Downunder

Whilst I'm happy to contribute, the project sounds a little more than I could commit to at the moment, Ruffmeister. I'm doing data extraction for another researchers paper at the moment which is pretty full-on and am also involved in some communications with a nurse burn educator in the UK. Besides, I'm not a credentialed academic or educator and have no formal qualifications in burns management. I only have my paramedic and intensive care background plus my experiences researching for my paper and material for the organisation a ways back. Setting up a formal course would need to meet some established pre-requisites I should imagine as well as contact hours I mightn't be able to commit to as well. Sorry if I sound like I'm chickening out after making an offer. Is there an alternative so I could still provide something for the troops? Downunder

Well Ruffmeister, that sounds like an offer. I'm always happy to contribute. What did you have in mind? What's ceu class? Downunder Just to let you know - its nearly midnight here and I'm off to hit the sack. I'll have to leave it with you until tomorrow. I'm getting e-mail notes on post updates and I check my e-mails all the time so I won't miss any posts you put up. cheers Downunder

Hi Rfitz57, Could you clarify what you mean by "until the burning stops". Part of the confusion with cooling is the idea that someone will wet down patient to put out the flames if his clothes are on fire but this is different and I addition to 20mins of cooling which is a clinical treatment rather than a preventative measure to limit further immediate injury. Not all patients have flame burn injuries of course, although they are the most common in adults (around60%). You see this is part of the problem - there are so many generalities applied to pre-hospital burn care that confusion arise just from the semantics. I have made it my mission in life to nuance burn first aid and make each and every step specific, with a stated purpose and clinical end point attached. The days of just throwing "whatever" on the burn and driving fast to hospital have to end. But they won't until everyone is clear about terminology, chronology, histology and pathophysiology!! Every step in burn care means something - each step has to be done properly to specified protocols with clearly defined goals and ultimately - when someone is prepared to shell out the research dollars - analysed to see if it needs tweaking or even changing. Did you know burns account for only about 9% of all trauma cases but accounts for over 65% of all trauma healthcare costs?!! We have all these fancy procedures for trauma - RSI, ETT, Decompression of TPT, drugs, fluids, mast suits, lifting devices, spinal care but what in burns? Throw some water on (or don't if your paranoid about hypothermia but will make the patient worse through burn progression by not cooling) and any old dressing, as long as its reasonably clean. An IV some pain killers and fluids and that's it. Somethings got to give. Thanks for listening to my rant Downunder

Are you enjoying retirement is the only important question? Pre-hospital is a tough gig these days if for no other reason than the diabolical workload - too many people. I'd have preferred getting off the road myself (been at it 25) and had an educational deal signed and sealed. Of course my organisation had other ideas and promptly "restructured" our department. I was tossed back into road duties. Anyway. You enjoy your retirement and stay involved - there's lots of enthusiastic newbies out there who might need a steadying hand. Pearls of wisdom are hard to come by these days. cheers Downunder

Thanks Ruffmeister. The dry dressing approach seems to be unique to the US but is far from universal there -there are a multitude of approaches. SO the question really is -what is the best way? The existing evidence suggests cooling with water (for 20mins as a single block) and covering with Clingfilm ticks all the boxes. There seems to be a paranoia in the US about hypothermia in burns but this is true in all trauma of course. The problem is the pendulum has swung too far back the other way. You have to cool a burn injury for a number of reasons including pain relief, limiting burn progression and improving clinical outcomes in terms of healing and cosmetic benefits. These benefits are well demonstrated in studies. Covering the wound afterwards remains a mystery because non-one has put up the money to do some decent pre-hospital clinical trials. I'm no advocate of hydrogels in pre-hospital. They have been a runaway disaster in many respects yet they are everywhere. Why? If you refer to my post above you will see I mention a systematic review. Well I wrote it. There is no evidence to show hydrogels are better than cooling with water and dressing with Clingfilm. But dry dressing is almost as bad probably worse in fact. You achieve little by just covering a burn and pumping in loads of opiates, which will be required because of the lack of analgesic benefit from no water cooling. And the wound has to be sealed which is why Clingfilm is best. Excessive opiate use may also be contributing to fluid creep - worth a pubmed search on the subject. The burn first aid situation is a basket case - I've been working on it for 4 years. I've presented an oral at the ANZBA conference in 2011, written a document that changed our ambulance guidelines here in Australia and in combination with the oral talk changed ANZBA's (and probably has or will influence the BBA's) guidelines as well. I've also written a 36 page burns chapter in a new paramedic textbook and done the study I mentioned. I'm also collaborating with educators in the UK who are having the same problems with burn first aid the divergence of approaches in the US also suggests. Something's got to be done because paramedics really don't have much of a clue really. There is a lot of confusion and misunderstanding of what we are trying to achieve in pre-hospital burn management. cheers Downunder

