carter, I just want to tell you a little bit about him. He serves as the Medical Director for the University Medical Center Burn Center in New Orleans as the Associate Professor of Surgery at Louisiana State University. Prior to moving to New Orleans, he served as the Associate Director for Wake Forest in North Carolina. So he has also served on multiple committees for the American Burn Association. So without further ado, I'm going to go ahead and turn this over to Dr. Carter and allow him to start sharing his screen. Thank you. Thank you. I always enjoy talking with this group. These are my disclosures. Whenever I do consultant work, I donate it to charities, so I don't take that money. I have about $100 million in research right now that I'm an investigator for, so I have a lot of different jobs with that. But these are the main things I'd like for you to take home today. I used to be a high school teacher in Mississippi for both physics and math, so I love to teach. But I want to make sure that we understand some of the resuscitation rates for pre-hospital care, a little bit about diagnosis and treatment of inhalation injuries, because that's really important, especially in early burn care, whether you're at a trauma center, burn center, or any type of hospital, a little bit about dressings for burn care, and then a little bit about disasters. And then the disaster portion, I'm going to talk about a recent trip, and one of the reasons we had to cancel recently. So this is a slide I put up commonly in my talks, and it's one of the ones that helps you understand why questions are important. So if you don't mind and you have questions, please put them in the chat, and we'll address them at the end. But when you ask questions, we begin to have discussion as a group. And then you remember about 50% of the material. This is at 24 hours. If you just sit there, and I just talk, and it becomes a very passive experience for you, and your retention is very low, which means that you're unlikely to change your behavior, you're unlikely to be able to learn from this. And so I really want you all to feel like you can be engaged and ask questions. Most of the times when we talk about burns and disasters, we think about the Boston Marathon, Oklahoma City, 9-11. But disasters come in a lot of shapes and forms. Over here on the left, we have these large trains that come through of hydrochloric acid, and they pass by the schools where our kids go to school. And then we have these large oil reserves like that that can blow up and catch on fire. And then all of us have daycares. And this is an example of a daycare fire that happened in 2005 just on the other side of the border where 49 infants died in just a few minutes. And just how devastating a burn disaster can be in our community, and how this can happen so quickly and be such a burden on so many systems. In New Orleans, one of the reasons we wanted to build a burn center was because of the Deepwater Horizon. They had a trauma center here that was doing over 4,000 trauma activations, now up to over 5,000 trauma activations a year. But they didn't have a burn center at the trauma center, and we felt like it was important to combine those two. And after opening, we found that there were a lot of disasters in our community. These led to both burn and trauma injuries. And we cared for many patients from these different events. And so I just captured these from the news. And a lot of these, we were unfortunately receiving patients from. And I just show it to you because it's there. It's just we don't always notice it. So this is one of the slides that I think we should all pay attention to, because it explains why what you do is so important to America. This is from the CDC. And it is the age groups at the top broken up by the rank on the side. And this is the leading causes of death in the United States. Everything that is a colored box is a form of trauma. And that is what you do. This is what you specialize in. And I hope you understand the importance of this, because for our children and for our young adults, it's not cancer and high blood pressure or stroke that takes them from us. It is trauma. It is trauma over and over and over again. And unfortunately, the condition that we have called life has 100% mortality. We will all expire from something. But hopefully, we do not expire when we are young. And we do not expire when we are taken suddenly and unable to say goodbye to our loved ones. So I just want to take a moment and acknowledge what you do, how important it is, and to show this to you so that you're aware why what you do is important. Now, this is the entire US. And you can actually go to the CDC. And you can download this for your own state. This is my own state. And you can see how the boxes change and move up in here. And you can see how homicide is a real problem in my state and how the boxes move. So I encourage you to look at it for your state also. This data has been collected by some different trauma organizations. And it just reinforces how it's a leading cause of death and how when you include the cost of lost wages, how trauma and burns being a form of trauma is actually very expensive relative to cancer, diabetes, and heart disease. This is actually from 2014. And it hasn't changed since then. I went to the CDC and checked it out recently. But this is how the states perform. And a lot of this has to do with access. But the darker the state, the higher the mortality rate for injury. And then this is for pediatrics in the purple. And unfortunately, you can see in the region of the country that I live in, we actually have a fairly high mortality for injury. So it brings purpose to coming here and to wanting to build a better system for both trauma. So at the end of this, I want to show you how that's changed. And hopefully in this discussion, you can take some of these tools back with you. This was one of the reasons for us opening. The white you see at the top is land. The blue you see at the bottom is all water. And all those dots are oil rigs. And so there's over 3,500 oil and gas rigs off the coast of my state. And it's one of the reasons we get a lot of injuries. Now, I want to show this to you also, because when you're looking at Texas, I noted back here on this state that Texas is a lot lighter in color than these other states. Look at the density of trauma centers Texas has in the east versus how many level one ACS recognized trauma centers we have in Louisiana, Mississippi, and Alabama. And that maybe gives us some explanation as to why the difference is there. This is burn centers when you add it on. And then this is hand trauma centers. And if you're not familiar, I encourage you to look at the ASSH, that's the American Society for Surgery of Hand. And now they have a hand trauma network on there. And if you are a center that specializes in hand or receives as a hand call pool, then you might want to look at what it takes. It's only five criteria to get on that. But replantation and hand injuries are still a significant form of disability. And I encourage you to look at it. So this is also important to look at is we hear a lot about disparities of care and access to care. And when you think about it, everything that's green here based on the 2020 census, that's considered rural. And everything that's