Physiotherapy Trauma Talks
In Physiotherapy Trauma Talks we discuss the key roles that physiotherapists and other healthcare practitioners play in the management and rehabilitation of patients with traumatic injury. Experts in trauma care offer their insights about in-hospital patient care and post-discharge follow up service delivery. New research in the field of trauma care and rehabilitation is shared to provide answers to your questions.
Physiotherapy Trauma Talks
Burns Part 2: A Nurse Manager's Perspective on Multidisciplinary Patient Care with Katinka Rheeder
What makes burns nursing unique? The world of burns care is explored with Katinka Rheeder, an experienced burns ICU nurse manager who has been working in trauma care since 1980. She shares her expertise in managing patients with burn injuries, highlighting how the multidisciplinary team approach ensures optimal outcomes for patients with complex injuries. For physiotherapists working with burns patients, this episode offers invaluable guidance on collaboration with nursing staff. As Katinka wisely notes, "We do not nurse on an island" – successful burns care depends on team work between all healthcare professionals involved.
Podcast website: https://physiotherapytraumatalks.buzzsprout.com
Book: Cardiopulmonary Physiotherapy in Trauma: An Evidence-based Approach’ published by World Scientific: https://doi.org/10.1142/13509
Hi there, fellow physiotherapists. I am Helene van Asvegen, your host for Physiotherapy Trauma Talks, where we discuss everything related to trauma care. So if you are passionate to learn more about physiotherapy in the field of trauma to ensure that you provide the best possible care for your patients, then this is the right podcast series for you. Today, my guest is Katinka Reeder. Katinka is a nurse by profession and has worked in trauma care since 1980. She was one of the principal developers of the burns intensive care unit at mall park net care hospital here in johannesburg, and this burns unit was opened in 2008. Since 2008, she has been the manager of the burns unit, so katinka has got vast experience in the field of nursing and particularly in the field of trauma and burns care. Katinka, thank you so much for joining me for this discussion today about the role of the ICU nurse in the management of patients with burn injury.
Speaker 2:Good afternoon, Prof. Thank you for having me.
Speaker 1:Katinka, can you tell our listeners what sparked your interest to work in Burns ICU?
Speaker 2:Like you already said, I started my career in trauma ICU when it was still a four-bedded ICU and then became a 12-bedded ICU and then a 30-bedded. Our Burns patients were nursed in cubicles or between plastic covers. Patients was nursed in cubicles or between plastic covers. There was no means to keep the patients warm during this time besides bear huggers. There was no positive pressure ventilation. The infection rate of our patients increased in the Burns patients as well as the rest of the trauma unit. Patients were traveling to main theater down the long corridors, contributing to hypothermia and infections. There was definitely a need for a dedicated burns unit, which I identified at that time as well. We had a plastic surgeon at the time which motivated for the opening of a burns unit, and it eventually happened in 2008, where I applied for the post and was successful to open the first private burns unit in South Africa.
Speaker 1:Wow, that's excellent. In your experience in burn care at Moorpark Hospital, what is the most common causes of burn injury among the patients that are admitted to your unit?
Speaker 2:Currently, our most frequent burns we see are electrical burns, which in itself is very devastating. We also see burns related to industrial explosions, chemical burns, hot water burns, petrol fires, gas cylinder explosions, hot oil steam burns, as well as the fault fires which normally falls in the category of the elderly farmers. So, yeah, we see a vast majority, but mostly at this given time, is electrical burns.
Speaker 1:Yeah, so you see quite a wide variety of causes of burn injury and I think the electrical burns must be quite complex to manage because of injury to the internal organs as the current moves through the patient's body.
Speaker 2:It is always a challenge because the extent of the burns is not always visible at the time, so they start with the initial debridement and then see the depth of the wounds.
Speaker 1:Yeah, no, I understand that often the patients may present with an outcome very different from what you expect because of most of the injury being internal and not visible at the time of admission. Most certainly, yes. Do you manage children in your Burns ICU at all?
Speaker 2:No, we do not. We only admit patients from 12 years and up. We normally refer children to our sister's hospital, which is mostly Garden City Hospital.
Speaker 1:Okay, with this sort of wide variety of causes of burn injury that you see, is there a particular tool that you use to determine the extent of a patient's burn injuries?
