WEBVTT - Ep 213 Burns Part 2: It’s like sci-fi but real 0:00:00.240 --> 0:00:04.680 This episode features descriptions that some listeners might find upsetting. 0:00:04.760 --> 0:00:06.120 Please listen with discretion. 0:00:07.520 --> 0:00:10.040 Hi, I'm Emma. In May of twenty twenty, I was 0:00:10.080 --> 0:00:13.320 working at my job as a bookbinder when a machine 0:00:13.440 --> 0:00:16.639 error caused my dominant hand to be crushed and burned 0:00:16.720 --> 0:00:20.400 inside a machine used for stamping foil designs onto book covers. 0:00:21.320 --> 0:00:23.640 That day, I went to the er for treatment, where 0:00:23.680 --> 0:00:27.000 I also got to have my first covia test. About 0:00:27.000 --> 0:00:30.720 a week later, I had my first surgery. The first 0:00:30.800 --> 0:00:34.360 procedure was extensive wound abreadment that couldn't have been achieved 0:00:34.360 --> 0:00:38.320 while I was awake, and the application of homographed, which 0:00:38.360 --> 0:00:42.120 is essentially a very fancy band aid that's cadaver skin. 0:00:42.840 --> 0:00:45.600 A couple of days later, after allowing the wound site 0:00:45.640 --> 0:00:49.239 to calm down a little bit, the homograft was removed 0:00:49.400 --> 0:00:53.920 and something called BTM, or biodegradable temporizing matrix was placed 0:00:53.920 --> 0:00:58.360 on the burn site. BTM is an incredible innovation. It's 0:00:58.440 --> 0:01:01.120 basically a sort of foam that acts as a structure 0:01:01.200 --> 0:01:04.880 for the body to rebuild tissue into over time. Over 0:01:04.920 --> 0:01:08.120 a period of several months, the BTM then dissolves, leaving 0:01:08.280 --> 0:01:11.640 just the newly grown tissues. After the BTM was placed, 0:01:11.680 --> 0:01:13.800 I went home for about a month to allow the 0:01:13.840 --> 0:01:17.080 sites to mature. During this time, I had to rinse 0:01:17.120 --> 0:01:19.720 the wound and the BTM every four hours with dake 0:01:19.760 --> 0:01:23.360 In solution, which is a diluted bleach concoction that's been 0:01:23.360 --> 0:01:26.199 in use since the Civil War for wound care. After 0:01:26.240 --> 0:01:28.960 a month, I went in for my third and final surgery. 0:01:29.280 --> 0:01:31.600 My surgeon took a skin graft from the right guy 0:01:32.120 --> 0:01:35.160 and applied it to the matured BTM. Watching the graft's 0:01:35.160 --> 0:01:37.440 heel and adhere to the healthy tissue around the wound 0:01:37.520 --> 0:01:41.600 site was really incredible and honestly felt miraculous. I eventually 0:01:41.880 --> 0:01:45.600 was made custom compression gloves and got to attend hand therapy, 0:01:46.040 --> 0:01:48.640 and about three months after my injury, I was able 0:01:48.640 --> 0:01:51.440 to return to work. But never fear. I don't work 0:01:51.480 --> 0:01:54.160 on that machine anymore. We keep a distance from each other. 0:01:54.600 --> 0:01:56.880 I'm very happy to say that I've had a really 0:01:56.880 --> 0:02:00.000 good outcome. I'm very fortunate to have an incredible risk 0:02:00.240 --> 0:02:02.720 of motion and good strength in my hand, to the 0:02:02.760 --> 0:02:04.880 point that I don't have to think about my injury 0:02:04.960 --> 0:02:08.360 most days. Dealing with the immediate aftermath of a burn 0:02:08.520 --> 0:02:09.480 is really difficult. 0:02:09.840 --> 0:02:16.160 I dealt with nausea, fatigue, lack of appetite, pain, discomfort, fear, 0:02:16.520 --> 0:02:20.080 and a lot of isolation, especially during my long hospital 0:02:20.160 --> 0:02:23.240 stays during COVID, I had a lot of support and 0:02:23.360 --> 0:02:27.000 care from my family, especially my parents who allowed me 0:02:27.040 --> 0:02:28.120 to stay with them and. 0:02:28.080 --> 0:02:31.360 Took care of a lot of really extensive wound care, 0:02:32.240 --> 0:02:36.520 my coworkers who visited and checked in on me frequently, 0:02:37.160 --> 0:02:40.080 and a really fantastic medical team that went above and 0:02:40.160 --> 0:02:43.639 beyond in caring for me. It took at least a 0:02:43.760 --> 0:02:46.480 year after my final surgery to begin to feel like 0:02:46.560 --> 0:02:49.480 