Foot and toes
This example shows a young child with severe burn wounds that did not receive adequate burn care. After a delay, the patient and his parents arrived at a hospital offering surgical burn care. Unfortunately, they disappeared before surgery could be performed. Later, they explained that they were afraid of the hospital bills. Two months later they returned to the hospital, desperately, with the child in a very bad condition. The patient survived however was disabled with severe contractures of knee and foot.
This example shows challenges of providing adequate burn care in resource- limited settings.
Medical history
A one-year-old, otherwise healthy child sustained a burn from the cooking fire. The parents were poor and stayed at home for one week. The explained later that this was because they were looking for money for transport. When they found the money, they went to Ikungi Hospital. However, surgical burn care was not possible there. Two weeks later the patient was referred to Haydom Lutheran Hospital, a 9 hour journey by bus (Photo 1).
Physical examination
At the first admission, 31 days after the injury, the child was weak and the feeding status was poor however there was no fever and no signs of shock.
Legs and feet: Old full thickness burn wounds were present. The eschar had come off before, exposing foul smelling wounds involving the full left leg, foot and toes. There was some granulation tissue present, individual toes were not visible anymore. There were no signs of reepithelization (Photo 2).
Conservative management
The child was kept warm and the mother was supported to breastfeed the child every 2-3 hours.
She had enough milk and did very well. Amoxicillin was given orally for one week. Daily wound soaking was started, and dressings with gauzes with Silver Sulfadiazine ointment (SSD) were applied.
The team hoped to improve the condition to be able to perform skin grafting but progress was slow and after a month the child was still very weak (Photo 3). The team succeeded in making the treatment affordable by providing a poor patient fund that covered the costs, but when surgery was finally scheduled, the relatives and the patient had left the hospital unexpectedly and were not reachable by phone.
They came back two months later. This time the boy was in a very bad condition, with severe malnutrition and pneumonia. The burn wounds had started to close with excessive burn scar tissue, forming severe contractures of the joints (Photo 4).
The child was treated for severe malnutrition and pneumonia according to the Pocket Book for Hospital Care for Children (WHO). The wounds received daily soaking and dressings again. The child was in a critical condition for weeks. The general condition improved and slowly the wounds became smaller (Photo 5).
Surgery
When the child was strong enough to undergo surgery, the team spoke with the parents again to propose skin grafting for the remaining wound. They agreed this time, five months after the injury.
A 1.5% TBSA defect on the lower leg and the sole of the foot was grafted (Photos 6 and 7).
Postoperative care
The skin graft was protected with a dressing of Vaseline gauzes and tetracycline ointment. It healed well as shown on the picture after three days (Photo 8).
Outcome
The patient was discharged two weeks after grafting. After three months the child was well-nourished and did not have any open wounds. However, the contractures of knee and ankle were severe (Photo 9). The parents were counselled to come back two months later for contracture release surgery during the next reconstructive surgery camp at the hospital.
Lessons learned
To find a hospital providing surgical burn care can be a challenge in countries like Tanzania.
Finding a way to provide affordable adequate burn care is a big challenge too.
Even when a ‘poor patients fund’ is available, it was still a challenge for the team to build trust and negotiate a fair price for services for patients without health insurance.
Malnutrition is a severe threat to the healing process of severe burn wounds. As long as the general condition has not improved, the risk of performing skin grafting is considered to be too high in these settings. The anesthesia risks are higher and the results of the skin grafting and wound healing are inferior.
Never give up. When you manage to keep a severely burned patient alive and focus on improving the general condition and the wound healing, don’t feel as if you have failed when contractures occur. Contractures can be treated later. Ask for help if you cannot do contracture release surgery yourself or refer to a center where this technique can be performed.
For this patient, the team will try to trace him again and offer contracture release at the next reconstructive camp, since the treatment had not been finished at the time of writing.