Tony Blair is visiting a new hospital in his constituency. He is ushered at great speed from ward to ward, chatting with patients and exploiting the photo shoot opportunity.“And how have you benefited from New Labour’s increased spending on health?” he asks one patient. The man looks at him and says “Some hae meat and canna eat and some hae nane that want it. But we hae meat and we can eat and sae the Lord be thankit.”“Er, quite,” says Blair, feeling he may have missed something politically profound. He goes to the next bed and says to a man with his eyes bandaged: “I’m Tony Blair, the prime minister, how…”

The man interrupts, “Fair fa’ yer honest, sonsie face, great chieftain o’ the pudding race, weel are thee worthy o’ a grace as lang’s me arm.” Blair thanks him, not sure if that is a compliment or what. He has hardly managed to finish saying “I hope you feel safe in the hands of New Labour” to the next man when he gets: “Wee, sleekit, cow’rin, timorous beastie, oh what a panic’s in thy breastie!” So he turns to the doctor and says, “What is this, the psychiatric ward?” The doc replies, “No sir, it’s the Burns unit.” In many countries, burn wound care is considered so important that special hospital units are used for all serious burns. The outcome has improved by quantum leaps in the last 10 years, with massive improvement in survival, impressive decreases in scarring and a huge reduction the number of in crippling injuries.

Unfortunately, in much of Africa, burns are very common and mostly treated - or mistreated - in the village, with disastrous consequences.

Most of us will get a burn or a scald every year or so, many of them at home and mostly trivial. Sometimes children pour hot coffee over themselves and the burns may look really horrific, so you rush off to a hospital. You may be quite amazed by how quickly they heal, and perhaps be quite impressed with the dramatic and complicated treatment you received. If you have driven through far-off villages, you may have seen horribly crippled children crawling on the ground, their limbs locked in full flexion by scar tissue joining the foot to the buttock. This may make you wonder what on earth went wrong. So what is the best first aid, what burns need to go to the hospital and which victims need specialized treatment? And how do I try and make a controversial and difficult subject simple enough for even the Cornish to understand?

The most important aspect of burn management is prevention. My new little friend Henry comes out with impressive ppff pfff noises every time he sees me drinking coffee. One year old and already he knows not to grab at something hot. It should be routine for all parents to teach tiny babies: “Hot! Ffpf! No! Don’t touch!” In Karamoja, 20 years ago, we were teaching women to make raised, fuel-saving cooking stoves out of mud. They work! The stove saves wood, prevents deforestation and global warming and most important of all: a child can’t crawl into the fire. Clever people, the Karimojong.
One the other hand, wiring in many Ugandan homes is appalling: I remember trying to simply change a bulb and getting a massive electric shock because the switch was on neutral and the bulb holder was broken. Think stoves, electricity, kettles, barbecues, and keep children at a distance.

First Aid

Simple! Pour cold water on it. Burns are caused by heat: in fact, only 45 degrees centigrade is enough to cause continued damage to exposed flesh once the skin is burnt. Obviously, drag the victim out of the fire, or away from the cable or out of the hot spring, then straight into colder water. If you don’t have water, use anything to cool the area: fan it, blow on it, pee on it, even dirty water is safer than a burn. So THE priority: cool it.
With chemical burns, such as acid, you cannot go wrong by pouring on loads of water as fast as possible. They are often horrible, deep and difficult and require specialist care.

Assessment

How bad is it, how deep is it, and does it need medical attention?
Here are some basic rules of thumb:
Anything more than 15% of total body surface area (TBSA) in a superficial burn or 10% of that area in a deep skin burn, or any burn affecting deeper tissue needs special care.
Estimation of TBSA is easy. In adults it is the “rule of 9’s.” with children slightly different.
There are 11 nines. The head is one, the trunk front and back: 2 each, the arms are one each, the legs make up 2 each. The extra 1% is only in men. So one whole leg burnt is 18%. One arm and half the face and head is 9 + 4.5 = 13.5%. Children are pretty much the same except the head is 2 nines and the legs are 14 each. Didn’t realize a child’s head is a bigger surface area than a leg? You learn something new every day. So, if it is over 15%, you need medical care because the amount of fluid lost in the burn could be important. The reason why so many people die when 50% of the body is burnt is because of fluid and protein loss. So a good rule: for all burns, drink a lot, and for any burns over 15% of TBSA, look for medical care urgently.

Superficial, deep skin, full thickness or deep tissue?

Deep tissue
This is easy. You see no skin, and charred flesh. That means fat, muscle, tendons and bone. They are not usually painful, but perhaps a bit uncomfortable, except for around the edges where the burn is superficial. So, if immediately you can see that the burn is smoking, or charred, or after a few hours it is painless and you can see charred flesh, that is a deep tissue burn, what we used to call 3rd degree. Immediate care is the same: cool it down as fast as possible by pouring cold water on it.
These days all deep burns should be treated surgically; usually within a few days. You need to get to somewhere able to cut out dead charred flesh, repair what is missing and cover it with new tissue. Fortunately, for Uganda there are many places in Kampala and increasing numbers of places up country for these procedures.

Full thickness skin burns.
These are the same as above really. You can see the skin is gone, there is no pain, the wound is either charred or white, may be oozing but no blister, and in a few days looks like leather. If it is more than a centimetre or two wide, than it probably needs to have the dead tissue excised and the wound grafted. So as above, don’t try and treat it at home.