I was returning to normalcy. But I also had a 0:02:49.680 --> 0:02:54.400 very small burned area, about one percent TBSA or total 0:02:54.400 --> 0:02:58.360 body surface area. I have so much respect and empathy 0:02:58.400 --> 0:03:01.320 for those that are recovering from large and the strength 0:03:01.320 --> 0:03:04.560 it takes to endure that every day. I also want 0:03:04.600 --> 0:03:08.079 to take a moment to recognize and emphasize the importance 0:03:08.400 --> 0:03:13.480 of workers compensation. Without workers' compensation, the cost for burn 0:03:13.600 --> 0:03:19.160 treatment and wound care supplies would have been astronomical. It's 0:03:19.200 --> 0:03:23.840 so important that workers have access to medical care and 0:03:24.000 --> 0:03:27.800 financial support to help them recover from injury. Sustained at 0:03:27.840 --> 0:04:09.240 work and receive long term care for any lingering complications. 0:04:18.279 --> 0:04:21.080 Emma, thank you, thank you so much for sharing your 0:04:21.080 --> 0:04:24.080 story with us. It is so meaningful, like and you 0:04:24.200 --> 0:04:29.680 hit on such a number a number of incredibly important points. Yeah, 0:04:29.720 --> 0:04:33.120 and we just really appreciate you being willing to relive 0:04:33.160 --> 0:04:34.440 that and I know, and. 0:04:34.480 --> 0:04:36.400 Go through it all and share it with us and 0:04:36.400 --> 0:04:37.680 share it with all of our listeners. 0:04:37.800 --> 0:04:39.080 Thank you, Yeah, thank you. 0:04:39.920 --> 0:04:40.120 Hi. 0:04:40.360 --> 0:04:42.360 I'm erin Welsh. 0:04:41.640 --> 0:04:43.400 And I'm erin Allman Updike. 0:04:43.160 --> 0:04:46.400 And this is this podcast will kill you. Welcome back 0:04:46.680 --> 0:04:50.680 to Burns. Welcome Back Burns Part two. We're here, We're here. 0:04:51.440 --> 0:04:54.360 This is the episode where if you didn't listen to 0:04:54.440 --> 0:04:57.119 the first episode, go check it out, because it really 0:04:57.160 --> 0:05:00.600 does lay some important groundwork for what burn are, how 0:05:00.640 --> 0:05:04.360 we measure the severity, what's going on, and I mean 0:05:04.440 --> 0:05:07.400 really the treatment of burns throughout most of human history, 0:05:07.520 --> 0:05:11.919 which is yeah, kind of which is grim, grim, it 0:05:12.000 --> 0:05:16.000 really is. But this episode is where things turned around. 0:05:16.880 --> 0:05:20.400 So yeah, today we're talking how we have figured out 0:05:20.440 --> 0:05:24.400 how to treat burns in modern times and how we 0:05:24.440 --> 0:05:25.479 treat them today. 0:05:25.440 --> 0:05:28.640 And how we treat them today. Yeah, it's pretty it 0:05:28.839 --> 0:05:32.160 just it It's one of those topics that makes me go, 0:05:33.120 --> 0:05:36.120 can you believe how far like medicine is so cool? 0:05:36.200 --> 0:05:37.320 Science is so cool. 0:05:37.520 --> 0:05:39.600 I feel like it's one of the topics. Wow, this 0:05:39.640 --> 0:05:41.400 is gonna get too niche. I just thought of this, 0:05:41.480 --> 0:05:43.800 but it's one of the topics that makes that would 0:05:43.800 --> 0:05:47.599 make doctor who be like humans? You know how Doctor 0:05:47.600 --> 0:05:50.200 Who Humans? 0:05:50.880 --> 0:05:51.680 That's adorable. 0:05:52.040 --> 0:05:56.880 Yes, yes, yes, anyways, anyways, before we can do any 0:05:56.920 --> 0:05:58.719 of that, it's quarantiney time. 0:05:58.800 --> 0:06:01.560 It is. We're drinking the same thing that we drank 0:06:01.640 --> 0:06:05.719 last week, which is a non alcoholic Beasneys that we're 0:06:05.800 --> 0:06:12.960 calling by degrees and listen. We're not equipped to create 0:06:13.000 --> 0:06:16.920 a new cocktail recipe every week. We're in the hundreds 0:06:16.920 --> 0:06:20.320 of episodes now listen, and so we drink it. We're 0:06:20.440 --> 0:06:25.480 making we're borrowing from established knowledge, which is Besney's. 0:06:26.240 --> 0:06:28.360 So you can find the full recipe on our website, 0:06:28.400 --> 0:06:31.159 this Podcastwekilia dot com, and on all of our social 0:06:31.160 --> 0:06:32.039 media channels. 