black, it's not bodies of water in these little areas. That's actually considered urban. And so when you look to see where our hospitals are, most of our hospitals are in urban areas where you see the black, which means all the green areas don't really have rural hospital access. And so the bulk of our hospitals are in urban areas. So when we talk about health disparities, particularly in Burns where this map becomes even worse, we really need to talk about time-sensitive illnesses and access. And trauma, stroke, heart disease, and burn injuries are time-sensitive illnesses. So with that, I'm going to transition into where does burn care occur? So there's over a million injuries a year. About half of those will go to an emergency room. About the other half will go to urgent care, primary care, or wound care centers. Of the half that go to emergency rooms, only about half of those actually get sent to a burn center. We've studied this in the past. We've noticed some alarming trends. And so one of the things we've done in the ABA is to reinforce the referral criteria. Now, referral doesn't mean admission. It means sending people to the right place to get care. And what we have found is that of the patients who don't get sent, a fair number of them still require some type of transfer or some type of care to a burn center. So the reason we bring this up, and I'll go back to Louisiana because some of this you might take back home for your state, is that burn-related care is intense. It's very costly. We see that it's worse in our low-income zip codes, particularly in our rural areas. And in a state like Louisiana, we have one of the poorer states. And so there's actually a fair number of burns that have occurred here. And I'll show you how we've impacted mortality. What's important, too, is that when you combine burn and trauma injuries, so that person has an electrical injury that's on a ladder and falls, a person who jumps out of a two-story window because their stairs are on fire and they couldn't evacuate their house, a person's in a car wreck and has a burn and a trauma, their mortality is not 1 plus 1 equals 2. It's 1 plus 1 equals 4 or 5. And this is based on a fairly large study, and it's an important thing to understand. And we've seen that delays in trauma increase mortality, but delays in burn also increase mortality. So if you don't initiate proper resuscitation, meaning not too much fluid, not too little fluid, you could increase the mortality dramatically in burns by up to 20% in the first two hours. So just to think about that, open-heart surgery has a 1% mortality right now. Significant burn injury, over 20% of the body, 20% mortality just by delaying resuscitation. So it's important to understand, what is a good resuscitation in burns? And so there's been some changes to how we do burn resuscitation, and this is probably the first one. So the slide's in red because it's important to remember. So the first thing is that if you're a pre-hospital provider, you know you don't strip the patient down in the field and then measure out the burn wound and calculate how much you're going to look at it, and you're going to say, this is a big burn, this is not a big burn. And for burns that are over 20% of the body, then we have some pre-hospital IV fluid rates. And what's recommended is for a preschool child at 125 an hour, for a school-age child at 250, and for an adult, to 500 cc's an hour. Now the next question comes, what? The recommended fluid is lactated ringers, but knowing that many pre-hospital transport EMS providers don't have LR, saline would be better than nothing, but we prefer LR. So when you have an opportunity to change saline out to LR, that's recommended. Also know that many pre-hospital providers don't necessarily have a pump where they can program it. So what does this mean? It means if you have a 45 minute transport with an adult with a 30% burn, you don't put four liters of fluid into them. Because you can overwhelm the fluid and cause edema and actually worsening burns and pulmonary complications also. So this initial fluid rate is not calculated based on their weight, their height. You look at it, their age, and if you say, this is a large burn, over 20% of the body, I need to start fluid resuscitation. 125 pre-hospital, 250 school-age, 500 for an adult. Now with that, we have a consensus formula. And many of the textbooks are wrong. I hate to say that. They still talk about the Parkland formula. And my colleagues at Parkland will tell you that they don't use the Parkland formula anymore. The ABA consensus formula was changed in 2010. And instead of using four cc's for an adult, we use two cc's. And that's four cc's, excuse me, two cc's per kilogram, per percent burn. With the goal you're an output about 30 to 50 an hour. Now to do this, you have to know the size of the burn. You have to know the patient's rough age and you have to know their weight. And so you calculate the size of the burn during your primary and secondary in the trauma bay. You don't do that in the field. And so this is called the adjusted fluid or the consensus formula rate. And so you need this information. And so we don't use the four cc's, now we use the two cc's. I can tell you recently when I was in Ukraine, they were still using four cc's and more and they were having fatalities because they were over resuscitating. And so when we showed them this information, they started dialing back their resuscitations. They started having survivors that they had not had survivors before. Now children, they have more surface area relative to volume. For example, a seven kilogram child has 30% of the surface area of a 70 kilogram adult, but it has one 10th the weight. And so that distribution, that difference in their surface area means that we use a slightly higher fluid rate in children. And it's important to remember that in kids less than 30 kilograms, we will give them some type of dextrose maintenance rate in addition to the resuscitation rate. Kids also have a one cc per kilogram per hour. Lastly, in electrical burns, we still use four cc's per kilogram per percent burn. And the goal to maintain you're an output of 100 cc. So electrical burns, or when you have conduction injuries, when you have electricity that goes on one part of the body and out another part of the body, or when you have symptoms consistent with an electrical injury, like someone who loses consciousness while working on electrical panel. So let's take an example here, a flame burn in a hundred kilogram adult with a 50% burn. That means you'd use two cc's times 50 times 100 kilograms. So that's a total of 10 liters of fluid you give them in the first 24 hours. Half of that you give in the first eight hours, half of that you give in the last 16 hours. So their rate would be 6.25 an hour. That's a large burn in a large patient. And I pointed out that that 500 cc's per hour is not too far off from this. And so, but this is the adjusted rate. Now, if you were to do this again in another patient and you look at someone who gets under resuscitated, you can see how that can adversely impact them and how that difference in fluid can occur. This is a calculation using a 10% burn. So one of the questions I commonly get is, why don't you use this formula for small burns? Well, the reason we don't use a formula