BY degrees
The recovery will be long and slow for the burned victims of the Whakaari eruption. Eleanor Wenman and Mandy Te report.
It’s more than skin deep. Burns can go beyond that, right down to the bone, into the lungs.
In hospitals throughout New Zealand – and now Australia – doctors, surgeons and nurses are battling to save 23 critically injured burn victims from the Whakaari/White Island eruption. Some of those 23 have burns to 90 per cent or more of their bodies.
On Monday, Whakaari/White Island – New Zealand’s most active volcano – erupted, spewing rock, hot ash and lava, while 47 people were standing on it.
An hour after the eruption, staff at Whakata¯ ne Hospital ran for Gladwrap, a makeshift bandage to do what skin does every day: keep everything inside.
The first 24 hours after a person is severely burned are vital, says Heather Cleland, a plastic surgeon and director of the Victoria Adult Burns Service at Melbourne’s Alfred Hospital
Immediate first aid and cooling the burn with water if possible are the main priority. But when a burn eats into the layers of skin, the victim faces serious issues as they lose body fluid.
‘‘If your skin is destroyed then a lot of fluid will leak out of your body and you get a sort of systemic, toxic effect on the cells in the body.
‘‘A lot of the fluid starts to leak out of the cells internally. Blood pressure drops and they go into shock, physiological shock.’’
To try to fix this, a large amount of resuscitation fluid needs to be pumped through the person’s veins to keep their blood pressure and blood volume up. Otherwise they risk other problems like kidney failure and organ damage.
But pumping in fluid adds to another issue: swelling tissue.
‘‘If you’ve got a lot of thick, deep burns, they can act as a sort of tourniquet around limbs and around your chest to limit breathing or circulation,’’ Cleland says.
Surgeons need to cut into the burned skin and tissue, to relieve the pressure.
Damage doesn’t come just from the outside either. Unless the person is extremely lucky, they will probably breathe in whatever’s around them: smoke, toxic gases from chemicals, sulphur, superheated steams. It can blast the lungs.
Doctors need to keep the patient breathing and protect the airways, using a breathing tube.
Those burned in the White Island eruption face further problems too. Counties Manukau District Health
Board’s chief medical officer, Dr Peter Watson, said on Wednesday that the acids involved in a volcanic eruption had made treatment more complicated than normal burns cases.
Severity of burns
Cleland says that, generally, an adult with more than 20 per cent of their total body surface area burned is classified as severely burned.
There are different tools for medical staff to quickly figure out how much of the body has been burned. One is the Rule of Nines: parts of the body – arms, torso, head and so on – are assigned a percentage based on a multiple of nine. The front of the torso is 18 per cent, the same with each leg. Arms are 9 per cent.
On average, people will spend about a day for each per cent
‘‘Someone with a massive burn is extremely susceptible to infection. Firstly, of their wounds because one of the things that our skin does is protect us from the outside world.’’
Heather Cleland
Plastic surgeon and director of the Victoria Adult Burns Service, Melbourne’s Alfred Hospital
burned in hospital – so a person with burns to 20 per cent of their body will be in hospital for three to four weeks – provided everything goes well.
That usually applies to fit, healthy people with up to 50 per cent of burns: so burns across the front of their body, up both arms and across the face.
But complications can develop at the higher end of the scale. So much skin may be gone or damaged that there probably isn’t enough unburned tissue to use for grafts. Wounds can’t be closed, leaving the person at risk of infection.
‘‘Someone with a massive burn is extremely susceptible to infection. Firstly, of their wounds because one of the things that our skin does is protect us from the outside world,’’ Cleland says.
‘‘When that barrier function is lost, there’s a huge opportunity for environmental organisms – bacteria and other infections – to occur. Generally speaking, a patient with severe burns has very decreased immunity so they’re also prone to getting pneumonia.’’
Recovery – if the person does survive – can stretch into months and years, especially when adding in rehabilitation.
Organs shutting down
One of the major causes of deaths in severe burns cases is multiorgan failure, caused by the body trying to provide protection.
University of Otago professor Madhav Bhatia has spent years researching inflammation.
One of Bhatia’s research areas is burn injuries, which fall under his work on systemic inflammation – an inflammation that spreads to different parts of the body, causing multiple organs to fail and even death.
‘‘That happens in many severe conditions and severe burns is one of them.’’
When a person suffers a burn, it’s categorised in degrees.
First degree is the type most people have had at least once in their life, for instance when they’ve spilled a mug of hot tea on themselves.
Second-degree burns occur when some parts of the skin are damaged, reaching down a couple of layers.
Third-degree burns burrow through all the layers of skin.
‘‘Even in third-degree burns where no internal organs are directly affected, there is an inflammatory response,’’ Bhatia says.
When a person is burned, their white blood cells leap into action to try to protect them from injury or infection.
But when there is an overactive inflammatory response – such as in severe burns – there is a systemic inflammatory response.
The body can turn against itself and the white blood cells end up damaging the site of inflammation and travel to other parts of the body – the lungs, the kidneys – and damage them too. ‘‘In many cases, multiorgan failure that is resultant from systemic inflammatory response, that is the major contributor to mortality in burn injuries,’’ Bhatia says.
Try to look at the positives
Troy Hall was 23 when he suffered two electric shocks while working on an avocado farm in 2011. The first shock killed him, the second brought him back to life but with serious burns to his torso, parts of his leg and face, and his buttocks.
Hall was told he would never walk or talk again but he wanted to prove to himself and the doctors that he could push through it.
It took him months and lots of work with a physiotherapist to get ‘‘any sort of normality of walking again, but the burns side of thing took years till I had no open wounds any more – [the accident] had taken all seven layers’’.
Now, his skin is very tight and doing everyday activities is not as easy as it was. He is also blind in one eye.
Hall credits his progress to having support around him and to the birth of his daughter, who was a huge drive in his recovery.
‘‘It’s not just a physical aspect, there’s a mental aspect you have to get through. After the accident was when I had her and she’s considered my miracle.
‘‘It’s definitely not easy . . . it’s a long road . . . but you will get through and you end up becoming a totally different person at the end of it, for the good too.’’
Everyone’s recovery is different. ‘‘It’s a very hard thing to overcome especially when you’ve been burnt. It hurts and
. . . you’ve got so many weighty feelings all in one.’’
Now, his mind is a lot stronger but he still has days when he is depressed.
The Whakaari victims have a long hard road ahead of them, he says. He believes the best remedy is for victims to reach out to family, friends and people who have gone through a similar experience.
‘‘If it wasn’t for me reaching out, I wouldn’t be doing what I do now . . . people have to look at the positives as best as they can.
‘‘There’s a lot of negatives at the moment and that’s fair enough but as a victim myself at one stage, I’m looking at the good side of my life now as opposed to a few negatives that still affect me today.’’