0:06:32.120 --> 0:06:35.039 You can. We didn't mention this, but it is honey 0:06:35.080 --> 0:06:38.280 and lemon and non alcoholic gin and it's great. And 0:06:38.560 --> 0:06:41.080 on our website, which is also great, you can find 0:06:41.279 --> 0:06:44.680 lots of things like transcripts, you can find links to 0:06:44.880 --> 0:06:47.880 merch links to our bookshop dot Org affiliate page, our 0:06:48.000 --> 0:06:53.080 Goodreads list, music by Bloodmobile, first hand account form, contact 0:06:53.200 --> 0:06:57.880 us form, and about us page that hasn't seen an 0:06:57.920 --> 0:07:00.359 update in a number of years and doesn't have that 0:07:00.440 --> 0:07:04.200 much information anyway, so to see what information is provided, 0:07:04.400 --> 0:07:08.760 check it out. You really sold that about us page? There? 0:07:10.240 --> 0:07:12.480 Do we even have like the start date of the podcast, 0:07:12.520 --> 0:07:14.200 which still blows my mind that we are in our 0:07:14.640 --> 0:07:16.200 ninth year of doing. 0:07:15.960 --> 0:07:18.800 This, I know, No, we don't have that on there. 0:07:19.400 --> 0:07:21.160 It might say that we're still in grad school, which 0:07:21.200 --> 0:07:22.880 is quite out of date. 0:07:22.960 --> 0:07:28.520 No, we graduate updated twenty eighteen. Yeah, yeah, listen. Anyways, anyways, 0:07:28.800 --> 0:07:33.640 let's get to the episode itself. Let us right after 0:07:33.680 --> 0:07:52.600 this break. Last week I took us through the history 0:07:52.600 --> 0:07:56.400 of burns from before humans were humans until the late 0:07:56.440 --> 0:07:59.760 eighteen hundreds early nineteen hundreds, which is quite a lot 0:07:59.760 --> 0:08:02.760 of time to cover just a few millennia, I think. 0:08:02.840 --> 0:08:04.800 I I think the earliest thing I mentioned was like 0:08:04.800 --> 0:08:08.280 four hundred million years ago fire was possible on this planet. 0:08:08.640 --> 0:08:13.680 So but for that entire time that we covered, burns 0:08:13.920 --> 0:08:18.960 remained pretty much beyond the reach of medicine in nineteen hundred, 0:08:19.480 --> 0:08:23.160 those who were under sixty one years of age who 0:08:23.200 --> 0:08:25.880 had burns covering more than twenty five percent of the 0:08:25.880 --> 0:08:33.320 body surface. Of those, one hundred percent died. Wow. One 0:08:33.760 --> 0:08:40.199 percent in nineteen hundred, twenty five percent total body surface area. Wow, 0:08:40.200 --> 0:08:42.200 in adults under fifty under sixty one. 0:08:43.440 --> 0:08:45.800 But it's actually interesting that it's not also an adults 0:08:45.800 --> 0:08:47.520 over age sixty one. But I wonder if they're just 0:08:47.559 --> 0:08:48.640 weren't that many of them? 0:08:49.840 --> 0:08:52.239 I mean, I'm sure that there were. I don't know why. 0:08:52.280 --> 0:08:55.920 I think because mortality even increases further at that point, 0:08:56.080 --> 0:08:58.360 but it doesn't. Okay, how can it increase beyond one 0:08:58.400 --> 0:09:00.280 hundred percent. I'm not sure why that. 0:09:00.280 --> 0:09:02.559 It might be a lower body surface area even or 0:09:02.600 --> 0:09:04.760 something like that. I think because age is a big 0:09:04.800 --> 0:09:07.920 part of it. Oh my god, though that's horrific. Yep, yep, 0:09:08.000 --> 0:09:11.360 that's very different than today. Just so everyone's aware. 0:09:11.520 --> 0:09:14.000 Well, and that's sort of what I wanted to kind 0:09:14.040 --> 0:09:18.679 of establish where where things stood in nineteen hundred. Yeah, 0:09:18.800 --> 0:09:25.160 fifty years later, nineteen fifty, nearly seventy percent survived. Wow. 0:09:25.320 --> 0:09:28.280 So the mortality had gone down to thirty percent, from 0:09:28.320 --> 0:09:32.319 one hundred percent to thirty percent. That's huge, that's huge, 0:09:33.080 --> 0:09:38.480 It's unfathomable. Yeah, yeah, wow. In those fifty years, burn 0:09:38.559 --> 0:09:43.240 care had undergone a profound revolution, and we've continued to 0:09:43.240 --> 0:09:46.640 make tremendous strides up through the present day. And I'm 0:09:46.640 --> 0:09:49.440 going to leave those present day strides to