for small burns is because it comes out at less than what your maintenance fluid would be. So the adjusted fluid rate up here, this is really for 20% larger TBSA. This is really for 20% larger TBSA. We don't use it in small burns because it actually comes out to be less than what your maintenance rate is. Another question that we get commonly asked is what about when you have a traumatic wound? And I always joke and I tell people, you know, ABCs and trauma, because I'm a trauma surgeon that trained additionally as a burn surgeon. So I believe in treating that hemorrhage first. You know, so those ABCs come way before S. Skin is way down there in the algorithm. So you got to get that hemorrhage under control. So that's what's really important is restoring perfusion and getting hemorrhage control. And then, you know, you'll resuscitate using massive transfusion guidelines at your facility. And then once you have that under control, then you can look at the burn shock. But I'll also tell you that, you know, resuscitating of blood is really good for burns too. So, you know, this is a common question that we get. So treat the trauma first. Trauma takes precedence over the burn. In fact, at our institution, the residents and the other faculty, we all know that every burn patient's a trauma patient until proven otherwise. These are the things that keep people up at night. You know, for the trauma, it's commonly bleeding or dead tissue, pus somewhere. And then you get the sequela from sepsis or reperfusion and the occasional heart attacks or strokes. In burns, what we tend to see is compartment syndrome. And that's because a burn can encapsulate all the way around an arm, a leg, a torso. And when you have that full thickness burn of the skin and soft tissue, it acts like a big tourniquet. It sucks the water out. That large tourniquet can prevent perfusion to underlying tissue. So we'll have to do something called escharotomy. And I'll show you an example of that. We also see resuscitation failure of cyanide and carbon monoxide poisoning. I'll go into more detail about that. MIs, in fact, I have a patient right now with an MI. They are very common on burns because your catecholamine levels are 50 times normal. And the only time that they go that high is during labor in women. And in burns, and the difference is that in burns, they're sustained high. So we commonly will see patients who will present with coronary disease and they will develop an MI while being a burn patient. And then never forget the risk of concomitant trauma or inhalation injury. And then in children, we always think about do they have something congenital that we've missed? So another question we get is about hypothermia and burns. They say, well, we know we're supposed to warm the room. So this is the fun part. The physics teacher gets to come out at me. So I want to explain the difference in hypothermia and burn versus trauma. So hypothermia and trauma, the reason why you have a cold patient in trauma is because of bleeding. When you're not delivering oxygen to the tissue, what happens is that tissue is not using the oxygen to make ATP. ATP, which is made in the little mitochondria, when that's formed, 60% of that entire energy, that chemical reaction produces heat. And that's why we are warm-blooded animals. That's why we produce heats. So when you stop delivering oxygen to the tissue, you stop making heat. And the way to restore a hypothermic trauma patient is to stop the bleeding and recirculate with oxygen, reperfuse of oxygen. And burns is slightly different. You might be delivering oxygen to the peripheral tissue, but once you remove epidermis, the outside layer of your skin, you then have an open system. You have water that can evaporate. And when water evaporates, you begin losing lots of fluid from your body. A normal person will lose about 700 cc's or 700 milliliters per day. A burn patient can lose multiple liters per day, depending on how much of their wound is involved. For every cc or every milliliter of water that converts from a liquid to gas, in other words, everyone that evaporates, like a normal evaporative heating, excuse me, evaporative cooling, you lose 533 calories of heat. So when you have a large burn and you don't cover up the wound, what happens is they begin, all that fluid begins to evaporate and through evaporative cooling, they will lose a lot of temperature very quickly. So the treatment for this is to cover up the wound. We've covered up wounds in the operating room with plastic bags, like sterile mayo stand covers. And then in the military, they've actually used different like Saran wrap and other types of plastics just to cover wounds, just to prevent that heat loss. But most importantly, the recommendation right now, and I know this is one of the questions that is commonly asked is, what do you do in that emergency room when you know you're, or trauma bay, when you know you got to transport that patient somewhere else? So the recommendations right now are not to put on the definitive dressing, it's simply to get a clean, dry dressing, I mean, clean, dry blankets or sheets on the wound. So anything you can do just to cover it up and keep them warm is what's important. So briefly, pre-hospital care. So I came to a state that did not have pre-hospital care standardized in it. And so one of the things that, you know, you might be interested in doing in your state is creating a pre-hospital standardization. And this is great for the EMS providers because then they know that they're gonna do the same thing. So it doesn't matter if they pick the patient up at this, in this region, and they go to that burn center or this burn center, they're gonna do the same thing in the field. And so by standardizing it across the state, it made things easier for pre-hospital and also made things easier for the referring hospitals because they knew that the care was similar amongst all of them. So you can see this was a destination protocol, but also a pre-hospital and ED burn care guideline. So those are available in the Louisiana Emergency Response Network, which is our centralized call system where they route time-sensitive illnesses. And you can see like the care guidelines go through and they explain some of the very basic things to do to treat a patient. So I encourage you to reference these if you're interested. The next thing is routing. And I think it's interesting that many places still don't see burns as a form of trauma, but according to the 2014 Improved Trauma Care Act, burn is a form of trauma. So we are included in the federal definition of trauma. This is an example of how our call center routes, meaning for our state. If the patient has trauma, they refer to the trauma destination protocol. If they do not have concomitant trauma, then they will then proceed down this algorithm. If they have something that results in them having an unstable patient, they will stop at the closest emergency room. If they do not, then if they meet these criteria, they will go to the closest burn center. If they do not meet these criteria, then they will go to the closest hospital. So this might just be something you find useful for your region or your state. Another question that we commonly get is how do you calculate the size of a burn? This again is available on that website that I noted