Archive for ‘healthcare’

March, 2014

Surviving Burns and Overcoming Burns

Dr Jonathan Reinarz

One of the most interesting aspects of burns work undertaken by Archibald McIndoe during the Second World War (see Wednesday’s post) was the establishment of the Guinea Pig Club. The Guinea Pigs were members of WWII Royal Air Force air crews who had undergone at least two operations for their burns injuries at East Grinstead Hospital, where McIndoe was based. Originally intended to be a drinking club for patients whose injuries could be dangerously dehydrating (see Monday’s post), it counted 39 members at its launch in June 1941, a year after the Battle of Britain. By the end of the war, there were 649 Guinea Pigs, most of whom were British (62%), but it also included Canadians (20%), Australians (6%) and New Zealanders (6%); 80% had served as bomber crew during the war. As war historian Emily Mayhew has suggested, the Club was ‘an attempt to institutionalise the unique spirit of the patient community at East Grinstead’ in order to aid the psychological recovery of burn victims. Patients collectively attended operations, assisted newcomers and otherwise offered support to each other when necessary.

‘Dealing with Disfigurement’

Rather than hide away these severely disfigured airmen, McIndoe considered both their physical and (as he termed it) psychical wellbeing. He recognised that patients relied on their surgeon ‘for mental support, for hope and encouragement.’ But he also encouraged his patients to resume ordinary lives, often commencing with a joint visit to a local pub. Most wanted to resume normal lives, but their wounds often made this more difficult than expected. McIndoe knew that his patients would inevitably attract much attention the moment they ventured into town to frequent pubs or restaurants, so he prepared the residents of East Grinstead for potential encounters with patients, some of whom were mid-operation, with tube pedicle grafts nearly in place to reconstruct missing chins or noses. He also invited key members of the town into the wards, encouraging them to become ambassadors in the community by regularly hosting concerts and balls, where patients mingled with locals. In this way, he made the residents of East Grinstead recognise and accept his patients and focus on their contributions to society, rather than their disfigurements. In the process, East Grinstead became known as ‘the town that didn’t stare’, while the hospital developed an international reputation for its Maxilla-Facial Unit. The staff was so successful at its work that 80% of aircrew patients eventually returned to flying duties. Such success continued into peacetime, but the details of McIndoe’s civilian work has been less documented. Despite the positive experiences of East Grinstead Guinea Pigs, many inevitably faced challenges when they re-entered their former communities. That said, many had learned how to deal with these difficult encounters from their membership of the Guinea Pig Club; a group of about 60 original members continue to meet.

Psychological support for burns patients has continued to grow since 1941. The emotional load on staff at burns units has also been recognised, with many practitioners expressing their own challenges coping with the onerous duties involved in caring for these unique patients. Unusually, when Guinea Pigs visited America following the war, their faces were kept out of the press for fear of alarming the public. Americans would inevitably learn about the psychological impact of burns in their own ways. The 1942 Coconut Grove nightclub fire in Boston was not the worst urban fire in twentieth-century America, but it had a huge impact on burns treatment. Besides directing attention to the consequences of inhalation injury, it provided valuable insights into the immediate and long-term psychological impact of severe burns and the importance of supporting patients after their physical wounds healed. As obvious as some of these lessons were, it seems they need to be relearned every decade or so. More often these days, the memories of disasters, collective and individual, are kept alive by patient groups. Many American victims of burns and scalds owe their emotional recovery to the Phoenix Society for Burn Survivors, a national organisation dedicated to burns patient support, public education and advocacy.  In Britain, patients with burns receive the support of similar organisations, including Changing Faces, BurnAid and the Katie Piper Foundation. So successful have burns units become at saving humans that their challenges have shifted. Many victims now expect medical teams to save lives and even restore former appearances. It is with such expectations that support groups also help a new generation of patients.

New portrait of Simon Weston recently unveiled at the National Portrait Gallery.