you, Aarin, 0:09:49.520 --> 0:09:52.240 And what I want to focus on instead is those 0:09:52.440 --> 0:09:57.200 fifty or so years what changed in medicine to drive 0:09:57.360 --> 0:10:01.680 such a transformation. There was no oh, single moment or breakthrough, 0:10:01.840 --> 0:10:06.080 but there were many. There was skin grafting, antiseptic technique, 0:10:06.400 --> 0:10:11.959 fluid balance and nutritional support, antibiotics, and airway management. Really 0:10:12.080 --> 0:10:15.920 it was through integrating all of these medical advancements, through 0:10:15.960 --> 0:10:19.800 the formation of burn care as a specialized approach, that 0:10:19.840 --> 0:10:24.079 the scales finally tipped. The survival rates that this integrated 0:10:24.120 --> 0:10:28.480 management could now achieve were beyond the imagination of any 0:10:28.480 --> 0:10:33.959 physician in past centuries. Like I imagine someone trying to treat 0:10:34.000 --> 0:10:36.600 someone with a burn in like fifteen hundred and then 0:10:36.679 --> 0:10:41.480 coming today to a burn center and just just like 0:10:41.679 --> 0:10:44.640 chills that. It's amazing to think about how much. 0:10:44.520 --> 0:10:45.800 The opposite of Outlander. 0:10:46.559 --> 0:10:52.000 Yes, yeah, here's some moldy bread, we'll try that out. Yeah, yeah. Yeah, 0:10:52.640 --> 0:10:55.000 But so what I want to do today is take 0:10:55.080 --> 0:10:59.520 us through how that happened piece by piece skin grafts 0:10:59.559 --> 0:11:03.960 and burn excision. Okay, So these approaches date back to 0:11:04.160 --> 0:11:07.920 ancient times. For instance, in the fifth century CE, Sushruda, 0:11:08.000 --> 0:11:11.440 the famous surgeon from ancient India, described how he treated 0:11:11.480 --> 0:11:14.360 amputated noses by taking a flap of skin from the 0:11:14.400 --> 0:11:17.320 forehead and then later the butt and then grafting it 0:11:17.440 --> 0:11:22.080 over the nose wound. Fascinating. Yeah, So skin grafting in 0:11:22.120 --> 0:11:25.720 that way has very very deep roots. Wow. And from 0:11:25.760 --> 0:11:29.280 this point until the eighteen hundreds, a few physicians had 0:11:29.320 --> 0:11:32.360 tried their hand at grafting over the centuries, with varying 0:11:32.440 --> 0:11:36.000 rates of success. Allegedly, the first rhinoplasty I think was 0:11:36.000 --> 0:11:39.679 performed in the sixteen hundreds or sixteenth century, I can't remember, Okay, 0:11:39.760 --> 0:11:42.960 like a while ago, Yeah, a while ago. Yeah. But 0:11:43.200 --> 0:11:46.800 still it was very much touch and go, not very 0:11:47.320 --> 0:11:49.320 It was definitely more of an art that a science, 0:11:50.000 --> 0:11:53.720 and things turned around in the eighteen hundreds. The early 0:11:53.800 --> 0:11:56.840 part of the century saw a few surgeons experimenting with 0:11:56.880 --> 0:12:00.559 skin grafting in animals, which showed some promise, but more 0:12:00.600 --> 0:12:04.920 importantly those experiments helped to clarify some crucial concepts about 0:12:05.200 --> 0:12:09.199 tissue death, circulation, and immune rejection. What's actually going on 0:12:09.600 --> 0:12:13.040 in the wound healing process, and what's necessary for the 0:12:13.080 --> 0:12:15.520 skin graft to actually take right. 0:12:15.600 --> 0:12:18.439 What is it that determines whether or not this one 0:12:18.520 --> 0:12:19.880 is going to work versus that one? 0:12:20.120 --> 0:12:24.080 Yep, yeah, okay. In eighteen sixty nine, inspired by these 0:12:24.160 --> 0:12:28.719 animal experiments, Swiss surgeon Jacques Louis Reverden, who was still 0:12:28.760 --> 0:12:32.520 a medical intern at the time, transplanted a tiny slice 0:12:32.520 --> 0:12:36.240 of skin into the middle of a wound, free skin grafting, 0:12:36.440 --> 0:12:40.439 no skin flaps required, so finding success with this, he 0:12:40.559 --> 0:12:43.600 varied his approach to see what was possible your own skin, 0:12:44.120 --> 0:12:46.719 skin from another human related to you, skin from a 0:12:46.800 --> 0:12:49.760 human not related to you, skin from another species. Just 0:12:49.960 --> 