SU­PER SKIN

SA’S BURNS REVO­LU­TION

The Advertiser - SA Weekend - - FRONT PAGE - WORDS MICHAEL MCGUIRE PIC­TURES TOM HUNT­LEY

The first time Ju­lian Bur­ton met John Green­wood he asked for a dif­fer­ent sur­geon.

Bur­ton had just been flown in from Ade­laide af­ter be­ing hor­ri­bly in­jured and burned in the 2002 Bali bomb­ings. He had been in the Sari club when ter­ror­ists blew the place up, mur­der­ing 202 peo­ple.

Some­how, Bur­ton sur­vived. But he re­ceived third de­gree burns, which ex­tend through the skin into the fat layer, to 30 per cent of his body, re­quir­ing him to spend months in hos­pi­tal, and en­dure mul­ti­ple skin grafts and op­er­a­tions.

At that point Green­wood was still the rel­a­tively re­cently ar­rived head of the burns unit at the Royal Ade­laide Hos­pi­tal. But Bur­ton wanted a dif­fer­ent plas­tic sur­geon to look af­ter him. One he had known af­ter a can­cer scare when he was 24.

“So when I came back (from Bali) and I knew I was in trou­ble, I re­quested this plas­tic sur­geon again,” Bur­ton says.

“John walked in and said some­thing along the lines of ‘ thanks very much for not choos­ing me’.”

But Bur­ton had no choice. He got Green­wood, an up­front, pos­si­bly ec­cen­tric English­man, with a wide streak of dry, black hu­mour who hap­pens to be some­thing of a ge­nius in the world of burns treat­ment.

Asked to de­scribe Bur­ton as a pa­tient he calls him a “prima donna” and reck­ons Bur­ton would “shower with the door open so ev­ery­body could see his arse. It was a night­mare”.

Sit­ting be­side him, Bur­ton laughs and says “you can’t be­lieve any­thing he says”.

But the bond be­tween the pair – the burns’ sur­vivor and the burns sur­geon – which started in the af­ter­math of that Bali hor­ror, is ev­i­dent.

Now the duo be­lieve they are on the verge of some­thing re­mark­able. Some­time next year we will see “the end of the skin graft for big burns in Ade­laide as far as I’m con­cerned”, Green­wood says. He is talk­ing about world-first treat­ment. “This tech­nol­ogy abol­ishes not only the need for the skin graft, but also pro­vides a so­lu­tion for sur­geons strug­gling with hor­rific in­juries, mas­sive skin loss and huge wounds,” he says.

At the RAH alone, some­where around 120 pa­tients a year re­quire a skin graft. And not just one. As with Bur­ton, many re­quire mul­ti­ple skin grafts in the course of their re­cov­ery.

“I un­der­stand the trauma and the pain of skin grafts,” he says. “I un­der­stand the days, the weeks, the months of re­ha­bil­i­ta­tion and the pain you have to go through to ba­si­cally get back to your life.”

Bur­ton and Green­wood have started a biotech com­pany called Skin Tis­sue En­gi­neer­ing, which next year will start hu­man tri­als on its patented prod­uct called Com­pos­ite Cul­tured Skin (CCS).

This is skin that will be grown in a spe­cially con­structed bio-re­ac­tor. It will start from a 10cm by 20cm patch taken from the body of a pa­tient who has tra­di­tion­ally needed a skin graft and, over the course of 28 days, it will grow to 2.5sq m, which will give enough new skin to “cover a full hu­man and more”, ac­cord­ing to Green­wood.

It will rev­o­lu­tionise how burns pa­tients, and any­body else who needs a skin graft, will be treated.

Green­wood says the tech­nol­ogy is al­ready gen­er­at­ing “con­sid­er­able ex­cite­ment” in the global burns com­mu­nity.

Its prom­ise has prompted Bur­ton to close down the Ju­lian Bur­ton Burns Trust, which he founded 15 years ago along with Green­wood and burns nurse Sheila Ka­vanagh, to con­cen­trate on this new ven­ture.

In the wake of Bali, Bur­ton re­quired ex­ten­sive skin grafts. He suf­fered third de­gree burns to 30 per cent of his body, mostly across his back and left arm.

Re­ceiv­ing a skin graft, he says, is a hor­ri­ble process. The skin that is grafted on to a burns wound comes from what is eu­phemisti­cally called a “donor site”. To cover Bur­ton’s wound, Green­wood had to take an equiv­a­lent amount of skin from the non­burnt side of Bur­ton’s back.