Hi adultcare pro, Couldn't help but notice how much your remark sounds like a cut and paste from a hydrogel marketing spiel - no offence intended. So as we can understand why the mentioned benefits all sound good but don't really tell the whole story I'll take it one step at a time. For starters hydrogels are opaque - at least until recently with the biggest hydrogel player in the US announcing a change to its burn dressing formulation to make it -you guessed it clear. I haven't seen them yet so don't know HOW clear they really are. Anyway, the question to ask is why clear is good as far as a burns dressing goes and why this company now decides to make their own brand this way. Clear is an advantage for visualising the burn - great for ED docs and the burns specialists so as not to unnecessarily disturb the wound. Makes sense. This particular advantage is owned by - you guessed it - Clingfilm, now the post cooling dressing most recommended by the major burns associations. Coincidentally, a certain "independent researcher" who happens to also be the "clinical educator" for this same company wrote a piece in the "Journal of Paramedic Practice" (Dec 2014) - (published July 2015) deriding ever so cleverly and subtly the use of Clingfilm as a dressing after you cool the burn. As academic articles go this one is a shocker. Biased, poorly referenced, misleading commentary, conclusion's drawn without substantiation from studies and evidence etc. Gee what a coincidence. You see all the major burns associations are pushing cool running water as the best cooling method - so it should be - its the best supported by evidence (going as far back as 1936 (Rose) right through to the present day - Cuttle, Bartlett, Yuan, Venter, Nguyen etc.) This means many EMS are dumping hydrogels as a first line treatment at least for cooling at this stage but many are still ignorant enough to use it as a dressing and wonder why the patient gets cold - two lots of cooling you see. Imagine what happens as EMS also drift away from hydrogels to clingfilm as the preferred dressing - its certainly way cheaper and besides - the evidence for the best pre-hospital burns dressing is non existent. (see Wasiak, Cleland et al Burns dressings for superficial and partial thickness burns 2013). All this sounds like conspiracy stuff - sounds like a pretty good appraisal of the facts to me. Now as for, moist healing, granulation, epithelialisation, autolytic debridement - actually hydrogels (not the same kind we use in pre-hospital) are really good for these purposes - in post acute, hospital treatment -i.e. in the days and weeks after burn injury. So these benefits have no value in pre-hospital. As for the "high water content, cooling the wound and providing pain relief up to 6 hours": a) clean running water has way more "water content" b)water has been shown to cool the burn wound far more effectively than hydrogels the temperature drop in the wound almost double that of hydrogels - (see Yuan, Bartlett, Venter from memory) c) I would be delighted if you could show me the study/studies demonstrating pain relief from hydrogels last up to 6hrs. And how the "pain relief" has been quantified. Well you need an analogue pain scale for that. Unfortunately -no-one has done one in pre-hospital and to he best of my knowledge no-one has done one in hospital (using the same kind of hydrogel dressing we use in EMS. Zippo studies. Now the spiel you presented comes straight from a particular "monograph" from memory and the company managed to scrounge as many articles as they could find that actually said anything good about hydrogels. Remember I said earlier - the best dressing choice is still up in the air -in hospital even (Wasiak). Hydrogels have an important role to play don't get me wrong. They are already of much interest in hospital settings, but different types, used for different reasons. As for pre-hospital - they may well yet serve a valuable role but at the moment there is no evidence they are better than running water and clingfilm. In closing, I'll point you to this paper which has been published in a reputable peer reviewed journal: "The efficacy of hydrogel dressings as a first aid measure for burn wound management in the pre-hospital setting: a systematic review of the literature". The International Wound Journal. kind regards Downunder

Hi Trackmedic What region of the states are you in if I may ask and does your local protocol reflect a state wide consensus or just your medical directors mandate? I am aware only 50% of US states even have statewide guidelines. I have written several documents on the burns subject including a systematic review on hydrogels in burn first aid published in the international wound journal. On your own protocol of dry management of burns in EMS first aid -is that philosophy driven by concerns over hypothermia due to cooling? Thanks for your reply. Downunder

Hi everyone, Haven't been around for a while. Have spent the last few years in the burns area. Am interested to know how many of your local agencies employ Hydrogel burn dressings (eg WaterJel, Burnshield, Burnfree etc) as the primary first aid treatment for your burn patients. Cheers Downunder