earlier, but it's about an anterior torso or posterior torso is about 18%. The entire head is 9%, so just the front of it is about four and a half. An entire arm is 9%, just the front of it is four and a half. An entire leg is 18% or just the front of it is 9%. In kids, they have larger heads, relatively speaking, and shorter legs. And so the larger head means that a child's head can be up to 18% of their total body surface area. So now I've got some gross pictures. So if any of y'all are like eating breakfast or drinking something, please let me just warn you right now, I am a guy of gross pictures and I apologize, but one of the challenges we have is assessing burn wounds. And as a trauma surgeon, when you roll through the door, I'm getting vitals on you, we're getting blood work on you, we're getting a fast, we might need plain films or a CT scan. We have all these tools to help us make diagnosis. And in burns, we have none of those. We don't have tools to help us make the diagnosis. And as a result, even the best burn physicians are wrong in 25% of the cases, and many other doctors are wrong in up to half of the cases. We conducted a recent study of emergency room physicians, and in 87% of the cases, they were in a patient who had biopsy-proven non-healing wounds, meaning the skin was thrombosed, the adnexal structures were all dead, the skin was dead, they had no chance of healing from the beginning. But in 87% of those wounds, they recommended local wound care, no need for surgery or referral. So we know that there's a need to improve that. And here's that study we're discussing, we're actually presenting that at ASEP next month. And so this is the reason why, is that this is a patient, this is a young, healthy woman with a 62% burn, she's 12 years old. I think many people would look at that and they would see, there's her normal skin pigment at the top of the photo here, this looks like a second degree burn. This is eight hours later, and when you're looking at it, you can see, okay, it looks a little bit more pale over the knee here, it looks a little bit more pale over that thigh, it looks a little different. This is 24 hours after injury. Burn wounds change, and because they change, it's important to reassess them. That's why we have referral criterias, because what initially looks like it might be partial thickness could change. And this patient here, she had no pressers, she was not put on, she had no history of immune suppression or any other medications that would prevent or impair her healing. This was a large burn and evidence of burn shock, and this was a patient who had gasoline that was exploded into her car and caused a severe burn. She had a great recovery, was discharged within 39 days with a 62% burn home. This is a Lund Browder, and so these are some of the fancy tools you can use to calculate a burn very exact, with great care and being very exact. One of the things I recommend people to remember is that the patient's hand, whether they're a child or whether they're an adult, you know, the patient's surface of their hand, meaning the finger, thumb, and palm is about 1%. Just the palm is about half a percent, but their hand is about 1% of the total body surface area. So you can always use the patient's hand as kind of a good metric to calculate the size of the burn if you don't want to, you know, learn these tables or the rule of nods. Another question we commonly get is, what's a good wound care dressing? So a really good wound care dressing is simple triple antibiotic ointment, Neosporin. Some people use Bacitracin only, but this type of dressing does require a daily dressing change, meaning that it needs to be washed or soaked in water and then reapplied. It's also important to note here that if you can use Telfa gauze or some form of non-adherent dressing, it'll help with compliance and pain control. This is not cheap. You know, it sounds cheap because you can get a tube of triple antibiotic ointment for under a dollar at Walmart, but when you add the Telfa to it and then you add the gauze to it and then you do it every day, it all of a sudden becomes a $5, $10 dressing every day and that adds up, especially if you have a large wound, it can be several hundred dollars. Other options include silver dressings, and I just want to take a second here and talk about silver dressings. So there's a lot of variability in silver dressings. Silver has been out for a long time. We've known that silver has been a good antibiotic since the time of the silver spoons. Silver comes in varieties of ionic and non-ionic. So back to your days in chemistry, when you had an electron in the outermost shell, that meant was that you had an ionic form of ion there. So in other words, silver can come in ionic form. And when it has an electron in the outermost shell, what it's doing is binding to the bacteria and preventing the bacteria from breathing, eating and replicating. And so silver has been a very good antibiotic for us. We don't recommend commonly putting a lot of silver on the face. It can be accumulated in the face, but other parts of the body, it works very well. The problem with dressings is that there's a lot of variability in the concentration of the silver and the type of silver that's in the dressings. And every vendor will tell you that their dressings do great, but I really encourage you to read and learn more about the dressings. Because the variation can be a hundredfold. So if you're giving a dose of antibiotics and you gave one person one milligram, the other person, a hundred milligrams, you would think twice about that, but people don't think twice about silver dressings. And that's the difference that we can see in the amount of silver in the dressings. So for example, if you use an inappropriate silver dressing in like a child with a small foot burn, like a skull burn or flame burn to their foot, you know, one or 2% total burn injury, and it doesn't have sufficient antibiotic in it, or you use triple antibiotic ointment and they don't change it every day, what can happen is they can get high colonization. High colonization becomes invasive infection. One of the ways they can have an invasive infection is to have toxic shock syndrome. So I've seen kids who've had an inappropriate dressing put on them and within 48 to 72 hours developed toxic shock syndrome and wind up in a PICU on pressers, intubated. So picking the right dressing, it's really important. Silvadene is still used by a lot of facilities. However, there's a lot of people who are disgruntled with silvadene, and there's some evidence that it's not the best thing we can use out there. As part of the strategic national stockpile, which is under BARDA, that's what we released in the event of a disaster, they have a dressing called Silver Lawn, which is silver and nylon that's bonded together. They also have other dressings that have been made available called Mepilex and others, and I'm trying not to use brand names, but I'm saying this to you because I know that some of you will be looking for them, but it's important to understand what they're indicated for. So I tell you that about the strategic national stockpile because that's one you should know. Why is this so hard? Why can it not be easier? Well, this is why it's so hard. Your skin is not the same anywhere on your body, and