Burn Injuries

Each year in the United States and Canada, thousands of individuals seek medical care for a burn injury. Some individuals are burned significantly enough they require treatment at specialized burn care facilities. Most of these injuries are preventable. This article presents an historical perspective related to burn prevention and elements of successful burn prevention programs and explores ways in which the plastic surgeon can promote burn prevention through education, advocacy, and the legislative process. Prevention efforts undertaken by the surgeon can increase awareness, ensure a safe environment, and reduce burn injuries.

Key points

  • It is crucial that the plastic surgeon, as the head of the prevention team, recognizes the influence such a position may hold in an effort to get the hospital administration to support fire and burn prevention initiatives.

  • Every effort should be made to collaborate with community fire and life safety organizations to address the fire and burn issues.

  • The goal of public education is to provide information that creates awareness that gets individuals to recognize and reduce their risks of sustaining a burn injury.

  • The plastic surgeon should have a working knowledge of the legislative process to influence legislation that could reduce burn injuries.

Introduction

Each year, more than 486,000 individuals visit emergency departments to seek some form of medical treatment for a burn injury (National Hospital Ambulatory Medical Care Survey, 2011). Additionally, more than 30,000 individuals are burned so significantly that they require admission to the 132 designated burn care facilities in the United States and Canada each year for the treatment of a burn injury (American Burn Association, 2016). Most of these injuries are preventable. The plastic surgeon is in a unique position to help promote prevention initiatives. This article presents an historical perspective related to burn prevention and elements of successful burn prevention programs and explores ways in which the plastic surgeon can promote burn prevention through education, advocacy, and the legislative process. Because the best way to treat a burn is to prevent it from occurring, prevention efforts undertaken by the surgeon can increase awareness, ensure a safe environment, and reduce burn injuries.

Introduction

Each year, more than 486,000 individuals visit emergency departments to seek some form of medical treatment for a burn injury (National Hospital Ambulatory Medical Care Survey, 2011). Additionally, more than 30,000 individuals are burned so significantly that they require admission to the 132 designated burn care facilities in the United States and Canada each year for the treatment of a burn injury (American Burn Association, 2016). Most of these injuries are preventable. The plastic surgeon is in a unique position to help promote prevention initiatives. This article presents an historical perspective related to burn prevention and elements of successful burn prevention programs and explores ways in which the plastic surgeon can promote burn prevention through education, advocacy, and the legislative process. Because the best way to treat a burn is to prevent it from occurring, prevention efforts undertaken by the surgeon can increase awareness, ensure a safe environment, and reduce burn injuries.

The history of burn prevention

Ever since humans first discovered fire, a burn injury probably occurred shortly thereafter. Numerous records exist that describes the treatment of burns dating from the times of cave dwellers to 1500 to 1600 BC. The first recorded burn injury in the United States occurred in 1609 to Captain John Smith of the Jamestown Colony. Records indicate that Smith was badly injured (burned) from a mysterious gunpowder explosion in October of that year. He returned to England for treatment and never set foot in Virginia again. Technologic advances and changes in cultural mores may have contributed to the increase in burn injuries, as little or no emphasis on safety was required for new products. It was not until the late 19th and mid-20th centuries that society began to recognize that most burn injuries could be prevented. It could easily be argued that the recognition for burn prevention came about because of published injury data reports and reaction to local, regional, or national disasters that resulted in injury or the loss of life. As a consequence of these incidents, legislation in the form of laws or codes and standards were enacted to prevent or minimize their reoccurrence. These regulatory measures, when adopted, help ensure the safety of the general public but may not necessarily be applicable to individuals or specific forms of burn injuries such as scalds and flames that may occur in the home environment. It is difficult to determine the success of such methods, but the steady decline in burn-related injures over the ensuing years may be one way to measure its success. Table 1 shows several major historical fire events in US history, their causes, and the resultant legislative changes enacted to promote public fire safety. Some of the significant fires of note were the following.

