An Acid Test

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An Acid Test

Sunday, 16 December 2018 | Shalini Saksena

An Acid Test

The annual burns incidents in India are 7 million a year. SHALINI SAKSENA catches up with doctors and survivors who say that a dedicated unit for burns management is set up at the earliest

I  was acid attacked in 2006 — just 12 days into my marriage — by a man whose proposal I had rejected. At that time I was studying in Delhi. My hometown is Varanasi. I was on a train traveling from Delhi to Varanasi when the incident took place. The man who threw acid on me was a distant relative. I filed a case against him; he was booked under Section 326A of the IPC (Voluntarily causing grievous hurt by dangerous weapons) since there was no separate law for acid attacks back then. We fought a legal battle for almost two years and finally, he was jailed for four-and-a-half-years. He served this sentence and is now out and leading a normal life,” Pragya Singh, founder of Atijeevan Foundation which fights for empowerment and rehabilitation of acid attack survivors, says.

Besides the physical and mental trauma that a survivor faces, there are several healthcare issues, she points out. This may involve over 30-40 surgeries, to begin with. That is not all, the problem with surgeries in case of burn survivors is that the skin grafting contracts and shrinks over a period of time if proper care is not taken like wearing a pressure garment and using a gel sheet. In other words, one requires surgery for the same burnt area time and again.

“The problem with any kind of burn injuries is that is most cases the survivor is from a low-income family. The thought process is very different. Acceptance of society is another roadblock. It takes a lot of courage for a survivor with a disfigured face to come out in the open and face the society. When people shun this person due her morbidity, it takes a toll on the survivor,” Singh says, who says that there is a lot more pent-up anger rather than sadness.

Seconds another burn survivor. Though she doesn’t want to share her name, she tells you that she sustained burns when her lehenga caught fire from a diya on the floor during Diwali this year.

“When I realised that my clothes were on fire I tried to put it out. I was running and trying to put it out, but the more it spread up my legs. This is when my uncle caught hold of me and tore the lehenga. In the process, he too sustained burns,” she recalls.

What she has not lost is her spirit to fight and get better. “I know that while my present situation looks bad (her legs are wrapped to prevent injection) I also know that will take time to heal but I will do everything to get better and be back in school at the earliest,” she says.

Another burn survivor sharing his story tells you that he sustained injuries when the gas cylinder burst while he was cooking. He tells you that there was a leak in the pipe which he was unaware of.

Thirtyfour-year-old Prabha sharing her story, tells you that she was in Delhi, on a vacation in May, when the incident happened. “I was in the kitchen, talking over the phone with the ear plugs and trying to cook, the perils of juggling too many things together. My parents were out of town. I had woken up late and was drowsy. I was wearing a loose dress when it caught fire. When I realised that it was on fire, I tried to take it off and that is the reason my hand is most affected and left side of my body,” Prabha says, who was working in Mumbai for eight years as a brand strategist in marketing.

She immediately called an ambulance which surprises people. They ask her ‘how she even knew the number’? And her counter question to them is ‘Why don’t you know the number’?

“People should be aware of medical emergency numbers. While waiting for the ambulance, I tried to give myself first-aid — poured water and ice. I did think of applying toothpaste but finally did not. I stood in front of the AC. When the ambulance arrived, they took me to Safdarjung Hospital where I was given the required treatment. I was in the ICU for three weeks and another two months in hospital,” Prabha tells you.

The kind of surgery that she now needs will cost around Rs 1 crore given the conversion rate. “I have tried to contact doctors here in India. Nobody proactively told me what I needed to do. That is why I have decided to migrate to Australia and get treatment there. The doctors there have been upfront and have told me what I need to do and how much it will cost. They are very systematic. Back in India, I have been told that my fingers (which are bent at first digit) will remain the same and some have said that they can do something. I have been undergoing physiotherapy for the last four months and am told that there is nothing wrong with the joints. But plastic surgeons tell me that these will have to be partially set,” Prabha tells you.