it's not the same anywhere during your life. It changes a lot. What you see here is a makeup of the different types of collagen and the different amounts of collagen in your skin. So if you've ever wondered why those at extremes of age are more likely to get burns, it's because of, and think of how thin the skin is here as a child, and as we age. Unfortunately, it's one of the reasons why we also get wrinkles, is that the collagen changes and it matures and breaks down as we age. So it's important to understand that those extremes of age might be more likely to suffer a deeper injury than what is initially assessed at. When we're talking about injuries, we talk about first degree burns, which is just the epidermis, just the outside. That heals, doesn't need referral. We have second degree burns where some component of the dermis and all of the epidermis has been compromised. There's a lot of variability in this, but typically they manifest by having blister formation, right, meaning the epidermis is either lifted off or it's about to lift off. And then there's some component of the dermis that's been compromised. In third degree, the dermis is compromised all the way through. And then in fourth, fifth, and sixth, you have fat, muscle, and bone that can be burned. So I'm gonna go through some examples and here's where the gross pictures come in. So many of us have had this. You know, we've gone to the baseball game, we didn't wear sunblock and we got a burn. We went to the beach, we didn't wear sunblock, we got a burn. We mowed the yard, same thing. Second degree, you begin to see the blister formation, the scald injury on the child, the guy who used gasoline and started a fire. And this picture on the right here is kind of interesting because you can look in the center portion of here and see where it's more pale. Now, he wouldn't like if you did this, but if you took your thumb and you pushed on it, you would see that it doesn't blanch, like the skin around it would blanch because the capillaries are already thrombosed in that area. That's likely gonna evolve into a deep second or a third degree burn. Then when you look around it, it's got these areas as pink and it's profuse, that area will blanch and there's a chance you can save that. So it's an important discernment between the superficial second, like you see here in the first and second photo and a deep second or third degree burn, like you see there. This is a classic example of a third degree burn. This is gasoline that got on a guy, caught a shirt on fire. As you can see, eschar here. Now, this is insensate skin. It's burned all the way through, epidermis is gone. A lot of times in people who are pigmented, we'll see that this burn skin here doesn't get counted, but that burn skin, that is non-viable skin. That's basically leather. And so you'll see this area of coagulation, necrosis in the middle. And then you can see stasis, hyperemia, like you're seeing here, the hyperemia is on the outside edge of that wound. And that's areas that are recoverable with a good resuscitation. And then this is a classic electrical injury where someone grabs onto something or they have contact with an electrical burn. And let me just take a second to explain. Electrical burns are not always someone grabbing a live wire. For every thousand degrees, excuse me, for every thousand volts in a live wire, it can arc about a centimeter. And some of the power lines have 70 to 100,000 volts traveling in them, which means it can arc several feet. And it doesn't mean that you have to touch the wire. It means that you can be holding something that can act as a conductor and you can get that conductor too close and it can arc to it. And you can have this type of severe injury. The other thing is that with alternating current like we have in the United States, when that arc occurs, it can cause tetany and cause multiple fractures. And so that's one of the reasons we say of electrical injuries, you treat them like they're trauma. We had a young girl who came in recently, high voltage electrical injury after one of the hurricanes, the line was down. She didn't touch the line. She touched something else that was touching the line, had an electrical injury and had multiple spine fractures from where the paraspinal muscles underwent tetany and she had compression fractures of her vertebra. Burns in general, what we see is that the skin begins to denature and it can happen as little as one second. The other thing that we'll see is traumatic injuries like road rash over here. I think many of you have seen this. This is the common motorcyclist not wearing all the protective gear, takes a slide. We also see degloving and laceration injuries, devascularization injuries. A common question I get in the courtroom is about scalds and injuries like that. Please, when you go home, check and make sure that your bathtub temperature is turned down, it's not turned up, particularly if kids are very high risk for this. It should always be less than 120 degrees and preferably even lower. Saves you on your power bill, but also can help prevent the risk of an injury. But the coffee that you're drinking this morning, it's over 180 degrees. That can cause a burn as little as one second. So I need to take a second to talk about inhalation injuries. So this is a video of how quickly an inhalation injury can occur. And I appreciate the group putting it together. I'm gonna slide through over here. This is a typical house with a recliner that catches on fire. I just want you to see the timer and how long it takes for the whole room to be filled with smoke. And so this is an example of a cigarette or a lighter that catches this on fire. I have to thank the National Fire Protection Association with this. I'm gonna skip through here just because it takes about two minutes to go through. So here are the clocks at 18 seconds. Here are the clocks at 38 seconds. Here are the clocks at one minute. And notice now the room is already filled with smoke halfway down. This is over 700 degrees in the upper half of the room. You can't walk through that. You can't breathe in that. So it's less than two minutes and you're having to crawl out of the room. Now, I want you to see this is a little over two minutes now and look how the smoke has already filled the room. People don't realize how little time you actually have to evacuate when a fire does occur. This is a bronchoscopy from when someone has an inhalation injury. That's the carina you're looking at. So you're looking at the trachea here. These are the tracheal rings. These bumps are actual blisters. And what happens is that soot and ash actually forms an acid and burns some of the airway. You have sloughing and you have very high risk of pneumonia. Over 80% of inhalation injuries will develop some form of pneumonia. When we talk about carbon monoxide poisoning, this is important. We saw a lot of this after the hurricane. Carbon monoxide poisoning can be very subtle. It can be from running generators, having gas heaters and that are not properly vented, fireplaces that are not properly vented. And it starts off with a slight headache. The headache gets worse, becomes very intense. You can have drowsiness. And the reason why you're having these CNS symptoms is because the brain needs oxygen so much. So it's one of the most sensitive