Deep skin burns and superficial skin burns.
Superficial means that it affects only the first layer of skin, the epidermis. Deeper burns affect the lower layer of skin, called the dermis, and they may look exactly like superficial burns in the beginning. It doesn’t matter, as early care is the same. Cool it, then assess it. If it is painful, that is good news because it is probably mostly superficial; deeper burns are less painful. If it blisters with a big, raised, tense blister, that is good. Superficial burns blister the most and the fastest. Many are mixed, especially the common hot water scald in children. After a few days the deep skin burns are usually pale pink or white; the superficial: pink to red. Pressure makes the superficial burn blanche, then go red again, the deeper ones do not change colour when pressed. The important difference is that superficial burns require no treatment and heal in about 2 weeks, the deep skin ones will also heal but take longer. In both, there should be no scar. If the dermis is destroyed, that is a full thickness burn and needs grafting unless it is smaller than a few centimetres.

Pain.
Burns are painful. The best treatment is cold water. Keep it in cold water for hours if needed. Swallow some brufen or panadol. Don’t panic, it makes pain worse. Screaming kids can be held under water. You know what I mean! If necessary, one tab of valium for each 10kg will make everyone a lot happier. Give some to the child, too!

Home treatment
Use home treatment only for small areas: less than 10% TBSA or up to 15% if it is all superficial.
Pain: As above
Assess: As above
Drink a lot of fluids.

Dressing of superficial and deep skin burns

Superficial burns require no dressing at all. Faces definitely require nothing. If it is a large area on the trunk, a good treatment is to make a cradle to keep the bed clothes off, let it dry and leave it alone. If there are blisters, leave them alone until they reabsorb on their own - usually within a week. If it is a small area on an active child, or on the limbs, or an adult who wants to work, a thick cotton gauze dressing wrapped not-too-tightly protects it from being knocked and lets it heal. Leave it there until it is either messy or for 4 or 5 days. Then soak it in water or hydrogen peroxide and let it float off on its own, very slowly. Unwrapping a dry, stuck dressing is painful and will pull off all the lovely new healing skin tissue. Take your time, soak it for an hour if you have to, and just let it float away.
When you take off the first dressing, assess it again for depth: pain, colour, does it blanche on pressure. You will probably find that some superficial burns have a few areas that are now clearly deep dermal. If they are small, it doesn’t matter, dress it again and leave it alone for another 5 days. If any areas are hard, look like leather, with a dried up shell called an eschar with no feeling at all, that is full thickness. It needs surgery, so go somewhere where good surgery is available.

Dressing material

For blistered wounds, simple dry cotton gauze many layers thick is fine. When the blisters burst or are burnt off and there are wet, oozing wounds, then keeping them wet makes them heal faster. Everyone has their favourite dressing, and most research shows that most are no better than nothing, some are definitely worse, and none are significantly any better than any other!
Antiseptics are OUT. They delay healing.
Simple paraffin gauze is fine. Personally, I find it sticks and is painful to remove so I don’t like it.
Most ointments are messy and may delay healing. If they contain antibiotics, they encourage yeast infection, and I never use them
Silver sulphadiazine ointment is as good as anything and cheap and easily available, so it is widely used. Stick a good thick smear of it all over the wound, or on the gauze and slap it on, bandage it on firmly but not tightly, and leave it alone until it is either messy or for 5 days. Then soak it off with diluted hydrogen peroxide.
My favourite dressing is honey. It is antiseptic but does not delay healing, it does not stick so the dressings float off easily, it also prevents yeast and fungi growing and is cheap and available. A lot of good research has been published on honey on all wounds, including burns. Some have even shown that certain species of flower or tree are better for certain infections! The best is the local runny honey with dead bees floating in it. We get through bottles and bottles of it. Pour it all over the wound, slap on the gauze and leave it for 2 to 5 days. We find most dressings get a bit messy after 3 days so 5 days may work for some people but not for your average active 2 year old.
Quick note: this “leave it for 5 days” business is for recent burns seen in a few hours, not the stinking, festering, infected horrors from neglected wounds inappropriately treated for a week that we see all the time. Those we dress twice a day until they are clean. If you look after a burn properly from the outset, it will never go like that and either nothing or a dressing change every 3 to 5 days is fine.

Infection

Superficial burns left alone to dry and blisters left alone or dressed with a thick layer of gauze do not get infected. Giving antibiotics is inappropriate. Antibiotics do not prevent infection and do more harm than good. They simply encourage yeast, fungi and resistant bacteria. Even the deep wounds with an eschar treated in hospitals do not require systemic antibiotics. When they get infected, good antibiotic treatment is necessary. The first sign may be a bit of redness around the edge, perhaps a slightly manky wound, and then antibiotic dressings are probably the best. When there is fever or red, swollen tissue and spreading infection in the surrounding tissue, then systemic antibiotics are needed.

Outcome.
Superficial burns should heal in 2 weeks without a scar, deep skin burns in 3 or 4 weeks with maybe some discolouration but no real scar and all other wounds probably require surgery. If it looks as if it isn’t healing in that sort of timetable, then it must be reassessed. See a doctor. It may require excision and grafting, and these days, earlier is better than later.

Summary:

Keep cool.
Buckets of water or anything else cold.
Assess TBSA and depth
Deep burns are best treated with early surgery
Superficial burns: keep it simple. Most ointments, creams, antiseptics and drama are inappropriate.
Honey rocks!