Dr Rajeev B Ahuja, a senior consultant, Sir Ganga Ram Hospital, Delhi tells you that from the extrapolation of burn incidence for India from the American Burn Association (ABA) factsheet of 2010, of the 50 per cent burn injuries in the country more than 50 per cent are related to the total body surface area. “According to the ABA factsheet 2010, there were 1.8 lakh admissions out of which 40-50 per cent resulted in deaths. The WHO estimates that in Nepal eight per cent of the population is disabled — five per cent due to burns. By this yardstick, India will have 5 million disabled from burn injuries,” Dr Ahuja says.

The magnitude of the burns problem in India is due to: High incidence, Social conundrum — poverty, illiteracy and safety norms. “People come to us with their burns wrapped in newspaper or body covered in toothpaste. Then there are economic factors; there is a shortage of trained manpower. No formal training in burn management. Burn nursing not a recognised concept. Nursing supplemented by relatives visiting patients. It is not possible to provide ideal treatment to all burn victims in developing world based on western models for several reasons. Cost-intensive, prolonged hospitalisation resource and material crunch, Government funding is inadequate, medical insurance schemes are not affordable. There is poor infrastructure for communication and coordination.  No coordination between a district hospital & a burn centre, patients travel long distances to get burn treatment, almost 50 per cent patients arrive six hours after sustaining burns, dire cases are referred to reputed burn centres. This consumes existing facilities which can be given to salvageable cases,” Ahuja says and tells you that the challenge is to provide the best possible treatment that can be compared to treatment that might be available outside of India with the same percentage of burns despite cash crunch.

“The constraints are that for higher percentage of burns is that one has to excise the burnt tissue. If you allow the burnt tissue to desiccate and to separate itself from the living tissue over a period of three to six weeks, the dead tissue invites infection. This goes into the blood and the patients die from this infection. If one prescribes too many antibiotics, over a period of time the bacteria become resistant to that medicine and we don’t have newer antibiotics. But if one excises the wound, there is need to cover it with a material (artificial skin of different kind) to prevent the blood fluids to leak. This material is very expensive and not available here. They are not available because they are expensive and nobody buys them. To make this material available in India at a cheaper cost, there is need for research in artificial skin and artificial resurfacing material. If we develop our own products they will be less expensive and easily available which will help the burn survivors,” Ahuja explains.

 

Dr William G Cioffi, president, International Society for Burn Injuries (ISBI), who was in the Capital for the 19th Congress of the International Society for Burn Injuries tells you that there is a need for specialised burn care in resource-restricted countries of the world.

“Once the person has a burn injury, the response is fairly similar. It doesn’t matter whether it is here in India or the US. The kind of intensive care, medical and the team care, not just the doctors but the nurses, the therapists and the people involved in rehabilitation of the patients back into the society is the same in the developed countries as developing countries. We don’t focus enough on how we are going to help these people to go back to school like that young girl said or back to work as the other survivor said. We need to focus as much on these issues as much on survival which is getting better and better in India. What matters is what we do after that is important,” Dr Cioffi says.

He tells you that while India has some great doctors and are well-trained what it needs to be done is to concentrate on team care. “The doctor is with the patient for a small period of time but a patient with severe burns — 50 per cent of the body — requires the care of two nurses round the clock. This is a big burden. Then you have the therapists who come in. One of the hardest things in the US was accepting that it was not just the doctor but the whole team of people and how to do that effectively,” Dr Cioffi opines.

He tells you that the advantage that the US has over India is the availability of resources. “We are fortunate that we have more resources compared to India, more skin sensitive products, we have access to more intensive care and more access to how we support nutrition to these patients. By doing this, we can prevent a lot of morbidity and contractures. Having access to these things is important. One doesn’t need expensive products, there are some simple things that work as well,” Dr Cioffi explains and says that through this congress one has to recognise that the problem is not going to get solved in six mon this or a year; it will take decades.

“The first thing is to recognise that it is a problem of poverty and violence and these issues need to be addressed and then build a system and each year set things that one needs to achieve — recognition of the problem, understanding the epidemic, prevention and patient care, rehab and rehabilitation in the society,” Dr Cioffi says.

Dr Vinita Puri who is the ISBI Secretary General and Head, Department of Plastic, Reconstructive Surgery and Burns, Seth G S Medical College and KEM Hospital, Mumbai tells you that as a plastic surgeon the biggest challenge facing burns is that it is primarily a problem of  poor.