Table 1
Historical fire events and the resultant safety legislation adopted as a result
Description of the Event Safety Codes or Standard Enacted
The Great Chicago Fire (1871) The Chicago Fire of 1871, also called the Great Chicago Fire, burned from October 8 to October 10, 1871 and destroyed thousands of buildings, killed an estimated 300 people and caused an estimated $200 million in damages. It is estimated that one-third of the city was destroyed by this fire. Fire and building codes in place for new spacing and construction materials required to be used for reconstruction.
The week of October 9th is known as National Fire Prevention Week marks the anniversary of this fire.
The Triangle Shirtwaist Fire, New York City, 1911 A fire in the rag bin spread from the rags to cutting tables and then to cloth patterns hanging on wire above the tables. Working conditions, locked doors, and lack of communication caused the deaths of 147 people. The New York City Fire Prevention Bureau was established. The first in the country, the bureau expanded the powers of the fire commissioner.
Publications regarding standardization of fire escape (exits) planning for factories, schools, department stores, and theaters were presented.
Coconut Grove Nightclub Fire – Boston (1942) More than 491 individuals died because of blocked or locked exits and overcrowding and flammable materials within the building. Advancement made in burn treatment (better comprehension of the treatment of inhalation injuries, fluid resuscitation, and the use of antibiotics).
Public safety (revolving doors required the addition of swing doors), disaster preparedness, no combustibles in places of assembly, battery-operated emergency lighting, and addition of codes to the Life Safety Code.
Ringling Brother’s Big Tent Fire (Also known as the Hartford Circus Fire of 1944) The cause of the fire is listed as “undetermined,” but an arsonist who was captured confessed to starting the fire and later recanted his story. A postfire investigation revealed waterproofing efforts (paraffin wax treated with 3 parts gasoline) had been recently applied to the canvas. A total of 168 individuals (two-thirds of them children) perished in the fire and hundreds were severely injured. It was thought the large amount of injuries and life loss was the result of the crowd rushing to the exits they had entered instead of using other exits. Two exits were blocked by animal cages. The waterproofing method of paraffin and gasoline were prohibited.
NFPA Standard 102 was developed (grandstands, folding and telescopic seating, tents, and membrane structures).
This code is also reflected in the 2000 International Building Code and 2003 NFPA 5000.
Our Lady of Angles School Fire, December 1958 Combustible interior finish work may have contributed to the fire spread. The investigative report of the fire indicated that inadequate facility exits may have contributed to the high number of deaths. Ninety students and 3 nuns died in this fire. The 1958 edition of the Building Exits Code provided for sprinklers in schools.
Reclassification of schools that may have different safety requirements.
The Beverly Hill Supper Club Fire, May 28, 1977 Inadequate training and preparedness of personnel, delayed notification, blocked exits, and noncompliance with codes contributed to this fire. A total of 164 people died. Sprinkler requirements for buildings having 4 or more stories required for new buildings (some retroactive for existing buildings).
Class A and class B buildings are required to be sprinklered throughout (applies only to new construction).
The Rhode Island Nightclub Fire, 2003 Pyrotechnics display ignited expanded foam plastic insulation after the band started to play. A total of 100 occupants perished and more than 200 were injured. It is ranked as the fourth deadliest nightclub fire in US history.
  • Changes made to fire and life safety codes in an effort to make public assembly occupancies safer.

  • Fire sprinklers must be installed in new nightclubs and similar assembly occupancies regardless of occupant load and in existing facilities that accommodate more than 100.

    • Building owners must inspect exits to ensure they are free of obstructions and must maintain records of each inspection.

    • At least 1 trained crowd manager must be present for all gatherings of more than 50, except religious services. (For gatherings of more than 250, additional crowd managers are required at a ratio of 1:250.)

    • Festival seating is prohibited for crowds of more than 250 unless a life-safety evaluation approved by the authority having jurisdiction has been performed. (Festival seating, according to NFPA 101, is a form of audience/spectator accommodation in which no seating, other than a floor or ground surface, is provided for the audience to gather and observe a performance.)

A fire at the Triangle Shirtwaist Company of New York was believed to have started in a rag bin on the evening of March 25, 1911. Hazardous working conditions, blocked exits, and poor communication played a role in the death of 147 workers. Codes enacted after this tragedy evolved into the National Fire Protection Association’s (NFPA’s) Life Safety Code 101. This code addressed the standardization of fire escape (exits) planning for factories, schools, department stores, and theaters.

The Coconut Grove Nightclub fire occurred on November 28, 1942 in Boston, Massachusetts. Because of a lack of sprinklers, blocked and locked exits, and other fire code violations, 492 individuals lost their lives. Significant advancement in the treatment of burns (comprehensive treatment of inhalation injuries, fluid resuscitation, and the use of antibiotics) and public safety initiatives (revolving doors must also have swing doors, disaster planning, and no combustibles in places of assembly) occurred as a result of this fire.