0:12:53.680 let's run the full gamut here. This free skin grafting 0:12:53.720 --> 0:12:57.480 technique was first applied to burns in eighteen seventy when 0:12:57.559 --> 0:13:00.360 a surgeon named G. D. Pollock treated his eight year 0:13:00.400 --> 0:13:03.959 old patients thigh burn by transplanting skin from her abdomen 0:13:04.040 --> 0:13:07.680 to the wound, and after six weeks the grafts looked 0:13:07.800 --> 0:13:12.959 pretty excellent, which is kind of incredible. Yeah, skin grafting 0:13:13.040 --> 0:13:17.800 became really popular and other surgeons refined various techniques like 0:13:17.880 --> 0:13:20.839 the split thickness skin graft where you take bits of 0:13:20.880 --> 0:13:24.319 the dermis along with the epidermis, and this technique promoted 0:13:24.400 --> 0:13:29.400 faster healing and less scar formation, which reduced scar contractures, 0:13:29.440 --> 0:13:31.040 which also you'll talk about. 0:13:30.800 --> 0:13:31.040 I know. 0:13:32.120 --> 0:13:35.320 And skin grafting proved to be a major advancement in 0:13:35.400 --> 0:13:39.520 burn care, and physicians also noticed that wounds healed much 0:13:39.559 --> 0:13:43.840 more quickly and completely when that burned tissue was removed beforehand. 0:13:44.640 --> 0:13:46.720 So that was where sort of the excision comes in, 0:13:46.760 --> 0:13:50.080 which people had experimented with in the past, but it 0:13:50.160 --> 0:13:52.439 kind of became more of like this seedms to be 0:13:52.480 --> 0:13:55.760 a routine part of things, right, age is actually helping, 0:13:55.920 --> 0:14:00.240 this is helpace. Was it was debated, yeah, okay, oh. 0:14:00.800 --> 0:14:05.000 By the early nineteen hundreds, grafting and burn decision with 0:14:05.120 --> 0:14:08.320 a wound decision was they were pretty well established techniques. 0:14:09.200 --> 0:14:13.240 But no matter how skillfully you grafted or debrided, if 0:14:13.280 --> 0:14:17.480 your instruments weren't clean, if the wound wasn't clean, infection 0:14:17.760 --> 0:14:22.720 often led to death. Aniseptic technique. This is like a 0:14:22.760 --> 0:14:25.520 mini history of many different medicine. 0:14:25.640 --> 0:14:29.320 Yeah, like the thing is that revolutionized all of medicine 0:14:29.400 --> 0:14:31.000 also revolutionized burd mars the. 0:14:31.640 --> 0:14:37.560 Surprise, surprise, Yeah, okay, so antiseptic technique. For centuries, surgery 0:14:37.920 --> 0:14:41.560 of any kind remained a last resort, an act of desperation. 0:14:42.360 --> 0:14:45.400 Before science and medicine had connected the dots between dirty 0:14:45.440 --> 0:14:49.280 instruments and deadly infections, anyone bold enough to go into 0:14:49.320 --> 0:14:55.120 surgery believed that the best surgeons wore the bloodiest, filthiest coats. 0:14:55.160 --> 0:14:57.160 So gross to think of it. It was like, Wow, you've 0:14:57.200 --> 0:14:59.960 got some experience. How many people have you operated on today? 0:15:00.280 --> 0:15:03.640 Fifteen and you haven't rinsed your hands once? That's what 0:15:03.680 --> 0:15:05.360 I want in a surgeon. 0:15:06.400 --> 0:15:09.600 No, no, thank you, please. 0:15:09.480 --> 0:15:15.880 No, no thankfully. Joseph Lister see our Sepsis Episode revolutionized 0:15:15.920 --> 0:15:19.000 surgery in the eighteen fifties with his recognition that if 0:15:19.000 --> 0:15:22.680 you operated with cleaning surgical tools and you cleaned the wound, 0:15:23.120 --> 0:15:27.360 your patients were less likely to die his solution of choice. 0:15:27.360 --> 0:15:30.680 His antiseptic solution of choice was carbolic acid, often mixed 0:15:30.720 --> 0:15:33.800 with vaziline for use in burn patients to reduce the 0:15:33.840 --> 0:15:37.760 pain of having acid rubbed into your wound. Yeah, okay. 0:15:38.440 --> 0:15:41.920 Later during World War One, other antiseptic solutions were developed, 0:15:41.960 --> 0:15:44.880 like boric acid, acetic acid, and a twenty five percent 0:15:44.960 --> 0:15:49.920 solution of sodium hypochlorite also called Dakin solution. Still use 0:15:49.960 --> 0:15:54.720 that today, Still use that today. Antiseptic technique was a 0:15:54.880 --> 0:15:58.320 major step forward in reducing infections and deaths following surgery, 0:15:58.360 --> 0:16:02.120 such as removing burnt tissue or performing skin graphs, and 0:16:02.440 --> 0:16:05.480 the same principles were used for wound management in burn 0:16:05.560 --> 0:16:09.680 patients even if they didn't have surgery. Because your skin, 0:16:09.840 --> 0:16:15.280 as you've talked about, is a barrier to infection. When 0:16:15.320 --> 0:16:18.960 that barrier is disrupted, it leaves it super vulnerable to infection. 