Speaker 2:Determining the extent of burns is mostly estimated using the rule of nine. The rule of nine is based on the concept of dividing the adult body area into anatomic regions, which is represented by 9% or a multiple of nine to calculate the total body surface area. In other words, the head accounts for 9%, which is 4.5% anterior and 4.5% posterior. Each arm is then 9%, 4.5 anterior-posterior, the anterior trunk 18%, that would include the chest and abdo, the posterior trunk 18%, each leg 18%, 9% anterior, 9% posterior and then the genitalia. The palmer method is a quick way to estimate the size of a burn using the patient's own palm, including fingers, as a reference, which is roughly one percent of total body surface area. This is used only in small and patchy burns. Furthermore, we use the revised bulk score to predict the patient's mortality. The revision bulk score equals the total body surface area plus the age plus 17, which then is obviously inhalation, and the higher the bulk score, the higher the likelihood is for mortality score, the higher the likelihood is for mortality.
Speaker 1:Okay, so when a patient comes into your unit.
Speaker 2:What does routine care of that patient entail? Burns Unit nurses collaboratively closely work with other healthcare professionals in order to provide the holistic care, patients' assessment and stabilisation, especially in the immediate aftermath of a burn injury. This entails monitor vital data and implement measures to stabilise the patient. Wound care performing procedures like wound cleaning, dressing changes. Pain management like wound cleaning, dressing changes. Pain management. Administer medication to alleviate the intense pain associated with burn injuries. Fluid and electrolyte balances ensuring patients receive adequate hydration and electrolyte to support healing. Infection prevention implementing strict infection control protocols and monitoring for signs of infection. Nutritional needs ensure patients are seen by a dietician and is receiving the correct feeds prescribed by the dietician. Assist the physiotherapist in mobilizing patients. Apply splints and positioning of patients. Emotional support to patients and their families. So we are part of a whole multidisciplinary team.
Speaker 1:Yeah, that's wonderful. What I take from what you've shared just now is that pain management must be extremely important in the management of these patients. Is there a particular type of pain therapy or pain medication that you use for most patients in your unit?
Speaker 2:We normally do use opiates. Our ventilator patients. Obviously they are on infusions of morphine. The awake patients obviously will be on titrations of morphine, of morphine, and then obviously, when we do dressings, we would administer fentanyl during and after dressing changes.
Speaker 1:Okay, and would you mind sharing a little bit with our listeners what specific infection control principles you have in your unit to limit the spread of infection from one patient to the other?
Speaker 2:We're very set on infection control. So obviously the staff that comes on duty, they do not work in their outside clothes, they change into scrubs. One is to one nursing, so they are allocated to one patient. Going into the room they will wear an apron when they touch the patient. They will wear an apron when they touch the patient. They will wear gloves when family comes. Obviously, washing of hands, spraying of hands and then obviously when they touch they also wear aprons and gloves when they want to touch the patient.
Speaker 2:We clean our environment when patients leave the unit to go to theatre. Obviously we use zapping to clean the cubicle before the patient comes back to decrease the microorganisms at that specific time. And, yeah, obviously we encourage hand washing. We do infection control rounds ensuring the environment is clean by checking on people stamping cubicles to make sure that the environment was cleaned for the day. And then we do antibiotic stewardship, obviously to see the use of antibiotics in the unit. Are we overusing, underusing, correct using of the correct antibiotic for the correct organisms? That has been specifically cultured. We do not treat prophylactically, we treat specific organisms.
Speaker 1:Yeah, so very comprehensive infection control policy. One thing that you mentioned there that I'm not so familiar with is the zapping of the patient's room. Would you mind explaining a little bit more about that?
Speaker 2:It is a machine that they bring in that releases ultraviolet waves that has been shown to decrease the organisms that is present in the room at the time because of, obviously, movement of linen and people moving in the cubicles, so that ultraviolet then will decrease the organisms present in that cubicle by infiltrating them with ultraviolet light, which is then done for 15 minutes at a time.
Speaker 1:Okay, yeah, that's very interesting. You mentioned at the beginning that you do get patients admitted to the unit that have had thermal burns or chemical burns, and sometimes this entails inhalation burns as well. How do you manage patients' symptoms of bronchospasm while they're in the unit with you, especially in the acute phase after the burn injury?
