Chapter 16: Consultations

consultations:

________pulmonary medicine

________OCCUPATIONAL THERAPY

________physical therapy

________primary care physician

________PERDIADTRIC OR FAMILY PHYSICIAN FOR PEDIATRIC ADMISSION

________ophthalmic service

________psychologist

________pastoral care

________registered dietician

________social service

________discharge planner

________infectious disease

 photography

I.          Pulmonary medicine

Pulmonary medicine should be consulted for any patient with suspected inhalational injury or patients with pre-existing pulmonary disease.

II.          Occupational therapy

Burns to the upper extremities or hands should be evaluated by an occupational therapist. Splinting recommendations and exercises are begun early and consultation arranged for fitting of pressure garments.

III.          Physical therapy for evaluation and treatment

Physical therapists work in conjunction with occupational therapists. Burns to the lower extremities should also be evaluated early by the physical therapist to assist with ambulation, range of motion exercises and fabrication of necessary splints.

IV.          Primary care physician

A primary care physician should follow any medical problems outside the care of the burn injury, and can provide an important link in addressing these concerns once the patient has been discharged. 

V.          Pediatric or family physician for pediatric admission

Evaluation by a pediatrician or primary care physician should be a routine for every burned child that is admitted. 

VI.          Ophthalmic service

Burns to the face in the area of the eyes warrants an ophthalmic consultation, especially if the patient complains of a decrease in visual acuity, or pain or unfamiliar ocular sensations.  Copious ocular irrigation of any chemical spills to the face or eyes should occur immediately and should not wait until the arrival of the ophthalmologist. 

VII          Psychologist

A.    The psychological ramifications of burn injuries include anxiety, depression, regression, and hostility.   Estimates of psychiatric disorders in burn patients are higher than the rest of the general population.[i]^{,[ii],[iii],[iv]} Some of the common premorbid disorders diagnosed in burn patients are depression, antisocial personality disorder, organic brain syndromes, and alcohol and drug abuse.^{3,4,[v],[vi],[vii],[viii]}   

B.    The psychologist plays an integral part in facilitating the psychological recovery of burn patients, and should be consulted for every patient admitted to the burn unit.

C.    Post Traumatic Stress Disorder (PTSD) occurs when patients repeatedly experience a distressing event (such as the intrusive memories of a burn injury), and avoid experiences that remind them of their trauma. PTSD is common, but brief in burn patients, and rarely do patients experience symptoms beyond hospital discharge.

D.    Children also pass through the early, intermediate, and long-term recovery changes, but have several adjustment differences compared to adult burn patients.  The child response to the hospital surrounding is age dependent.  Children aged 1 to 2 years may experience separation anxiety, while school-age children often respond with agitation and anger.  Adolescents may react to treatment demands with either regression or rebellious noncompliance. 

VIII.          Pastoral care

A.     The hospital clergy can play an important role in focusing patients’ religious convictions on the healing process.  Spirituality increases the emotional well being of the patient, which may translate into faster physical recovery.  Scientists often reject prayer-based healing because modern medical science is material based, with little confidence in the possibility that nonmaterial forms of healing exist.  Spiritual healing is often equated with mysticism, and there is a lack of replicability of healing phenomena in many cases.[ix]

B.    Physicians should, however, be flexible and tolerant in honoring a patient’s point of view, though it may differ from his or her own.

IX.          Registered dietician

The dietitian should follow all admissions to determine if the patient is receiving adequate nutrition relative to the size of the burn and the patient’s age and co-morbid medical problems. 

X.          Social service/ Discharge planner

The social worker and discharge planner ease the transition from hospital to home upon discharge. They provide the proper arrangements for both patient and family concerning issues relating to disability, housing and transportation.

XI            Infectious disease

The infectious disease service is routinely consulted upon admission for any patient with massive burns, patients with histories of burns with likely infectious complications (i.e. Patients who were exposed to dirt or pond water after the burn injury, or patients who delayed treatment of their burns).  Any antibiotics administered to the burn patient should be given in concert with recommendations by the infectious disease specialist. 

XII          Internal medicine

An internal medicine consultation can be initiated on admission or at any time during the patient’s hospitalization to follow any pre-existing medical issues or medical problems that arise during treatment of the patient in the burn unit.  A cardiologist should be consulted for patients with electrical injuries and those with documented cardiac arrests or arrhythmias, or for any patient with known cardiovascular disease.

XIV          Photography

All burn wounds should be photographed either immediately, or on the next standard working day.  This serves as a record of the burn wound, as seen initially on admission, as well as a source of evidence for later legal use.  A standard camera is suitable.  Digital cameras offer the advantage of easy storage and retrieval of images.