Fridismo vigente y transmedialidad, el caso de Lila Downs

Burn care presents a huge challenge not only to the Burn Surgeon and the rest of the Burn Team, but also to the patient and his or her loved ones who also face many challenges in the bid to enable the patient to regain good health. The socioeconomic and other costs of burn care are absolutely staggering and this has been shown by this and other studies.7,12,16,17

In the series of fifty-two cases studied, burn injuries were seen to cut across all age groups, both sexes, and different socio-economic groups.

The younger age groups were mostly affected in the study suggesting that the injuries were more common in the more active years of life (fig 1, page 51). The average age was 25 years.

Both sexes were almost equally affected. This is not surprising in our society where both sexes are almost equally involved in economic activities. Most of the injuries were sustained at home; workplace accidents were next in frequency.

Most of the patients studied had some form of formal education. Thirty-five percent had secondary education, and 26.9% had primary education.

Only two patients (3.8%) had no formal education. Four patients (7.6%) were infants. They were yet to commence formal education.

Flames accounted for an alarming proportion of the injuries (63.5%). This may be due to factors which include irrational handling and supply of fuel, kerosene contamination, erratic power supply and other factors that have been highlighted by previous workers.^1,3,11,15 Scalds were responsible for 25% of the injuries. This is similar to a study done at Osogbo which reported a 25% incidence of scalds,¹²⁰ and unlike the results of other studies at Ilesha: 50.6%,²³ Ife: 40.5%,²⁴ and Maiduguri: 64.4%.⁴

Many of the patients underwent treatment and were followed-up in the out-patient department for several months after the injury. The average duration of treatment and follow-up was 9.6 months, while the range was 2 to 12 months. This underlines the protracted nature of burn injury management and, hence, the colossal cost of management.

The average burnt surface area in the study was 21%. The study done at Ife had an average burnt surface area of 25.4%,²⁴ while the Osogbo study reported 22.9%.¹²⁰ The cost of treatment is known to correlate well with the severity of the injury.¹⁷ In most patients multiple parts of the body including the critical areas - especially the hands – were also affected. Due to the functional requirements of the hand, extra precautions were taken to preserve functions. Patients that presented with impaired functions had

multiple, staged surgical procedures to restore function. These added considerable cost to the management.

Thirty-two of the patients studied (61.5%) had injuries considered to be deep burns. These injuries are more difficult to manage. Deep wounds take a longer time to heal. Operative treatment is required for this category of patients. These factors contribute to increasing the cost of managing deep burns. Management of this form of injury is more often undertaken at the highly specialised centers. This may be responsible for the high proportion of deep burns seen in the study.

Only 6 of the patients (11.5%) had associated mechanical injuries. This correlates with the low incidence of road traffic accidents and assault recorded in the study. The presence of mechanical injuries places greater physiologic demands on the patient. This may contribute to the immune depression associated with burns. Ultimately, there may be a rise in the cost of managing the burn injury. Some resources will also be devoted to managing the mechanical injury itself.

Fourteen patients (26.9%) were managed by general practitioners and 7 (13.5%) were seen initially at the General hospitals. The large proportion of patients with moderate and severe injuries managed by non-specialists gives room for much concern. This factor leads to a higher incidence of

complications, prolonging the duration of treatment thereby contributing significantly to cost.

In-patient treatment was given to 48 (92.4 %) of the patients (table 1, page 53). Seventy-five percent (39) left the hospital within five months.

The longest duration of stay was 12 months with an average of 3 months.

Most of the patients studied (67.3%) did not require special resuscitation measures. Three patients required total parenteral nutrition. Sixty-seven percent had wound dressings alone while only two (3.8%) had wound excision and grafting (fig 2, page 54). Twenty-seven percent had skin grafting after prolonged wound dressing. Deep burns should be completely excised and skin grafted as soon as the patient is resuscitated. The procedure of early wound excision and grafting is not routinely practiced at our centre. The reasons for this include limitations in infrastructure and resources. Most patients are unable to afford the procedure at the time of injury. Many are impoverished by the fire incident, and have to depend on friends and relatives for sustenance. Patients also, are often averse to surgery. All patients had antibiotics and haematinics. Only 5.7% had dressings with special synthetic dressing materials such as Acticoat. These dressing materials are exceptionally expensive.

Thirty-eight (73.1%) of the patients had early (fig 3, page 55) and 37 (71.2%) late complications. One mortality was recorded. The study done

in Lagos by Sowemimo reported a similar spectrum of complications.¹ The Osogbo and Zaria studies and others also reported similar complications but at much lower incidence.^2,120 Most of the patients with no complications were managed by burn specialists in tertiary institutions.

Hypertrophic scarring was the main problem for most other patients managed by tertiary institutions who had late complications. At the NOH, Igbobi this problem is being addressed by the routine use of pressure garments for all burn patients. The pressure garment, drugs that are used to control infections and appliances for preventing contractures are all expensive and contribute heavily to the cost of management.

Thirty-two patients (61.5%) had reconstructive surgery. Major surgical procedures were performed in 30 (93.8%) of this group of patients. Most of the patients required multiple, staged procedures. Many were still scheduled for further surgery at the conclusion of the study. Many patients also had residual functional impairment of various degrees. Experiences from previous studies have shown the multiplicity of surgical procedures required to correct post burn deformities.^16,115 The procedures are often extensive and expensive.¹⁶ Most of the patients with severe deformities and with moderate deformities required such surgical interventions.

Physiotherapy without surgery was used as part of the management for the rest of the patients with minor deformities. Half of the patients were

dissatisfied with their present appearance and 53.8% out of these desired cosmetic surgeries. All these additional surgical operations will add heavily to the overall cost.