Speaker 2:Well, the term inhalation injury comprises of three main components, which can occur separately but which frequently present or can be in combination. And then obviously, history taking of the type of burn is very important. So this could include systemic poisoning due to inhalation of gases produced by combustion, such as carbon monoxide and hydrogen cyanide, then obviously obstruction of the upper airway due to effect of heat and subsequent edema, and then injury to the lower respiratoryway due to effect of heat and subsequent edema, and then injury to the lower respiratory system due to inhalation of noxious chemicals and particulates present in smoke. So routinely we will use a fiber optic bronchoscopy which is done for the initial diagnosis of inhalation injury. If there's obvious signs of inhalation injury in early phases, while the patient is still in the emergency department, a secure airway will be placed. And we do administer bronchodilator therapy via nebulizers to ventilated and non-ventilated patients. To ventilated and non-ventilated patients Not often, but we do use penotrol and ipratropium six hourly if prescribed when prescribed.
Speaker 1:Okay, do you also administer mucolytics through the nebulizers for those patients that may have secretion retention and struggle to clear the secretions effectively through suction?
Speaker 2:We would. Normally, if the secretions are thick, we would provide saline flushes during vibrating of the physio. We will provide that through the ET tube and then suction the patient.
Speaker 1:Okay, so it's more direct saline installation into the ET tube, correct, okay. And when you use nebulizers as part of the ventilator circuit, do you have a policy in your unit about how to ensure that the nebulizer doesn't become contaminated? We?
Speaker 2:definitely have a policy which includes that when the nebulizer is open, a patient sticker will be placed on the nebulizer. The nebulizer will be kept in a sterile green towel or blue towel at the patient's bedside. It is quite easy, because the patients are nursed in an isolated cubicle, so the nebulizers will not leave the cubicle. And when the patient then goes to the ward and the nebulizer goes with the patient, it will be placed in a green towel and accompany the patient to the wall.
Speaker 1:Okay, let's talk a little bit about wound care of patients within your unit. You mentioned earlier that nurses are involved in cleaning the wounds and dressing the wounds. Do you want to elaborate a little bit on that?
Speaker 2:Well, the nurse is responsible for assessing of the wounds for signs of infections complications. They ensure, obviously, adequate pain control is administered prior to and also during dressing. They ensure sterile technique is followed at all times when they do the dressings or finger digits. Ensure that the fingers are wrapped individually, obviously to make movement easier for the physiotherapist as well. Ensure patient's temperature is optimal prior to exposing of major burns wounds. So normally we would ensure that the heaters are on in the cubicle and the patient's temperature is above 37 degrees Celsius prior to exposing the wound. Of course, now we're removing the dressings, ensuring dressings cover the entire wound without causing maceration of surrounding skin. Cover with appropriate materials such as clay bandages to help with edema and scar management and then also report any concerns swelling, pus to the healthcare providers.
Speaker 1:Yes, I just wanted to highlight what you said about dressing the wounds of patients' hands and that you wrap each finger individually in the dressings to ensure that the physiotherapist can still do exercises with the patient's hands, and I think that's absolutely brilliant because we don't always see that happening in other units, and it's wonderful to see how your policies in the unit embrace optimal rehabilitation of your patients, so I wanted just to commend you on that, thank you. So you wanted to share more about the type of wound dressings that you use.
Speaker 2:We have a vast majority of plastic surgeons, so we have a vast majority of preferences plastic surgeons, so we have a vast majority of preferences. But we use and buy a brain, which is mostly a synthetic burn dressing. It's a. It's flexible, man-made, composed of nylon, mesh, silicone and collagen, which acts as a temporary skin cover. We have silver dressings, which is antimicrobial, which decreases infection, hydrocolloid foams, hydrogel and alginate, which provide a moist wound environment that promotes healing as well. So, like I said, you know, sometimes we have different plastic surgeons with different preferences. We have different plastic surgeons with different preferences.
Speaker 1:So the decision about the type of wound dressing to use would be determined by the surgeon, correct? Are there any precautions that physiotherapists need to know about with regards to movement and exercise therapy for patients with any of these wound dressings that you've just mentioned?
