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Burns
management turns into a burning issue
Even
with 7 lakh burns patients being hospitalized and 1.2
lakh dying annually, there are only 32 burns units,
with inadequate facilities and around 40 burns surgeons
in India. Not to mention the cost of treatment that
runs up to Rs 4,00,000. Rita Duta finds out what ails
burns care in India.
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| A
burns patient being attended at the Eric Kharas
Burns Research Unit of Masina hospital, Mumbai |
Ask
any burns surgeon about burns care in India, and not
a single one would hesitate to portray the gloom that
prevails over this particular discipline, marked by
alarming morbidity and mortality. On an average, burns
centre of a public hospital is able to save patients
with burns below 40 per cent. Those having burns close
to 50 per cent have 50 per cent chances of survival
and very few cases survive having burns beyond 60 per
cent. In West Bengal, the survival rate of for 50 per
cent for burn is a dismal 25 per cent. This is in stark
contrast with the developed countries where patients
with more than 70 per cent burns also survive and the
survival rate of patients with 50 per cent burn is from
75 to 90 per cent. Experts lament that even after the
passage of more than 30 years since the first department
of burns care in India was established by the doyen
of burns care in India, Dr M H Keswani at J J Hospital
and Grant Medical College, and the establishment of
32 burns units later, burns care needs a healing touch.
With around 7,00,000 major burn victims needing hospitalisation
and 1,20,000 succumbing to the injury, the meagre 32
burns units in the country, (of which only 19 are said
to be up to the mark with a low mortality and morbidity
rate), are not able to meet the demands and render quality
care.
The irony is that while 70 per cent of the burns victims
are at the village and taluka level, all the burns units
are located in the city, depriving a sizeable population
from burns care and thus dipping the mortality rate.
The scenario of burn care in the north eastern states
is abysmal, in the absence of any burns unit, except
one in Assam. Even West Bengal has only one major burns
unit. Expert say India with a population of one billion
needs ten times more number of burns units in the country.
In the US, there are about 120 burn care facilities
for a population of less than three hundred million.
Because of the lack of facilities for treating burns
in villages and talukas, all referrals are made to the
tertiary care centres, forcing the latter to treat burns
either in the casualty ward, small burns unit, or even
general wards of the hospital. Most of the city hospitals
(government or private) complain of being overburdened
with patients, resulting in delayed critical burns care.
“Most
city hospitals complain that they are unable to perform
excision of skin, which is labour intensive requiring
the help of nurses and attendants, not before 12 days,
when ideally it should be done within 48-72 hours,”
states Dr Madhuri Gore, HOD, surgery, Lokmanya Tilak
Municipal General hospital, Mumbai, which receives around
700 burns patients annually.
Burns care in government hospitals is plagued by lack
of infrastructure, whether it is sophisticated equipment,
availability of medicine, spacing between beds or man
power. With burns care needing the facilities of intensive
care unit, in India some burns units are run without
basic equipment like ventilator, pulse oxymeter, infusion
pump, patient weighing machine and mesh grafting (needed
for skin grafting). According to Dr Siti Roy Chowdhury,
former head of plastic surgery and head of burns unit,
S S K M Hospital, Kolkata, which is the only major burns
unit in West Bengal, “Burns units are not up to
the mark with facilities of intensive care being unavailable.”
To which adds Dr B P Sarma, Chief Medical officer, Indian
Oil Corporation Limited, Assam Oil division, who is
credited with starting the first and only burns care
in Digboi, “We do not have adequate space, equipment,
laboratory facilities and manpower for treating burns.
Further, being remotely located, we face problems of
procuring pressure garments and some essential medicines.”
The story of government apathy is repeated in other
states. However, there is silver lining in the Government
of Maharashtra already taking steps to improve the burns
units at the various districts level hospitals. A part
of the Rs 750-crore World Bank project allocated to
strengthen primary and secondary level, is invested
to improve the infrastructure of burns units, said Dr
Subash Salunke, director general, health services, GoM.
Though the survival rate of burns patient in private
hospitals is around 50-60 per cent in comparison with
20-50 per cent in government hospitals, burns care is
marked by the severe lack of private participation.