“Ba­si­cally they graft like with a po­tato peeler, and they peel it off,” Bur­ton says.

If it sounds ex­cru­ci­at­ing, the re­al­ity is even worse.

“That donor site takes longer to heal and is more painful than your burnt site.”

Har­vest­ing the skin for the graft cre­ates an­other wound, an­other scar – and an­other trauma for some­one al­ready highly trau­ma­tised.

I“It will rev­o­lu­tionise how burns pa­tients, and any­body who needs a skin graft, will be treated.”

t’s been 15 years since Bur­ton was caught up in Bali. He had been with his team­mates at the Sturt Foot­ball Club on an end-of-sea­son trip cel­e­brat­ing the club’s first premier­ship in 26 years.

Bur­ton was stand­ing near a bar in the Sari Club when the bomb, which would kill player Josh Deegan and club of­fi­cial Bob Mar­shall, went off. A third South Aus­tralian, 19-year-old An­gela Golotta, also per­ished.

The blast knocked Bur­ton un­con­scious and when he came to he was trapped un­der py­lons and the build­ing was ablaze.

“You wish for no one to see what ter­ror­ism looks like. It’s a blood­bath.” He is still not sure ex­actly how he es­caped. “I was burn­ing, I could feel it. I could see what was in front of me and I could see peo­ple who had lost their life, so it is very vivid and it will never go away.”

Bur­ton was evac­u­ated, first to Dar­win, then home to Ade­laide where he met Green­wood.

All th­ese years later, while the mem­o­ries are still vivid, the phys­i­cal scars are fad­ing.

Bur­ton is not afraid to dis­cuss his rec­ol­lec­tion of Bali but is cau­tious in as much as he is wor­ried that talk­ing about his own good for­tune in sur­viv­ing is “dis­re­spect­ful” to those who died.

The fact that he did make it out alive he puts down to be­ing “lucky” and noth­ing more. He knows he could eas­ily have died.

“There are po­ten­tially 202 fam­i­lies around the world that wake up ev­ery day hav­ing lost their son, or daugh­ter, or mother or fa­ther or a loved one,” Bur­ton says. “Whereas I wake up ev­ery day, I have a beau­ti­ful wife, with four beau­ti­ful chil­dren and I con­tinue on with my life.”

The men­tal scars are still there as well. Loud noises can still shock him, and the all­too-fre­quent ter­ror­ist at­tacks re­ported in the me­dia also serve as a re­minder.

“There is al­ways flash­backs,” he says. “When I see ter­ror­ist at­tacks on TV, I have a lot of em­pa­thy and a lot of com­pas­sion for the fam­i­lies.

“It’s re­ally sad that in­no­cent good peo­ple, ei­ther their life is taken away or their life is changed com­pletely be­cause of an evil act.”

Be­fore Bali, Bur­ton was a Phys-Ed teacher at Wood­croft Col­lege. His de­ci­sion to move into the char­ity, he says, was not mo­ti­vated by Bali, but by the kind­ness and care shown to him by the doc­tors and nurses dur­ing his re­cov­ery.

De­spite his view that he was “lucky”, the re­cov­ery process was, at times, trau­matic and left him an “emo­tional wreck”.

“When you get badly burned you have to learn to walk again, you have to learn to get back to nor­mal­ity. You have to learn how to drive again, sit in a car again, have a shower again, go to the toi­let again.

“When you suf­fer a ma­jor life threat­en­ing burn you are dis­fig­ured, your body is dif­fer­ent and you have to have the emo­tional and phys­i­cal strength to get back to that (your life),” he says.

Bur­ton did re­turn to both teach­ing and the footy field, but it was the Burns Trust that was to be his driv­ing force af­ter Bali.

The idea for the Burns Trust started when Bur­ton de­cided he wanted to do­nate some DVDs and equip­ment to the unit as a way of say­ing thank you.

Green­wood told him to keep his money but sug­gested they put their heads to­gether and come up with a more com­pre­hen­sive fundrais­ing method.

The doc­tor thought Bur­ton’s pro­file and sta­tus as a sur­vivor would be a good ral­ly­ing point for a burns char­ity.