The average duration of man hour loss was 14.9 months. Thirty of the patients (62.5%) that were studied had resumed work while the rest had not, mainly due to on-going treatment (fig 4, page 57). Six members of this subset (33.3%) could not cope physically, 2 (11.1%) had changed jobs, 3 (16.7%) were unemployed and 1 (5.6%) was undergoing retraining for other vocations. Two (11.1%) were psychologically unable to cope and had changed jobs. These lost man-hours and lost jobs pose a huge economic cost.

Forty-seven (92.1%) were fully re-integrated to family life while 4 (7.9%) were partially re-integrated. Thirty-eight (74.5%) had a normal social life while 11 (21.6%) had a sub-normal social life, and 2 (3.9%) had none.

The most frequent opportunity cost was the relatives either stopping work or school (51.9%). Others had to sell their properties to fund the treatment. Some had business-related or family problems (fig 5, page 58).

These findings point to a highly significant social cost.

Twenty-seven patients (52.9%) reported an overall good quality of life, and 9 (17.6%) actually declared an excellent quality of life. The quality of life was fair to 15 (29.4%). No patient reported a poor quality of life!

The total cost of treatment for the 52 patients studied was N10.884 million (fig 8, table 6, page 64). Dressings accounted for 29.5% of total cost. This highlights the lengthy duration of treatment characteristic of burn injuries,⁷ and suggests an under-utilisation of surgical techniques for early wound cover. Twenty-six percent was spent on in-patient charges which were made up of bed fees, meal charges and nursing fees. Surgery accounted for 19.1% of this total cost, a surprisingly low figure. This affirms the earlier suggestion that surgery is underutilized.

Five million, six hundred and sixty-four thousand, seven hundred and fifty-three naira was spent on early costs in treating 27 acutely injured burn patients, an average of N209,806 per patient (fig 6, table 2, page 59). The cost ranged from N14,470 to N2,206,950. The average cost per patient per day was N8,855 for the early treatment. In, the year 2006, real take home wages in the Public sector was estimated at N7,422 for a Grade Level (GL) 01 officer, N24,869 for a GL 08 officer, and N68,794 for a GL 15 officer.¹²¹ All these public officers would have various degrees of financial difficulty if faced with the responsibility of footing the bills for a patient with a major burn injury. For the GL 01 officer, this would be an absolute disaster.

Dressings took up 51.6% of the cost, mainly due to the use of the highly expensive dressing materials and prolonged dressing of burn wounds.

Acticoat dressing was used for two of the patients studied. At the time of the study, Acticoat cost N250,000 per pack. ⁶⁷ Eighteen percent was spent on in-patient charges and 17.8% on drugs. Four percent was spent on surgery. Surgical management of acute burns was not carried out on most of the patients in the study. Reasons for this have been discussed earlier, but the large amount spent on dressings and in-patient charges is an indication for increased role of surgery in the early management of burns.

Antibiotics took up 53.6% of the portion of the early costs spent on drugs, while intravenous fluids accounted for 18.5%. Prophylactic antibiotics were used in the management of these patients. The high rate of wound infection necessitated the prolonged use of therapeutic antibiotics adding significantly to cost. Ugburo et al did not find any benefit in the use of systemic antibiotic prophylaxis to control burn wound infections.¹⁰⁷ A high rate of infections among these patients indicate a failure of the existing burn ward protocols aimed at preventing infection, and a need to make early wound cover a greater priority.⁴⁶

Intravenous fluids are crucial to success in resuscitation following major burn injury. However, they play a limited role in the nutrition of burn patients, being an inadequate substitute for enteral feeds. Early enteral feeding is strongly advocated in the acutely burnt patients.⁸² Adherence to these guidelines will limit excessive use of intravenous fluids. The use of

Ringer’s Lactate solution does not represent a significant addition to cost, as it is required only for resuscitation and is not more expensive than normal saline.

Analgesics were liberally used to relieve pain in the patients. The cost of these analgesics was significant. Early wound cover would have reduced the need for these analgesics. Low molecular weight heparin was also used to prevent thromboembolism in the patients at risk. It was an important component of the miscellaneous expenses on drugs. Ambulant patients are less likely to develop deep venous thrombosis.

Smaller amounts were spent on other aspects of management including prophylactic splinting, physiotherapy, and pressure garments which play an invaluable role in the prevention of late complications such as contractures, joint stiffness, and hypertrophic scarring.

Five million, two hundred and nineteen thousand and thirty-nine naira was spent on late costs; an average of N 208,762 per patient (fig 7, table 4, page 61). The cost ranged from N13,050 to N738,940. Surgery accounted for 35.1% of this, emphasizing the role of surgery as the mainstay of post-burn reconstruction. Major surgical procedures accounted for 64.7%, intermediate procedures, 27.1%, and minor procedures, 8.2% (table 5, page 62). The tendency to subject patients to surgery decreased as deformities became less obvious and function improved.

In-patient charges accounted for 33.5%, while 12.8% was spent on drugs.

Dressings were responsible for 5.6% of the cost. Prolonged wound dressing and use of expensive dressing materials were not common features of late post-burn management. However, the patients still spent a lot of time in the hospital.

Antibiotics (45.2%) and haematinics (22.2%) accounted for large portions of the N666,484 spent on drugs in the course of post-burn reconstruction.

The antibiotics were used mainly prophylactically. The patients undergoing burn reconstruction are usually fit patients and able to eat well post-operatively. They do not require prolonged intravenous fluid infusion which accounted for 8.2%. Twenty percent was spent on analgesics.

Splints, pressure garments, and physiotherapy played important corrective roles in post-burn reconstruction. Clinic visits were much more in this phase.