Two years later, on July 6, 1944, a fire occurred in the big tent of the Ringling Brother’s Circus in Hartford, Connecticut. This fire was thought to have occurred as a result of arson, but waterproofing efforts applied to the tents (coating with a mixture of paraffin and gasoline) may have contributed to the death of 168 individuals (two-thirds were children). Furthermore, blocked exits and a panicked crowd that headed for exits in which they entered (instead of more accessible exits) created congestion and slowed egress from the burning structure. New codes and standards initiated after this fire addressed the construction, location, protection, and maintenance of grandstands and bleachers. This code also affected seating facilities located in the open air or within enclosed or semienclosed structures such as tents, membrane structures, and stadium complexes.

The middle of the 20th century saw significant progress related to fire and burn prevention. For example, Congress passed the Flammable Fabrics Act in 1953. This act was designed to regulate the manufacture or sale of highly flammable clothing. Technology in the mid-1960s brought about the introduction of residential smoke alarms. Although considered to be expensive at the time of its introduction, smoke alarms served (and continue to present day) as early warning devices that alert consumers of a possible fire and permit early egress. In 1972, the independent federal regulatory agency known as the Consumer Products Safety Commission was founded by the Consumer Product Safety Act. In that law, Congress directed the Commission to “Protect the public against unreasonable risks of injury and deaths associated with consumer products.” Since its inception, the Commission has called for and removed many products that have proven to be dangerous to the public. Some products that may cause or have actually been related to a burn injury have been the focus of many such recalls. However, safety is not totally the responsibility of regulatory agencies or technologic advances. As the US and Canada become more culturally diverse, Fire and Life Safety professionals along with medical and public health officials recognize that everyone must work together to educate and ensure the safety of the general public.

Fire and burn prevention today

Fire and burn prevention initiatives of the last half of the 20th century have tended to focus on specific topics or behaviors. Campaigns such as National Fire Prevention Week, National Burn Awareness Week, and The National Scald Prevention Campaign are a few examples of such initiatives. These campaigns have encouraged consumer knowledge and participation in the proper installation and maintenance of smoke alarms and the setting of hot water heater temperatures, creating a safe home environment, and the practice of home escape planning in the event of a fire. A unique feature of these campaigns is the collaboration and inclusion of fire and life safety professionals. For example, fire fighters may canvass a targeted high-risk residential area to ensure that smoke alarms are installed properly. Fire safety education and a free home safety inspection may be offered during the installation process. Fire department personnel may also benefit by gathering previously unknown information about the home such as the presence of window bars (which may block a second means of egress in the event of a fire), home oxygen (which could accelerate fire growth or cause an explosion), or the health of the resident(s) (invalid, blind, deaf, or hard of hearing). Such information may assist fire personnel in designing their plan of action when answering an emergency call.

In addition to the aforementioned campaigns, formal fire and burn safety education curriculums have been promoted by national organizations such as the American Burn Association, the NFPA, the Centers for Disease Control and Prevention, the American Red Cross, Safe Kids Worldwide, and the United States Fire Administration. Each of these curriculums provides vital injury prevention education and advocacy to the general public and those considered at highest risk—the very young, older adults, and persons with disabilities. For example, The American Burn Association’s National Burn Awareness Week campaign focuses on a variety of fire and scald prevention topics aimed at specific high-risk groups. The NFPA’s Learn-Not-To-Burn and Learn-Not-To-Burn Preschool curriculums are designed to enhance preschool and elementary student’s knowledge and safety behavior regarding fire and burns. Another program offered by this organization (Remembering When) addresses fall, fire, and burn safety education targeted to the needs of the older adult. The Centers for Disease Control and Prevention offer key prevention safety tips and other resources that may be useful for the establishment of community-based safety programs. The American Red Cross and Safe Kids Worldwide offer a variety of fire and burn safety tips specifically aimed at the general public and caregivers for the very young, respectively. The United States Fire Administration encourages fire departments and other life safety organizations to increase community awareness about preventing home fires through the use of its Fire is Everyone’s Fight program.

The aforementioned prevention efforts may take many forms in the delivery of their messages. Most of these programs tend to follow the premise of the Injury Control Model (introduced through the public health model of injury prevention), the Five-Step Process (utilized by public health and other federal agencies) or the Five E’s of Prevention when creating and establishing safety and prevention programs. These models use tools and concepts that allow educators to thoroughly evaluate the problem, create an intervention strategy, and evaluate the results after implementation. Use of these models also ensures and promotes consistent messages and safety guidelines.