0:16:19.120 --> 0:16:20.920 And so if you can find a way to decrease 0:16:20.920 --> 0:16:26.680 that vulnerability through aniseptic ointments, antimicrobial ointments, bandages that are 0:16:26.720 --> 0:16:33.160 infused with antiseptic components, stuff stuff. These things are integral 0:16:33.280 --> 0:16:37.200 in improving outcomes for those who have burns, both minor 0:16:37.280 --> 0:16:42.440 and major. By reducing infection through aniseptic technique and these 0:16:42.480 --> 0:16:46.800 specialized ointments, physicians could chip away at one major major 0:16:46.840 --> 0:16:52.640 source of mortality for burns, but other threats remained. Fluid 0:16:52.640 --> 0:16:56.440 balance and nutritional support. Yeah, yeah, this is a big one, 0:16:57.680 --> 0:17:00.840 more than I realized. I think, despite having rewatched all 0:17:00.880 --> 0:17:03.320 of ER, I don't think it really hit home to 0:17:03.400 --> 0:17:06.960 me how important this part of it was. As though 0:17:07.240 --> 0:17:11.639 ER is a super super accurate It's like I'm saying, 0:17:11.720 --> 0:17:18.960 despite med school to bite er same same. Over the centuries, 0:17:19.119 --> 0:17:21.960 a handful of physicians had noticed that providing a burn 0:17:22.000 --> 0:17:26.200 patient with lots of replenishing fluids and food seemed to help. 0:17:26.960 --> 0:17:29.320 But this was very much against the beliefs of the day. 0:17:29.840 --> 0:17:33.520 Things like blood letting and purging were still the standard 0:17:33.640 --> 0:17:37.920 for centuries, and it wasn't really until the late eighteen hundreds, 0:17:37.960 --> 0:17:40.760 the late eighteen hundreds that doctors began to crack the 0:17:40.800 --> 0:17:43.240 code on fluid balance and nutritional support. 0:17:43.680 --> 0:17:44.160 Wow. 0:17:44.520 --> 0:17:47.760 And it started when a few doctors observed that the 0:17:47.840 --> 0:17:51.920 renal failure in burn patients looked very similar to that 0:17:51.920 --> 0:17:56.719 that they observed in cholera patients. Oh yeah, or their 0:17:56.760 --> 0:17:59.879 bodies were extremely dehydrated and they just their fluid balance 0:17:59.920 --> 0:18:03.560 was not it was in super imbalance. I guess right. 0:18:03.560 --> 0:18:05.800 They're losing tons of fluid and they're losing tons of 0:18:05.800 --> 0:18:09.600 electrolytes because they're pooping pure water's at a time in cholera, 0:18:10.720 --> 0:18:12.960 and that totally makes sense because the same thing is happening. 0:18:13.000 --> 0:18:16.320 It's just going out through this surface area that you 0:18:16.400 --> 0:18:17.960 have lost from your skin. 0:18:18.200 --> 0:18:21.880 Yep. Fascinating. Yeah, that was sort of like the first 0:18:21.920 --> 0:18:25.440 little light bulb of moment. And then one doctor went 0:18:25.520 --> 0:18:29.760 further and discovered in eighteen ninety three that blisters and 0:18:29.840 --> 0:18:34.120 burned tissues were filled with plasma, meaning that fluid, that 0:18:34.160 --> 0:18:36.560 fluid was not where it should be. And so it 0:18:36.640 --> 0:18:39.720 was like, oh, this is the same thing. It's just 0:18:40.040 --> 0:18:42.840 longs in our blood lung somewhere else, not we're in 0:18:42.880 --> 0:18:46.520 the blister. Yeah. And some people then tinkered around with 0:18:46.600 --> 0:18:51.840 fluid replacement with saline administered orally, rectly or intravenously, But 0:18:51.920 --> 0:18:54.800 it wasn't really until World War One that the technique 0:18:54.880 --> 0:18:58.119 was refined, and not until nineteen twenty one