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COVER FEATURE
  The (mis)management of burn injuries in Nepal  
 

CILLA KHATRY

“A burn victim in Nepal receives treatment only on the third day” should have read the newspaper headlines when a gas explosion left Radha Shrestha and her mother with severe third degree burns.

The incident happened on a weekend. On the third day, they were shifted to Sushma Koirala Memorial Hospital for Plastic and Reconstructive Surgery (SKMH), Sankhu, from Teaching Hospital where they were rushed after the accident.

Finally, their treatment began. The next day, her mother passed away. Had they received proper medical care the very day of the accident, then maybe the outcome would have been different.



Shrestha miraculously survived. But life as burn victims is extremely difficult as they are stigmatized and shunned by the society due to their appearance. Now she has to think twice before stepping out in public as people make comments that hurt her self-esteem.

She never takes the public transport fearing the sniggering and snide comments people pass looking at her.

“I’ve had people say that their day has been ruined by getting a glimpse of my face first thing in the morning,” says a teary-eyed Shrestha. “I feel sad that I lost my mother but I’m happy that at least she doesn’t have to bear the society’s harassment and maliciousness.”

Burn injuries are the second most common injuries in Nepal. Burn cases are mostly accidental and sometimes even homicidal and suicidal. Almost 61% of all burn victims are children and most accidents happen when they try to untangle their stuck kites and end up coming in contact with electrical wires in the process. In winters, most burn cases are 50 plus females who sit with their backs to the fire to escape the freezing cold.

In summers though, electrical burns in metal workers are the most frequent cases. Suicidal and homicidal cases in Nepal are frequently related to dowry. Sometimes, girls can’t handle the constant nagging and abuse and set themselves alight but mostly their in-laws are the main perpetrators of the crime. Sarita Khanum (name changed) of Bara district is one such case. Her brother-in-law poured kerosene over her and burnt her because of insufficient dowry. Khanum survived but not without extensive burn injuries on her neck, shoulder and chest.



Nepal ranks at number one position in the list of countries with the highest rate of mortality by fire-related accidents with an estimated 1,700 deaths per year, according to WHO. Managing burn injuries properly is important because not only are they excruciatingly painful but can result in disfiguring and disabling scarring, amputation of affected parts or even death in severe cases like that of Shrestha’s mother. Complications like infection, shock, electrolyte imbalance, multiple organ dysfunction syndrome and respiratory distress may occur in case of mismanagement and negligence which further adds to the woes of the already stressed victim.

In Nepal, burn cases are handled by Teaching Hospital and Bir Hospital with Kanti Children’s Hospital looking after pediatric cases as private hospitals in the Valley are not well equipped to handle such patients. Private hospitals don’t have separate burn wards and the number of beds for burn victims is limited to just one or two while Teaching and Bir Hospitals boast a separate burn ward with nine beds. But even then, many patients end up being referred to SKMH for further treatment upon the unavailability of beds in these hospitals.

Dr Niroj Banepali, a medical officer at Bir Hospital, clarifies that since SKMH specializes in reconstructive surgery like skin grafting, the suggestion to go there is often made on that basis. Teaching Hospital also refers patients to other hospitals upon the lack of a bed. Kalpana Sitoula, nurse-in-charge of the burn ward for 25 years, asserts that they don’t recommend any particular hospital but leave that decision to the patients and their families. But SKMH is surely one of the select few options they have.

“Many patients who come here are cases referred to mostly by Teaching and Bir Hospitals,” says Dr Sushil Ram Shrestha, of SKMH.

SKMH specializes in plastic and reconstructive surgery after the recovery of burn wounds. Though it attends to cases of fresh burns as well, it is better equipped to address post-burn cases like those that have developed burn scar contracture which is the tightening of skin after second- and third-degree burn. Contractures should be treated as soon as possible, as scars can restrict the movement around the injured area and the hospital has a team of doctors specializing in these types of treatments.

“We can’t take in patients who have sustained more than 30% burn injuries, as these patients need constant monitoring and we are not aptly prepared for that due to the lack of an ICU setup,” says Shrestha. These types of cases are again referred back to Teaching Hospital as they handle acute burn cases, and burn victims who need ICU monitoring are also advised to go there.

The lack of all necessary facilities under one roof is what forces patients to get shuffled from one hospital to another. In the case of burn injuries, the earlier the victim gets treatment, the better are the chances of survival and healing after surgery. In Shrestha and her mother’s case, too, if their treatment had started on the day of the accident, then probably her mother would still be alive and maybe even Shrestha would have recovered much earlier and come out of it with lesser scars.

