Burning passions

14 September 2010

 Meshed skin graft over a burn
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Colour-enhanced scanning electron micrograph of a meshed skin graft over a burn. Wellcome Images.

I have a guilty pleasure: British medical TV series. I love the melodrama of ‘Casualty’, and ‘Holby City’s’ intense-but-predictable storylines. So imagine my delight when Isabel Jones, consultant burns and plastic surgeon at Chelsea and Westminster Hospital, was announced as the next Packed Lunch interviewee. A chance to experience a real-life account of the drama of medicine, I hoped.

I wasn’t disappointed. Isabel arrived at the Wellcome Collection straight from an operation that had started at 8.30 in the morning. Her day had begun at half past midnight, when she received a call to say a young woman had been brought in to the hospital with severe burns to her chest – caused by a fire she had accidentally set in her house after a drunken night out.

There was a tingling sense of shock in the audience, yet Isabel spoke matter-of-fact. She explained that Chelsea and Westminster Burns Unit is a specialist referral centre for Greater London and the South-east, meaning anyone within the M25 with significant burns comes to them for treatment. Dealing with this kind of injury is a regular part of her job.

Any burn over 15 per cent of the body’s surface is life-threatening. Isabel’s patient had 25 per cent. When skin cells are damaged and die, the body’s barrier to the outside world is breached. Risk of infection increases, fluid is lost. The body undergoes a massive inflammatory response that can be fatal. The first 24 hours are crucial to the long-term outcome of the patient. At this stage, Isabel’s job is to remove the dead skin tissue causing this response. Previously, burns were left until a scar began to demarcate, nowadays, early excisions of burns is one of the most important modern progressions in the treatments of burns and is ‘critical for survival’.

Isabel prefers to plan a surgical procedure in advance, hence the midnight call. At 04.30 she went back to bed, waking again in time for the start of the procedure. She set the scene of the operation: three consultant surgeons, scrub nurses, intensivists. Sometimes, music is played in theatre. Not today though, as a lot of communication between the team is required during a procedure on a patient with injuries that could cause them to die.

Isabel is one of many in a team dedicated to the patients on the 20-bed burns unit. There are microbiologists, focused on the threat of infection; physiotherapists who get the patients back on their feet; psychotherapists to help them through the psychological consequences of their injuries. Isabel had spoken to the woman she was operating on this morning. She told us this woman knew her actions caused the injuries that will stay with her for the rest of her life. If she lives. When Isabel told us that the psychotherapists are available to staff too, you could see, and hear from her voice, that however much steely resolve and professional detachment she has, she is strongly affected when a patient she has cared for loses their battle for life.

When a critical patient comes in to the unit, the first priority is the quick and safe healing of their burn. Cosmetic outcome is kept in mind, but can be improved later with grafts and reconstruction. Another concern is the cause of the burn – why did this patient faint into the bonfire they built? Is this child’s scald the result of carelessness in the kitchen, or something more sinister? The burns unit works closely with social services. In the case of Isabel’s patient today, the large amount of alcohol she had drunk caused the careless lighting of a match and too slow a response to the resulting flames that burned her body.

It is likely that Isabel’s patient will need skin grafts to replace her damaged tissue. Grafts cannot come from another person, as this skin is antigenic: the body will recognize it as foreign and reject it. When performing a skin graft, Isabel will take a layer of skin from the thigh, buttock or scalp where there is minimal visibility of scarring. This is then carefully stitched onto the ‘wound bed’, using the wound as a template. A murmured laughter went through the audience when Isabel revealed her mother was a seamstress.

Artificial skins and skin substitutes are being developed, but the technology has not been perfected. The problem is creating something that is non-antigenic and can work universally for all skin types. Biotechnology is used, however, in the form of dermal replacements that enable a thinner graft to be used on the wound. This means less skin needs to be taken from the healthy site, and there is less scarring. I can only imagine the scars that Isabel’s patient will have when her trauma is over.

Reconstruction takes place long after a patient has received initial treatment. This is done to improve the cosmetic appearance of burns, and functionality. Sometimes contractures of the skin will form around joints, where the healed skin becomes very tight and restricts movement. Isabel will release these contractures, and perhaps move scar tissue around from one site to another, where there is more movement. The relationship between a patient and a surgeon can be lifelong.

At the end of the interview, Isabel was asked if she felt frustration about the cosmetic outcome of some burns. Her answer was yes, but the satisfaction of taking a seriously ill patient back to full health outweighs that. “The human level of positive feedback from patients is very rewarding,” she said. And as Isabel left the room, I could only hope that the young woman she was returning to operate on would live to thank her fantastic surgeon.

Louise Crane is a Project Officer at the Wellcome Trust.