Ini­tially, the Trust was to raise money for the unit at the RAH, but Bur­ton soon thought that was too nar­row a brief and it was de­cided to take it na­tional.

At the time there was no other na­tional not-for-profit burns or­gan­i­sa­tion in Aus­tralia. This is de­spite the sever­ity and ex­tent of burn in­jury in Aus­tralia.

A 2013-14 re­port by the Aus­tralian In­sti­tute of Health and Wel­fare found in that year there were 5430 burns cases that re­quired a hos­pi­tal stay, and 48 deaths.

It also found the high­est pro­por­tion of those burnt were un­der the age of four. And within that age group, the main cause of the in­jury was ex­po­sure to a “con­trolled fire”.

Since it started, the Trust has raised more than $17 mil­lion, run pre­ven­tion pro­grams for 225,000 school chil­dren, run burns first aid pro­grams, pro­vided money to hos­pi­tals to im­prove fa­cil­i­ties across the coun­try, and do­nated money to fam­i­lies and com­mu­ni­ties af­fected by tragedies such as the Black Satur­day and Pin­ery bush­fires.

Bur­ton is cur­rently talk­ing to or­gan­i­sa­tions such as Kid­safe and the Aus­tralia and New Zealand Burn As­so­ci­a­tion about con­tin­u­ing some of the Trust’s pro­grams. A big wind-up event will also be held next year and all sur­plus funds given to other or­gan­i­sa­tions. Bur­ton has no re­grets about the de­ci­sion. “It was the right de­ci­sion for the burns com­mu­nity, it was the right de­ci­sion for the Burns Trust and, thirdly, it is the right de­ci­sion for me.”

Green­wood’s drive to end the need for skin grafts started in 2004. He had trained as a doc­tor at the Univer­sity of Manch­ester in

England. Af­ter gain­ing his med­i­cal de­gree he started as a plas­tic surgery regis­trar in 1996. He would end in a pae­di­atric burns unit in Manch­ester and found he had an “em­pa­thy” with the kids there.

In 2001, Green­wood was head­hunted by the Royal Ade­laide Hos­pi­tal who wanted him as the first di­rec­tor of its burns unit. He had never been to Ade­laide be­fore but de­cided to take an “enor­mous punt”.

“The qual­ity of life is bet­ter, food is bet­ter, cli­mate is bet­ter, schools are bet­ter. You have to be a bit daft to turn it down,” he says.

Green­wood ar­rived in Ade­laide with his fam­ily at the end of 2001. Bali would hap­pen in Novem­ber 2002 and he treated 67 pa­tients in the im­me­di­ate af­ter­math of the bomb­ing.

But it was a cou­ple of years later that he first started to se­ri­ously think about how pos­si­ble it would be to re­place the skin graft.

Skin grafts had been around for 150 years and were re­garded as an es­sen­tially suc­cess­ful way to treat the prob­lem of cov­er­ing burns and other wounds.

Green­wood, though, was per­turbed by the death of some of his pa­tients – “young pa­tients, with de­cent-sized burns, who died and there was no rea­son for them to die that I could see”.

He started cat­a­logu­ing in­juries. He wrote pro­to­cols on how treat­ments should be car­ried out on pa­tients with dif­fer­ent types of in­juries. The pro­to­col on non-sur­viv­able in­juries nat­u­rally trou­bled him.

He pegged “non-sur­viv­able” as 80 per cent “full thick­ness” burn plus in­juries to lower air­ways. But, as he says, any­one “with a shred of hu­man­ity” will keep look­ing for an­swers to change the equa­tion.

Green­wood thought if he could some­how deal with the burns side of the ledger then there were ways of keep­ing some­one alive.

One of the big­gest prob­lems with a pa­tient with an 80 per cent burn is that there is no donor site. There is no place to find the skin for the graft.

Even in those pa­tients who have “donor sites” avail­able, there can be prob­lems with in­fec­tion, de­layed heal­ing and poor scar­ring. “Even with­out prob­lems, donor site wounds are ex­cru­ci­at­ingly painful,” he says.

“In a big burn sit­u­a­tion, where donor sites are scarce, I can’t keep go­ing back to the same small donor site over and over,” Green­wood says. “The sec­ond time I want to take a graft from it, the donor site is ‘thin­ner’ and if I keep go­ing back to it, sooner or later the donor site it­self will need a skin graft to heal.” The so­lu­tion is a two-stage process.