“Had we received timely treatment, my mother might still have been with me,” laments Shrestha. Referring patients from one hospital to another causes delay in treatment but hospitals sometimes have no other option than to do just that as they work with limited resources.

Dr Ishwor Lohani, plastic surgeon at Teaching Hospital, believes that most hospitals don’t like to take burn patients since the cost of treatment and the mortality rate both are high in burn cases. He believes this to be the reason why burn victims end up being referred from one hospital to another.

“Hospitals are not ready to take complicated cases like burns. It’s not that they are ill equipped, they just don’t want to go through the hassle when they can easily send the patients somewhere else,” he says with an exasperated sigh.

Lohani’s comments can be validated by Khanum’s case. She could not afford treatment and sat on the roadside begging while her father sold stickers to collect money. Such is the scenario in Nepal. Victims are deprived of treatment till they can afford the high-priced procedures. Shrestha, on the other hand, considers herself lucky to have had family and friends who funded all her expenses.

But surely not everyone is as fortunate. During her stay at the hospital, she saw many patients who were not getting the required treatment because they could not afford certain medications and some didn’t even have access to a protein-rich diet that is essential for recovery in case of burn victims.

Lawrence Shakya of Burn Violence Survivors (BVS), an NGO that works for the rehabilitation of burn victims by providing them counseling and vocational training besides providing financial aid to them for treatment through private donors, blames the government and says that there is a lack of proper care of patients as the government has not recognized burns as a disability inducing disease.

“If the government was to pass a law that recognized burns as a disability-causing disease, then it would probably be better managed at hospitals,” says Shakya. Burns, if treated right, would not cause disability. But lack of proper management of cases leads to disability and 5% of the total 8% of the disabled population in our country is due to burn injuries.

Dr. Senendra Raj Uprety, chief of curative services at the Ministry of Health and Population, agrees that burns need timely and quality management which can greatly affect the outcome of the final state of the victim and that way even the mortality rate would go down considerably.

When asked why the government does not take any drastic measures to address the vacuum that is present in terms of resources and facilities available at the hospitals for burn victims, he said, “Burn management is difficult and we’re quite concerned that we’re only able to save just about 50% of burn victims. This is because there’s a lack of sufficient resource and facility allocation. We hope in the future all tertiary care level hospitals will have a separate burn ward, plastic surgery facility and more than enough beds. We’ll work on that.”

With burns being a common household injury, the question remains that since hospitals at the moment don’t have all the facilities required or the limited number of beds available restricts intake of patients, where does one go?

Though the government acknowledges that there is a problem, when will they act on it? How many more lives does the country need to lose in fire-related accidents or how many more citizens need to be scarred for the government to finally sit up and take notice?

What you do immediately after a burn may help reduce the severity of the injury. Outlined below are some basic dos and don’ts.

Dos
• In case of a minor burn, cool it in running water until the burning sensation subsides. (10-15 minutes)
• Apply a cold compress but don’t use ice. Use sterile gauze dipped in cold water.
• If there is any bleeding, try to stop it by applying a light pressure over the area.
• Cover the burn area with a sterile pad.
• Open doors and windows or make sure the victim gets fresh air as CO poisoning may occur due to inhalation of smoke in an enclosed space.
• Remove rings, belts, shoes and tight accessories, including clothing before swelling occurs.
• Only for first-degree burns, apply ointment or lotion to soothe the area.
• For chemical burns, remove any clothing that has come in contact with the chemical, and in case the chemical has reached your eyes, flush them with water continuously.
• Seek immediate medical attention for second- and third-degree burns.

Don’ts
• Try to attend to a serious burn without medical attention.
• Use ice-cold water, as this may cause hypothermia.
• Break blisters as the blister fluid contains toxic inflammatory mediators.
• Apply butter or oil to the affected area as this will only make it worse.
• Apply lotion or ointment to a second- or third-degree burn.
• Remove any clothing that is stuck to a burn. Only cut around the fabric to clear as much as possible from the affected area.
• If an electrical burn occurs, don’t touch the victim as there may still be an electrical current left. Just shut off the current at the source, and wait for medical help to arrive.

 
Published on 2012-02-10 17:24:47
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The (mis)management Of Burn Injuries In Nepal
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