organs when you begin to withdraw oxygen from it. So you start with these headaches and you get drowsiness and you get impaired judgment, nausea, vomiting. The headache gets worse and then you pass out and you expire. When this says percent of carbon monoxide in the blood, what that means is your hemoglobin, say if you're young and you're healthy, you have hemoglobin of 14, what that means is like when you have a 31 to 40, what that's saying is 31 to 40% of your hemoglobin is bound to carbon monoxide. It's not carrying oxygen. Because remember, carbon monoxide and hemoglobin, they have a love affair. It has over 200 times the affinity for carbon monoxide than it does for oxygen. So the hemoglobin would much rather carry carbon monoxide. And when it does that, you're now not delivering oxygen to the peripheral tissues. The treatment for this is 100% oxygen. It takes a half-life from over 200 minutes down to about 40 minutes. So when a patient presents and you have a suspicion of them being in an enclosed fire or any suspicion of inhalation injury, 100% oxygen is the treatment every single time. I tell people that when you have carbon monoxide poisoning, it's like you can have perfusion, you can have blood circulating, but it's not bound to oxygen. So it's like sitting at the table and you got all the utensils there, but you have no food. You have no oxygen that you can use. Now with carbon monoxide poisoning, now what we're seeing is more and more cyanide poisoning. And in cyanide, what happens is you're blocking the utilization of that oxygen in the mitochondria to make ATP. You're blocking what's called oxidative phosphorylation. So in other words, it can't use the oxygen that you are delivering. So it's like sitting at the dinner table and then not having utensils. You can't do anything with the food, even if you have oxygen that's being delivered. This is the blood gas of a patient that was transferred to us who had severe cyanide poisoning. So her PO2 is 422. She had plenty of oxygen, but her pH is 6.95. And then when you begin to look at her base deficit here, this was all due to carbon monoxide poisoning. So the treatment for that was hydroxyqualamine. And for adults, it's just one kit. For peds, it's 70 milligrams per kilogram. So that's just an important thing to know. If you take ABLS, the Advanced Burn Life Support class, they'll tell you that this is actually a minority of burns. But if you look at some of the more recent data coming out of Europe, you'll find that it's actually over 60% of inhalation injuries, there's an element of cyanide poisoning. Unfortunately, there's no lab tests we can send off very quickly to get that back. You can get an elevated lactic acid, which is a good sign when they have an elevated lactic acid that they have a possible cyanide poisoning in addition to that. It's always prudent whenever you have an acidosis, it's not explained, to look for other causes, including traumatic injury. So please don't rule out other things like that. Now, I know that many of you might be young, have young families at home. So I want to take one second and explain this for a minute. I know that you also are very active in injury prevention. But for every dollar you spend on a smoke detector, you'll save $28 in health care. You saw the video earlier, you have two minutes on average to evacuate a home, a house when a fire happens. I know I have three small kids, if I have to get them out in two minutes, it'll never happen. Most of these fires happen at night. They happen actually between 11 PM and 7 AM. That's not when you're all together having breakfast. That's when everyone's in their own bedroom. So trying to get everyone out of a house very quickly, that doesn't happen. Very few people even practice an escape plan. Personally, in my own home, we have two different staircases. Every bedroom has its own ladder to escape. And the kids know where to go in the event of a fire. We have an internal, we have an alarm system connected to the smoke and carbon oxide detectors. And then I have a redundancy level of fire detectors. And if we ever build, I'm putting a sprinkler system in my home. This is another thing to be aware of. Children don't hear smoke detectors. Studies have been shown for over 10 years. The children from age 5 to 12, when they get in deep sleep, they can't hear the beeping of the smoke detectors. And they do better with a voice-assisted smoke detector. So if you can choose one, please choose one of those. They've tried making them more fancy, like having the woman's, having the kid's name in it. But that didn't actually change things. What did change things was actually having a woman's do it. So in other words, they didn't listen to dad, they listened to mom when it came time to evacuate. So it's just an important thing to understand that kids don't always hear the smoke detectors. Another thing that's important to understand is what firefighters look like. When firefighters are going into a building, they're scary. They have all this gear on, there's alarm, there's smoke, kids are scared, the parent's not there. And so children don't assess risk the same way that adults do, and they tend to hide. So firefighters will be looking for children hiding. And children will hide because this is scary. I asked this firefighter friend of mine from DC to please send me a photo of firefighters. And this is what he sent me. I told him, I was like, that's not what firefighters look like. I know that's what you think you look like. This is what you guys really look like. So now I want to take a minute and explain like what happens at a burn center. Like why do you send these patients and why do they need all this treatment? So this is that same patient. You saw his back where he had the burn, that full thickness burn. This is normal skin, this is all third degree burn on the leg. We're performing an escharotomy here with a bovie, where we're cutting the skin and it'll actually separate over the next minute or two, two or three centimeters on each side because there's so much pressure where the skin has just been cooked and it's condensed around it. It's much like, I'll be gross for a minute, it's like a food dehydrator where you suck the water out. Skin's 30% water. So we take that water out, it shrinks that skin around the tissue. And if you don't do this, you can actually risk losing that limb. What we do in the operating room is to remove this. A lot of us would do this by hand using a technique. This is a Gullion blade or a Weck knife. And what we're doing is using a tourniquet to minimize blood loss. We're removing dead tissue one level at a time until all the dead tissue is gone. And then we put skin grafts on top of this. There's different ways to do skin grafts. This is an example. Once it's excised, we drop that tourniquet. It's always makes the anesthesiologist nervous, but you drop the tourniquet here. And what you'll see is a lot of punctate bleeding. The punctate bleeding is where we try to preserve as much dermis as we can, or as much residual tissue as we can. But you can see why we use a tourniquet for the excision because otherwise these are very bloody cases. There's different ways to do skin grafts. There's one way where we just take a piece of skin and you mesh it and you put it on. Another way to do skin grafts is a