that it 0:18:58.160 --> 0:19:02.120 was applied systematically to burn patients. Okay, so that year 0:19:03.119 --> 0:19:06.560 a fire broke out at the rialto Theater in New Haven, Connecticut, 0:19:06.760 --> 0:19:10.399 and a professor at Yale, Frank Underhill, saw that the 0:19:10.440 --> 0:19:13.440 composition of fluid and blisters was the same as plasma, 0:19:13.840 --> 0:19:16.880 and loss of those compounds, he suspected is what led 0:19:16.920 --> 0:19:20.479 to shock in burn patients, and so he was like, 0:19:20.680 --> 0:19:25.080 I think that this is actually causing that fluid loss 0:19:25.119 --> 0:19:29.600 is causing mortality in burn patients. It's not toxins. So 0:19:29.640 --> 0:19:33.800 previously it was believed that toxins were the thing that 0:19:33.880 --> 0:19:36.560 killed people, which it can still be if you think 0:19:36.560 --> 0:19:41.119 of toxins as like bacterial infection or fung infact, that. 0:19:41.119 --> 0:19:45.200 Would be more usually later rather than like immediately following. 0:19:45.400 --> 0:19:47.720 Yeah, So he's like, this is an emergency, Like, this 0:19:47.760 --> 0:19:51.040 is what's happening right now, fluid loss. We can we 0:19:51.080 --> 0:19:54.119 treat fluid loss. I mean this was a huge step 0:19:54.160 --> 0:19:58.120 forward because fluid loss could be reversed by providing saline 0:19:58.119 --> 0:20:02.639 solution with protein intravenously, and later work in this area 0:20:02.840 --> 0:20:06.040 led to formulas to quantify how much fluid was needed 0:20:06.040 --> 0:20:08.000 depending on the age and the size of the person 0:20:08.040 --> 0:20:10.320 and the surface area and the depth of their burn. 0:20:11.480 --> 0:20:15.520 About a decade after the rialto Theater fire, which happened 0:20:15.520 --> 0:20:18.440 in nineteen twenty one, physicians began to notice that burn 0:20:18.520 --> 0:20:22.640 patients also needed an increased caloric intake, and that extreme 0:20:22.760 --> 0:20:25.040 loss of lean body mass put them at high risk 0:20:25.119 --> 0:20:29.359 for poor outcomes. So death decreased wound healing, impaired immunity, 0:20:29.400 --> 0:20:32.439 and so on. So the nitty gritty of how to 0:20:32.560 --> 0:20:36.240 best provide adequate nutrition and calories that took decades to 0:20:36.280 --> 0:20:40.240 figure out or again consensus on, but the recognition of 0:20:40.280 --> 0:20:48.720 this issue was absolutely critical. Next up is antibiotics. Antisepsis 0:20:48.720 --> 0:20:52.919 and antimicrobial dressings were a huge step forward, but they 0:20:52.960 --> 0:20:57.720 didn't always entirely prevent infection. The development of penicillin in 0:20:57.760 --> 0:21:00.159 the early nineteen forties, I mean, it was discovered in 0:21:00.240 --> 0:21:02.560 nineteen twenty eight, but it wasn't widely available until the 0:21:02.560 --> 0:21:06.080 war ended in nineteen forty five, and then later broad 0:21:06.160 --> 0:21:10.040 spectrum antibiotics. This really helped to control infection when it 0:21:10.080 --> 0:21:13.520 did arise in burn patients. One of the very first 0:21:13.760 --> 0:21:16.679 uses of penicillin in the general public was, in fact, 0:21:16.800 --> 0:21:20.840 after the Coconut Grove nightclub fire in Boston on November 0:21:20.880 --> 0:21:26.240 twenty eighth, nineteen forty two. Huh, Yeah, I didn't know that. Yeah, 0:21:26.480 --> 0:21:29.640 I think I feel like I remember talking about it 0:21:30.080 --> 0:21:32.560 in our Antibiotics episode, and you. 0:21:32.600 --> 0:21:39.320 Probably what that was season three years so I remember it. No, no, 0:21:39.760 --> 0:21:43.320 But Coconut Grove sounds vaguely familiar, though, isn't it. 0:21:43.600 --> 0:21:45.679 Yeah, Okay, but yeah, so that was the first time 0:21:45.720 --> 0:21:48.960 that penicillin was used to see if it improved. And 0:21:49.000 --> 0:21:51.840 I don't think I think that the data were not 0:21:52.160 --> 0:21:55.920 strong enough to see did this actually help anything. Yeah, 0:21:55.960 --> 0:21:57.280 there was a lot of still a lot of other 0:21:57.320 --> 0:22:00.280 things that needed to