Experts say that burns unit is not something that the
private sector evinces interest with high infection
control, medico-legal problems (with every burns case
to be reported to the police and requiring evidence
in the court in case of complications) and the average
length of stay of burns patients in hospital being not
less than two and half months. Explains to Dr V I Buch,
chief burns surgeon at Nanavati trust hospital, Mumbai,
which has a 9-bedded burns unit, “Private hospital
can earn Rs 4 to 5 lakh from a patient for cardiac care
unit in ten days. A patient of burns unit would pay
the some amount over a period of two months.” The
expensive treatment, which amounts to Rs 3,00,000 to
4,00,000, due to long stay in the hospital, expensive
dressings, expensive antibiotics, intensive care, pressure
garments, splints and multiple operations have forced
most burns surgeon to strategise ways of cutting corners.
With dressing of burns wounds amounting to be Rs 1,000
per day, a few burn surgeons have devised unconventional
ways of dressing material, like banana leaf and potato
peal. For instance LTMG hospital uses banana leaf for
dressing, for which the hospital is encouraging the
growth of banana plantation in its own compounds. “Being
priced at Rs 16 banana leaf dressing is the cheapest
form of dressing. It is also non-adherent, making the
dressing less painful,” says Dr Gore, who settled
down for banana leaf after trying out many alternatives.
Also, the depleting funds from the government has resulted
in the various hospitals resorting to seeking funds
desperately from NGOs and social workers. The concerned
doctors spend a lot of their constructive time on strategizing
ways to gather funds. Very often by the time the funds
could be organized, it is too late for the patient.
Experts suggest that a unique insurance scheme for the
burns victim can also be of help.
With the life of a burns patient threatening to deteriorate
any time, burns patients require continuous monitoring
and special attention by nurses, another area that is
lacking in India, says Dr Arvind Vartak, HOD, Eric Kharas
Burns Research Unit, Masina hospital, one of the reputable
private burns care centre in Mumbai, “Considering
the fact dressing for burn patients is a laborious process
which requires skill and extra care, nurses specially
trained in burns management is a necessity,” adds
Dr Vartak. The nurse-patient ratio which is one to one
in western countries for burns, is also skewed in India,
with one nurse per 10 to 30 patients. One to one ratio
also decreases the chances of cross infection. While
authorities are emphasising on training their nurses,
hospitals are grappling with the outflow of nurse in
burns. Says Dr Shobha Chamania, chief of burns unit,
Choithram Hospital and Research Centre, Indore, “Burns
care need specialized training. But no sooner we train
the nurses to handle burns patient, they leave for abroad.”
While the chances of survival of severe burns patient
can be enhanced by skin grafting, burns surgeon rue
that cadaveric donation of skin cannot be practiced
with the non-inclusion of skin in Transplantation of
Human Organs (THO) Act, 1994. Though burns surgeon did
lobby to allow cadaveric donation of skin, the government
had tuned down the proposal on the ground that skin
is a tissue and not an organ and hence cannot be included
in THO Act. According to Dr Vartak, this has dealt a
big blow to skin grafting, which is necessary to give
a temporary cover to the burnt skin and helps the burnt
patient recover faster. Live skin donation is hampered
by unavailability of donors, the risks associated with
contacting Aids virus and the pain and trauma that the
donor has to undergo.
With not more than 40 burns surgeon to treat a vast
populace of 7 lakh burns cases, existing burns surgeons
say burns care need more active participation from plastic
surgeons, with the kind of treatment needed for burns.
However, plastic surgeons prefer to opt out for cosmetic
and re-constructive surgery, which is more remunerative
and less laborious. “Burns care is a laborious
task, requiring hours of service. A plastic surgeon
would rather prefer doing reconstructive surgery for
a few hours, than put on hours every day for dressing
the patient,” rues a burns surgeon. And surgeons
who are diligently delivering the goods face problems
of appearing in the court to give evidence. “Since
I have to sign the statement, every time I am only expected
to go to the court, whenever the case comes up for hearing.
The court does not even pay for the travelling,”
laments Dr Gore.
Experts say that burns care need more active participation
from NGOs, training, proper referral networking, funds
and development of an emergency trauma system. With
AAPI taking an interest in standardizing burns care,
probably there is a glimmer of hope.
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