new technique where we harvest the stem cells from the patient's own skin using a little kit here that we spray it on. And you can do this with or without mesh graft, just depending on the depth of the injury and what your goals are. But this is a nice technique. It's relatively new. It was approved in 2018 and allows us to transfer melanocytes over so you get repigmentation. This is a patient who came in, 48-year-old male, electrical injury. He was trying to steal copper from a hospital that was closed during a hurricane and thought because they lost power, that'd be a great time. He had these rough tattoos from when he was in jail. And you can see he's got a contracture in his arm over here from shooting up heroin in the past, but he has 72% burn. So you see some of this is partial thickness on the flank. Some of this is full thickness, like on the chest and arms here. You can see he's already got the blood vessels that are ruptured. This is 35 days later and here he is doing pushups and riding a bike. Bear in mind, the average length of stay for a 72% burn in a man his age is closer to four to six months and not having the wounds closed at 35 days doing pushups. This is what his follow-up photos look like. And I'm just showing this to you because burn care has changed a lot and I want you to appreciate how different it is. But here you can see the mesh skin graft where there are spray on top of the mesh to get these wounds to heal. And you can tell that the depth of injury was was legit because he's lost a lot of his tattoos. The tattoo ink is deposited in the deep dermis and so it's gone by and large. He was actually really kind and when he woke up after surgery, he said, thank you for removing my tattoos. I never wanted those. But you can really see how soft and supple the skin is here. He still has that contracture because that was a deep contracture and a tendon underneath that. This is an example of a face burn and where the spray skin was used on her and she's repigmented. This is another example of a face and neck burns electrical injury and how he's repigmented over time. And now what he looks like at 16 months. So you know what you remember about burn injuries from years ago might not be how burn care is now. And I just want you to be reassured that you know a lot of progress has happened to change burn care. I'm trying to give us time at the end and but I wanted to show you a few things because I think a lot of it has to do with quality. So you heard me say how long the length of stay used to be and the goal is to stay one day for every percent burn. So 10 days for 10% burn. Think of it like that. This is my own burn center which you can see that we're at half a day per percent burn. So you know people are getting out of the hospital much much more quickly and it was in 2018 that the average stay was two and a half days per percent burn for all ages. So by comparison we're one-fifth the length of stay. So that's great. Now I want to take a moment and talk about disaster planning and I'm sorry I'm talking your ear off but I want to save time for questions at the end. But disasters are really important to plan for. This was a great example. This was after Hurricane Ida here in New Orleans last year. We had 42 injuries that came in primarily from people using generators putting gas in them and then blowing up catching on fire. So 42 admissions of over 10% burn in two weeks. The nurses had lost their homes in a lot of cases or had severe damage to their homes and so they were actually living at the burn center in our clinic. So the night team would sleep during the day in the clinic and the day team would sleep during the night in the clinic and then they worked shifts back to back as we did with the burn attendings to take care of all the patients. Thankfully we had a great facility that was designed. We had a washer and dryer built into the burn center. We all learned to bring more than three pair of underwear the next time there's a three pair of underwear the next time there's a hurricane. But one of the things we saw were a lot of carbon monoxide poisons and thankfully our trauma surgeons here helped us take care of all these patients because we would not have been able to do it without their support. Just like their stop the bleed, we're working on stop the burn and in our state we've actually built these disaster kits. This allows us to treat up to 10 patients of less than 10% burn in the field so that if there's a disaster like on an oil rig, instead of getting you know 50 patients transferred in, we can at least treat 10 to 20 of them there that have relatively small burns and then see them in a clinic setting the outpatient. So we're working on creating the training that goes with this for first responders. There's no IV or injectable medicines here. This is a like a water gel. It's a coolant to put on the burn. This is a silver nylon dressings, gauze dressings, ace wraps, oil rehydration packets, mylar blankets to keep them warm, headlamps, trauma shears, and then irrigation for eyes, irrigation for wounds, the few tourniquets in the event of traumatic injuries also. One of the things that your tax dollars have done, I just want to you know thank you know you know trauma has not always been supported the way it should have been but one of the ways they've done is to through BARDA. You'll hear about BARDA. They're underneath ASPR. ASPR is underneath the DHH. This is federal dollars but you know what they've done is to build medical countermeasures for disasters and those include chemical, biologic, radiologic, nuclear, and burn. And so you know you'll see something called Project Bioshield and this is the group that's responsible for our strategic national stockpile. So they've been investing a lot of time and effort in helping us develop new technologies to take care of burns. So they've been developing a camera that uses artificial intelligence that's more accurate than doctors. Right now this thing's over 90 percent. You heard me say earlier that burn surgeons were only right 75 percent. You know general surgeons were right 50 percent of the time. Your doctors were right even less than that. They developed a new skin that you know has grown that we can put on people. They have a new enzyme made from the stem of pineapples that will eat the burn scar off so we don't have to do that gross stuff with the cutting and everything. There's a lot of new technologies that are really transforming burns. This number one is not FDA approved yet. It's probably going to be shooting for FDA approval in 2023. Number two got FDA approval this year. Number three is looking for FDA approval in early next year. Now quickly I want to transition when we're talking about disasters to one of the larger disasters in our world right now. I recently had the opportunity to go to Ukraine and I apologize for missing our meeting before but I was having some travel difficulties getting back. This is a 1,400 bed hospital over in Lviv. This is a 1,000 bed burn hospital and emergency hospital over in Lviv also. This is our municipal hospital so they do a lot of safety net care like many of you do. It's been impressive to see how they've responded because while their medical care is is far behind us in some regards their ability to be adaptable is far ahead of us. So these are you