Speaker 2:Physiotherapists need to consider the latest grafting that was done and also the area of the graft that was done to avoid moving or percussion on those areas. Then patients that had recent grafting done obviously no mobility for the first five days post grafting, which causes a lot of frustration, but it is necessary to ensure that the skin is adhering prior to movement.
Speaker 1:Okay yeah, and I just want to remind our listeners that if they want more information about physiotherapy management of patients with burn injuries, the next episode will cover that extensively. Katinka, do you sometimes use negative pressure wound therapy for wound care in your patients with burn injuries?
Speaker 2:Yes, definitely. Negative pressure wound therapy is definitely used more and more frequently in our burns patients. The wound therapy stimulates wound healing and lowering the infection rate of the burn wound. It is a closed system, can be applied to wounds of diverse etiology to promote healing. Promote healing and negative pressure wound therapy create a moist healing environment, decreases tissue edema, promotes blood flow to the wound. It improves granulation. It stimulates angiogenesis. So therefore, negative pressure wound therapy provides a positive wound environment by removing the healing inhibitors in the wound, exudate and clear microorganisms from that wound bed as well.
Speaker 1:Okay, and if any of your patients are on negative pressure wound therapy, are your physiotherapists allowed to mobilize them out of bed?
Speaker 2:Yes, they are Because the pump has got a battery backup. It is easy to place those items onto a movable trolley and then the patient can mobilize down the corridor. It is just important, when the patient do return, that it will be plugged in, because the battery life is not that very long Okay.
Speaker 1:After having covered all of these aspects of nursing care for patients with burn injuries and the extensive amount of time that you've worked in the burns unit, is there maybe a success story of any of your patients that you would like to share with our listeners?
Speaker 2:Well, we, have a variety of success stories and it's not necessarily the major burns that turns out to be a success story. We have had very small burns, most recently a 10% chemical burn which was caused by caustic acid, which the length by caustic acid, which the length of stay was over two months. The patient was blinded by the accident. He had major sloughing of his trachea as well as his esophagus was ventilated for three weeks and there was major challenges with speech as well as with the ENT. You know we do normally look at success rates when it comes to the 70% or 80% burns, but then the smaller burns also has such a good outcome, looking at the devastating effects. Then thinking back of a 60%, which was an open flame burn, electrical length of stay was one month. Patient had ARDS from day one, went for ECMO and then has been discharged.
Speaker 2:So, yes, we have quite a few success stories.
Speaker 1:Yeah, and I just want to highlight something about the first story that you shared with a patient with a 10% burns but then who developed complications and where you would look for involvement of healthcare professionals on a broader context. So I'm sure for this particular patient, the ophthalmologist was also involved and potentially a psychologist as well.
Speaker 2:Most certainly. All our patients are seen by psychologists, psychiatrists if need be that was involved a speech therapist which assists with swallowing, and an ophthalmologist. All our patients, all facial burns, are seen by an ophthalmologist and then to identify if there is any corneal burns present. If there isn't, the ophthalmologist will not see the patient unless we identify any problems later on.
Speaker 1:Yes, Okay, katinka, thank you so much for sharing your vast knowledge of burn injuries with us. Before we finish this episode, do you have any last thoughts that you would like to share with our physiotherapy listeners? Or maybe a word of encouragement to junior physios, who are not so experienced in working with patients with burn injuries and may find it intimidating Well, burns is a challenging environment with critically ill patients mostly, and it is important to know that we cannot function as an island.
Speaker 2:We are part of a multidisciplinary team to ensure the best outcome for our patients and to provide support to our families as well. And the junior physios are normally accompanied by the most senior physios in the unit, so there's a lot of teaching that happens, accompanied by the most senior physios in the unit. So there's a lot of teaching that happens. We are very privileged when it comes to our physiotherapists. They are accompanied by seniors and obviously taught from day one what is to happen and what's not to happen. There's always a sister next to the bed to ask if they are not sure. Like I said, we do not nurse on an island. There's always somebody available to us.
Speaker 1:Yeah, no, I think that's very important Continued communication with other members of the team, as you so nicely put it, and also the importance of continued education while working in the burn setting from experienced team members. Katinka, thank you so much for your time and we hope to get some questions from our listeners within the chat so that we can expand on a little bit further. And I just want to remind the listeners again the link to leaving a comment or a question is in the show notes of the episode. Thank you, katinka.
Speaker 2:Thank you so much for having me.