The Injury Control Model

The Injury Control Model has been in use since the 1950s and 1960s and was introduced by William Haddon, Jr, an engineer and public health physician. Haddon theorized that injury prevention depended on controlling the agent. He introduced the Haddon Matrix ( Table 2 ), which consisted of a framework that allowed for the identification of factors related to the host, agent, and environment. A guiding principle of injury control that emerged from Haddon’s work was that effective injury control (prevention) relied on a combination of intervention strategies. Haddon’s work was initially applied to motor vehicle safety and is credited with saving more than 300,000 lives from 1960 to 2002. Because the model provides a compelling framework for understanding the origins of the injury problems and identifying multiple countermeasures to address those problems, it has been adopted and used to develop other safety initiatives such as fire and burn prevention. Table 3 uses the Haddon matrix to address the problem of residential fires caused by cigarettes igniting upholstered furniture.

Table 2
Haddon matrix
Human Agent/Vehicle Environment
Physical Social
Pre-event Driver age, gender, experience, drug or alcohol use, vision, fatigue, frequency of travel, risk-taking behavior Vehicle speed, brakes, tires, road-holding ability, visibility (eg, daytime running lights) Road design and traffic flow, road conditions, weather, traffic density, traffic control (lights, signals), visibility Speed restrictions, impaired driving laws, licensing restrictions, road rage, seat belt and child restraint laws
Event Age, pre-existing conditions (eg, osteoporosis), restraint use Vehicle speed, size, crash-worthiness, type of seat belts, airbag, interior surface hazards Guardrails, median dividers, break-away poles, road-side hazards Enforcement of speed limits
Postevent Age, comorbidities Integrity of fuel system Distance from emergency medical care, obstacles to extrication Emergency medical services planning and delivery, bystander control, quality of trauma care, rehabilitation
Courtesy of The McGraw-Hill Companies, Inc; with permission; and From Western Journal of Emergency Medicine, Orange, CA. Need for injury-prevention education in medical school curriculum. Available at: westjem.com/articles/need-for-injury-prevention-education-in-medical-school-curriculum.html . Accessed July 28, 2016; and Runyan C. Using the Haddon Matrix: Introducing the third dimension. Inj Prev 1998;4(4):303; with permission.

Table 3
Haddon matrix applied to the problem of residential fires caused by cigarettes igniting upholstered furniture
Host (Children in Home) Agent/Vehicle (Cigarette, Matches, and Upholstered Furniture) Physical Environment (Home) Social Environment (Community Norms, Policies, Rules)
Pre-event (before fire starts) Teach children not to play with matches Redesign cigarettes so they self-extinguish before ignition of upholstery. Lower flammability of structures. Improve efforts to curb smoking initiation. Improve smoking cessation efforts.
Event (during fire) Teach children to stop, drop, and roll. Plan and practice a fire escape route with children. Teach children not to hide during a fire. Design furniture with materials that are less toxic when burned. Design upholstery that is flame resistant. Install smoke detectors. Install sprinklers. Increase number of usable exits. Pass ordinances requiring smoke detectors or sprinkler systems. Fund the fire department adequately to provide enough personnel and equipment for rapid response.
Postevent (after child injured by fire) Provide first aid and CPR training to all family members. Design heaters with quick and easy shutoff device. Build homes with less toxic building materials. Increase availability of burn treatment facilities.
Abbreviation: CPR, cardiopulmonary resuscitation.
Data from Runyan CW. Using the Haddon matrix: Introducing the third dimension. Inj Prev 1998;4(4):302–7.

The Five-Step Process

Beginning in the mid to late 1970s, injury prevention professionals recognized that the Haddon matrix did not fully address the safety needs faced by a changing society. Fire and burn safety awareness was greatly influenced by the publication of the report America Burning in 1973 and America Burning Recommissioned in 2000. This report laid the foundation that identified, among other things, (1) the need for the establishment of codes and standards, (2) fire protection planning programs, and, most importantly, (3) fire and life-safety education programs. Whereas the matrix continued to provide a blueprint for exploring the problem, newer initiatives such as the Five-Step Process and the Three E’s provided a step-by-step process approach as called for in the report. The Five-Step Process was created and first introduced by the US Fire Administration to specifically assist with public fire education programs. The process used a systemic step-by-step approach that assisted the educator in designing, implementing, and evaluating their specific community safety education programs. Unique to this process was the encouragement of public educators to collaborate with local community partners (ie, police, churches, senior centers, civic groups) to assist with gaining access to high-risk communities and support the implementation of their programs. The 5 steps consist of the following:

  • Step 1: Conduction of a community risk assessment

  • Step 2: Development of community partnerships

  • Step 3: Creation of an intervention strategy

  • Step 4: Implementation of strategy

  • Step 5: Evaluation of results

Fig. 1 lists the step-by-step components of implementation of the Five-Step Process.

Nov 21, 2017 | Posted by in Dental Materials | Comments Off on Burn Injuries
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