know community hospitals that have flipped a switch and are now caring for military and civilian casualties. They're typically set up as wards. There's not a lot of air conditioning in the wards. There are some things like in the burn hospital where they didn't have portable O2s. There was a lot to overcome but they're they're progressing dramatically. This is an example of using the spray skin and the injured pilot from the war. This is teaching them how to make that spray skin. This was us teaching them how to do another early excision and grafting. Now these are actually some scrub hats we brought them to have built-in sweat bands. It's really hot over there because you don't have an air conditioner in the operating room. It's 95 degrees those days. We actually had the windows open in the OR. A little unusual to have that. But these are some of the great team members that we got to work with there. This is the burn director in Lviv and this is their anesthesia. Mario and I were actually there from New Orleans. He's actually our head nurse educator, retired lieutenant colonel from the Institute for Surgical Research in San Antonio. This was a child that was cared for here in Shriners and then transferred over. And just to tell you how small the world is, I knew the doctor that took care of him. We were able to call him and be able to connect him. And then this is the group of anesthesiologists and burn surgeons in Lviv. And this was us teaching the first advanced burn life support course in that country. It was just great to be able to go over there and to be able to bring education to them the same way that we've had education today. But most important is that all these things lead to changes. And so this is the fantastic team. Everything you've seen does not happen without this great team of people here. But this was mortality in our state and in our region before we opened. This has been the mortality decrease since we opened. And that's really makes a big statement for our community. Since we implemented routing, like I mentioned earlier, we've seen a decrease in the mean and median length of stay. And we're presenting this at several of our scientific meetings. So I encourage you all to work on having routing in your state and in your region. In summary, I just want to state, number one, thank you for the opportunity to present today. I want to save a few minutes for questions at the end. Don't forget the pre-hospital fluid 125, 250, 500. Don't forget when you have carbon monoxide, cyanide, poisoning to intubate, don't hesitate. And then every inch, every day, every patient. That's one of our mottos here. So we really appreciate the time to present to you today. And I'm happy to answer any kind of questions that you have. All right. Thank you, Dr. Carter. This was excellent information. I've been kind of taking a look at question and answers in chat and haven't seen any questions in there just yet, but I actually have a couple for you. Could you describe the role of the pulse ox in the patients that you're taking care of? Yeah, that's a really good point, Jamie. The pulse ox measures bound and unbound hemoglobin. So if you have someone with a high carbon monoxide level, what happens is it's measuring the carbon monoxide and the oxygen. So it might say a hundred percent, but you don't know what percent of that is carbon monoxide. So if you have a suspicion for inhalation injury, please get an arterial blood gas or the carboxyhemoglobin so that you can reference that against the pulse ox. And then the recommendation is not to wean the oxygen, treat them with a hundred percent oxygen until their carboxyhemoglobin gets below 10%, but the pulse ox is not your friend with inhalation injury. It just tells you they have a pulse. It doesn't tell you how much oxygen they're really getting, but that's a really good question. Any other questions, comments, statements, rebuttals, derogatories, remarks? Y'all are a quiet bunch. I'm looking forward to going to some trauma meetings this year, and we'll have some more burn meetings. There is some exciting research that we'll have coming out looking at accuracy for, you know, how much oxygen is in the bloodstream. So that's something we'll have coming out, looking at accuracy for wound depth, both in surgeons and the nurses and therapists. I look forward to getting to share that with the team later on. And I'll also mention this, that the number of burn surgeons in the United States is decreasing dramatically. Unfortunately, it's not a specialty that's being able to sustain itself. We're doing our best to recruit and retain, but we know that many trauma centers will be helping carry the flag in the future. The number of burn surgeons, number of burn centers has gone down from 180 in the 1970s down to about 135 today. So that's about a 25% decrease while the number of trauma centers has grown 25% in the same time period. So there's only 250 burn surgeons that are in the entire United States right now. By that same comparison, we produce that many trauma surgeons every single year that sit for the boards. So I think you're going to see a decrease in the number of burn centers and burn surgeons. Unfortunately, we're hoping that that's not the case. We're doing our best to recruit and change that, but I appreciate my trauma colleagues and for the wonderful work that we do together. I think that kind of drives home the point that you, that one slide you talked about in regards to the mortality of, you know, where you were and where you are now. So I think that's excellent information. I did see one question come across, and it was in regards to burn dressing. Has anything changed with dressings prior to transfer to burn centers? Clean, dry dressings is still the recommendation. And the reasoning for that is that they're going to remove the dressings whenever you do get to the burn center. And so, you know, putting some type of expensive dressing on is not going to really help you very much. I do see a couple other questions come over here. I miss y'all too. Yeah, it looks like Leanne has typed one in regards to level one trauma centers. And how do you see the future with that, with ACS and the type of care that is required for burns? We just recently had a burn center in Ohio that hired all trauma surgeons and is now completely staffed by trauma surgeons. And that's fine. As long as they're trained and they're comfortable with that, I look forward to working with them. I imagine that level one trauma centers will be keeping more burns in the future as we have difficulty staffing and maintaining burn centers right now. So I would anticipate that, you know, the referral criteria are still the same. In fact, we just updated them, but I don't know that it'll maintain that same, it'll be the same in the future. So. Gotcha. Gotcha. Is there, if there's no other questions, I think we will go ahead and adjourn and I appreciate everybody jumping off or jumping in. I know everybody's busy and appreciate you jumping in for the education. And thank you again, Dr. Carter for everything. My privilege. Thank you very much. Look forward to seeing y'all again. Thank you.

Dr. Jeffrey Carter

burn care

pre-hospital fluid resuscitation rates

inhalation injuries

dressings for burn care

disasters

resuscitation

early intervention

pulse oximetry