With a com­pany called Poly­novo, and its NovoSorb tech­nol­ogy, he de­vel­oped what is called a Biodegrad­able Tem­po­ris­ing Ma­trix (BTM), which im­proves the wound, re­sist­ing con­trac­tion and dis­cour­ag­ing in­fec­tion. A biodegrad­able poly­mer foam is placed in the wound and acts as a “scaf­fold” so the pa­tient’s own tis­sue and blood ves­sels grow into it and cre­ate con­nec­tive tis­sue. It was first tried in mice, sheep and then pigs in 2010. The first hu­man tri­als started in 2012. Now the method is be­ing tri­alled in all adult ma­jor burn cen­tres in Vic­to­ria, NSW and Queens­land as well as in the United States. South Africa will start us­ing the BTM soon.

When it is com­bined with the Com­pos­ite Cul­tured Skin, which is the sec­ond stage, Green­wood says the pain and suf­fer­ing caused by donor sites will be a thing of the past, and those burn vic­tims with ex­ten­sive skin loss and no donor sites will have a treat­ment to save life and im­prove out­come. To cre­ate the CCS, Green­wood has had to in­vent a bio-re­ac­tor to en­cour­age the skin to grow in 40 pieces 25cm x 25cm. The polyurethane foam is ini­tially seeded with der­mal cells and sub­merged in the biore­ac­tor in a spe­cific fluid, un­der spe­cific con­di­tions. Once the der­mis has been cre­ated, epi­der­mal cells are added to give cul­tured skin with both lay­ers found in nor­mal skin.

Of course, just by re­mov­ing the donor site, scar­ring will au­to­mat­i­cally be re­duced. “So in­stead of leav­ing pa­tients look­ing like a big lizard you ac­tu­ally get a very flat re­sult, it is very elas­tic, very soft,” Green­wood says.

Fund­ing was pro­vided by Tech­inSA, the old Bioin­no­va­tionSA, and the Life­time Sup­port Au­thor­ity. But in the world where the cost of med­i­cal tri­als can run into the bil­lions, it was small beer.

“We have man­aged to abol­ish, pretty much the skin graft for $1.5 mil­lion, which is a bit ridicu­lous,” Green­wood says.

The ben­e­fits are not just the phys­i­cal im­prove­ments that end­ing skin grafts will pro­duce. There is the men­tal side as well.

What it should mean is fewer op­er­a­tions, less time in hos­pi­tal, a greater chance of a full re­cov­ery, and the abil­ity to get back to life and work much quicker.

It is es­ti­mated a life-threat­en­ing burn in­jury to an adult costs be­tween $750,000 and $1m and, for a child, more than $1m. That doesn’t in­clude the cost of re­ha­bil­i­ta­tion and re­cov­ery, or the loss of work.

“In­stead of be­ing three months in hos­pi­tal, you might only be one month in hos­pi­tal,” Bur­ton says.

“You will still have pain and trauma, don’t get me wrong; but your re­cov­ery and your re­ha­bil­i­ta­tion will be 50 per cent less.”

Bur­ton and Green­wood are con­fi­dent they are on the verge of some­thing re­mark­able. And not only in skin grafts. They be­lieve the tech­nol­ogy used in the BTM process could also help treat Type 1 di­a­betes by re­plac­ing the pan­creas to pro­duce in­sulin.

But given the links of both Bur­ton and Green­wood to the trauma of burns pa­tients, it is the hope that they can elim­i­nate a lot of that suf­fer­ing that is re­ally driv­ing them.

“One day, if I’m 85 sit­ting in a rocking chair look­ing back on it, if we could change the way burns are treated glob­ally and if we can do that from here in South Aus­tralia that would be phe­nom­e­nal,” Bur­ton says.

“He is the vi­sion­ary, I am a burns pa­tient. It’s a bit of a love match that re­ally works.”

Dr John Green­wood and Ju­lian Bur­ton founder of Ju­lian Bur­ton Burns Trust char­ity for burns vic­tims at the RAH

Dr John Green­wood with a cas­sette con­tain­ing a com­pos­ite cul­tured skin

Ju­lian Bur­ton with burns pa­tient Kather­ine Brook­man at the Royal Ade­laide Hos­pi­tal; Bur­ton af­ter his sec­ond op­er­a­tion fol­low­ing the Bali bomb­ing

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