“Treatment of acute burns is draining. First, it is a long-term treatment; second it is a drain financially. In public hospitals the facilities may not be that adequate. Also doctors in such hospitals are not just dealing with burns. We are dealing with every other emergency that comes to us. Because I have a lot of interest in treating burns, a lot of emphasis goes towards the treatment.

“We don’t have a dedicated unit but attached to some other unit. If we had a team only to treat burns maybe the level of care may go up. Then there is lack of awareness. First is prevention. Around 80-90 per cent burn injuries are accidental. This means they can be prevented. If you have lady using a defected stove or cooking food wearing a loose fitting garment, it can lead to an accident. Second, the morbidity that results from burns. Many are not aware that the scars are treatable for negligible cost in public hospitals. There are doctors like us but sometimes we get patients very late.

“Third, lack of awareness at the primary care level,” Dr Puri says and opines that the media can help in creating awareness and use the existing system in place like the anganwadis who can do so much more.

Dr Ahuja’s solution to better burn management in the country should include prevention strategies that should address the hazards for specific burn injuries.

“Education for vulnerable populations, Training of communities in first aid, Burn injuries are ‘accidents of poverty, Huge burn load exists in the developing world (India), burn morbidity is quite comparable to HIV morbidity-at least in India, Burn incidence automatically decreases with economic prosperity, Poorly designed Kerosene stoves - still a major reason for accident, Prevention activity in developing world is sparse –  individual driven - yielding limited results, Countries in the developing world need to have their own models for improving burn care,” he says.

How to prevent burns: Dos & Don’ts

Burns are preventable. High-income countries have made considerable progress in lowering rate of burn deaths, through a combination of prevention strategies and improvements in the care of people affected by burns. Most of these advances in prevention and care have been incompletely applied in low- and middle-income countries. Increased efforts to do so would likely lead to significant reductions in rates of burn-related death and disability.

Prevention strategies should address the hazards for specific burn injuries, education for vulnerable populations and training of communities in first aid. An effective burn prevention plan should be multisectoral and include broad efforts to:

  • Improve awareness
  • Develop and enforce effective policy
  • Describe burden and identify risk factors
  • Set research priorities with promotion of promising interventions
  • Provide burn prevention programmes
  • Strengthen burn care

The WHO has some basic guidance on first aid for burns.

What to do

  • Stop the burning process by removing clothing and irrigating the burns.
  • Extinguish flames by allowing the patient to roll on the ground, or by applying a blanket, or by using water or other fire-extinguishing liquids.
  • Use cool running water to reduce the temperature of the burn.
  • In chemical burns, remove or dilute the chemical agent by irrigating with large volumes of water.
  • Wrap the patient in a clean cloth or sheet and transport to the nearest appropriate facility for medical care.

What not to do

  • Do not start first aid before ensuring your own safety (switch off electrical current, wear gloves for chemicals etc.)
  • Do not apply paste, oil, haldi (turmeric) or raw cotton to the burn.
  • Do not apply ice because it deepens the injury.
  • Avoid prolonged cooling with water because it will lead to hypothermia.
  • Do not open blisters until topical antimicrobials can be applied, such as by a health-care provider.
  • Do not apply any material directly to the wound as it might become infected.
  • Avoid application of topical medication until the patient has been placed under appropriate medical care.

 In addition, there are a number of specific recommendations for individuals, communities and public health officials to reduce burn risk.

  • Enclose fires and limit the height of open flames in domestic environments.
  • Promote safer cookstoves and less hazardous fuels and educate regarding loose clothing.
  • Apply safety regulations to housing designs and materials, and encourage home inspections.
  • Improve the design of cookstoves, particularly with regard to stability and prevention of access by children.
  • Lower the temperature in hot water taps.
  • Promote fire safety education and the use of smoke detectors, and fire-escape systems in homes.
  • Promote the introduction of and compliance with industrial safety regulations, and the use of fire-retardant fabrics for children’s sleepwear.
  • Avoid smoking in bed. Encourage the use of child-resistant lighters.
  • Promote legislation mandating the production of fire-safe cigarettes.
  • Improve treatment of epilepsy, particularly in developing countries.
  • Support the development and distribution of fire-retardant aprons to be used while cooking around an open flame or kerosene stove.

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