be figured out. But but this 0:22:00.440 --> 0:22:04.080 tragedy also led to the refinement of fluid replacement calculations 0:22:04.520 --> 0:22:08.160 and the recognition of airway injuries after a fire. Yeah, 0:22:08.480 --> 0:22:11.879 and so but since since then, since this nightclub fire, 0:22:12.160 --> 0:22:16.560 antibiotics have often been employed in treating systemic infections that 0:22:16.600 --> 0:22:20.640 arise after a burn, or used prophylactically to prevent infection 0:22:20.720 --> 0:22:24.320 in the first place. But their use in burn patients 0:22:24.359 --> 0:22:28.199 can be tricky. So, first, antibiotic resistance is a major problem, 0:22:28.320 --> 0:22:33.560 especially for certain types of bacteria found after burns, like pseudomonous. Yeah, 0:22:33.600 --> 0:22:37.760 and antibiotic use can also lead to other opportunistic pathogens 0:22:37.800 --> 0:22:41.240 taking over, so for example, certain fungal species such as 0:22:41.240 --> 0:22:47.359 Canada albacans. So it's it's not, it's not it's a 0:22:47.359 --> 0:22:49.560 little bit of a mixed bag, or it's like, it's not, 0:22:49.800 --> 0:22:53.600 it's not the way that antiseptic technique or fluid replacement 0:22:53.880 --> 0:22:57.280 is the role that it plays in the history, especially because. 0:22:57.080 --> 0:23:01.280 You're talking about like systemic antibiotics, right, like ivy antibiotics 0:23:01.359 --> 0:23:03.400 or oral antibiotics, like the kind that you would use 0:23:03.440 --> 0:23:07.520 to treat an infection, And yes, that and that makes 0:23:07.520 --> 0:23:09.679 sense because we don't really use them that much in 0:23:09.800 --> 0:23:10.760 burns today. 0:23:11.119 --> 0:23:13.000 Yeah, unless we need to. 0:23:13.280 --> 0:23:18.199 Unless exactly, so having it needed exactly exactly yea. 0:23:18.600 --> 0:23:21.320 But yeah, like you said, I mean the systemic part 0:23:21.320 --> 0:23:25.119 of it, and so having this knowledge of anti microwheal 0:23:25.200 --> 0:23:28.639 properties to then infuse bandages. I kind of lumped that 0:23:28.680 --> 0:23:30.639 in with the aniseptic technique, but like that was a 0:23:30.720 --> 0:23:33.439 huge part of it. Yes, just like how do we 0:23:33.480 --> 0:23:35.480 topically treat this and prevent infection? 0:23:35.720 --> 0:23:35.960 Yeah? 0:23:36.040 --> 0:23:40.800 Right, And then last on the list is airway management. 0:23:41.560 --> 0:23:45.119 So this includes both the recognition of airway injury as 0:23:45.160 --> 0:23:48.000 well as ways to treat it. Now, if we're still 0:23:48.080 --> 0:23:51.439 considering just that fifty year window between nineteen hundred and 0:23:51.480 --> 0:23:55.440 nineteen fifty, airway management was mostly restricted to recognizing the 0:23:55.520 --> 0:23:58.440 damage that smoke inhalation could do to lungs that could 0:23:58.480 --> 0:24:02.480 lead to poor outcomes. The doctors treating victims of the 0:24:02.520 --> 0:24:06.000 coconut Grove nightclub fire in Boston in nineteen forty two 0:24:06.160 --> 0:24:09.920 made note of this quote. It was obvious almost at 0:24:09.960 --> 0:24:12.399 once that we were dealing with something more than the 0:24:12.440 --> 0:24:17.200 problem of burned skin. A severe impairment of respiration also existed. 0:24:17.480 --> 0:24:18.000 End quote. 0:24:18.400 --> 0:24:22.400 And this was due to Yeah information, that's so interesting 0:24:22.440 --> 0:24:23.480 that that's so late. 0:24:24.720 --> 0:24:28.520 I think that people recognized it, but it like what 0:24:28.720 --> 0:24:31.960 can men do about it? Right? I mean, I think 0:24:32.040 --> 0:24:35.080 that I don't know. I don't know, I don't know. 0:24:35.640 --> 0:24:37.960 I know it's a lot there's a lot of components there. 0:24:38.000 --> 0:24:39.720 There's a lot of components. This is like the one 0:24:39.720 --> 0:24:41.480 where I was like, I don't even know where to 0:24:41.560 --> 0:24:48.520 begin covering the history of this, because respiratory issues following burns. 0:24:48.760 --> 0:24:52.240 It could be due to direct burns. Carbon monoxide poisoning 0:24:52.240 --> 0:24:55.399