New portrait of Simon Weston recently unveiled at the National Portrait Gallery.

Jonathan Reinarz wishes to thank Emily Mayhew, Rebecca Wynter, Naiem Moiemen, Tony Metcalfe, Shah Mamta, Ken Dunn and James Partridge for their help with his research.

Dr Jonathan Reinarz is Director of The History of Medicine Unit and a Reader in the History of Medicine at the University of Birmingham.

March, 2014

Burns and Infections: The Birmingham Accident Hospital

Dr Jonathan Reinarz

Nearly 60% of burns patients die of infections contracted after their initial injuries. Historically, burns-related infections have proved particularly challenging. Burn wounds contain devitalised tissue and remain moist and warm during the healing process, thus an excellent breeding ground for bacteria. In the early twentieth century, burns did not appear to respond to existing antiseptic methods. Many doctors believed that burns themselves released toxins and attempted to neutralise these by treating burns with dyes and acids, which often hindered recovery. As a result, many practitioners continued to regard the infection of burns as inevitable.

In the 1940s, important research in this field began to be undertaken in the English midlands at Birmingham Accident Hospital. When an existing general hospital on Bath Row in the city centre was moved to facilities behind the newly constructed Birmingham Medical School in 1938, the old site was renovated and reopened in 1941 as the Birmingham Accident Hospital. (Incidentally, the site was also the last voluntary (or charity) hospital established in England and Wales before the introduction of the National Health Service). The new hospital’s Surgeon-in-Chief and Clinical Director William Gissane (1898-1981) regarded this as an experiment in the care of trauma in order to improve local accident services, which were inadequate across the country. At the outbreak of the Second World War and the associated production of military hardware, this had become obvious; the incidence of local industrial injuries, including burns, increased by 40%. During 1943, a small unit to treat burns and scalds was opened, and Gissane invited Leonard Colebrook (1883-1967) to be its first Director. Like Gillies (see yesterday’s post), Colebrook was a veteran of the Great War and contributed to a Government-appointed war wounds sub-committee run by Archibald McIndoe during the Second World War. Colebrook had investigated the bacteriology of wounds at the burns unit at Glasgow Royal Infirmary, where he had previously investigated puerperal sepsis in maternity cases. He therefore had experience of both burns and streptococcal infections when called on by Gissane to run the Medical Research Council-funded unit.


‘The Topical and the Local’

On arrival, Colebrook quickly turned to the investigation of streptococcus infections in burns. With new topical anti-microbial agents, such as penicillin and propamide, he and his team managed to reduce the prevalence of these infections to 5%. Controlling infection, whether through topical creams, or ventilated wards and bandaging stations, allowed for new burns treatments, such as early excision, which is still described as an important measure to prevent infection as well as disfiguring contractures. When he retired in 1948, Colebrook turned to organising local and national burns prevention campaigns, focusing, for example, on safer electrical heaters and the introduction of less flammable clothing for children.

Colebrook’s successor was Edward Lowbury (1913-2007), who became bacteriologist at what was later renamed the MRC Industrial Injuries and Burns Research Unit in 1952. Among other things, Lowbury initiated the first properly controlled clinical trials in burns, and infection rates continued their downward trend, until the emergence of antibiotic-resistant bacteria in the late-1950s. The introduction of silver nitrate in 1966 halted this rise, but rates would continue to fluctuate, as safer alternatives were introduced. By 1963, the burns unit had already become a large regional centre comprising 36 beds, a ‘clean air’ dressing station and expanding research facilities, with Lowbury compiling a unique record of resistance changes until his retirement in 1979. Treating over 18,000 burned patients between 1941 and 1993, the burns unit developed a planned, systematic approach to the treatment of these injuries, which greatly reduced the frequency of associated infections.

Problems of infection in hospitals in the wider Birmingham region led to the establishment of the Hospital Infection Research Laboratory in the grounds of Dudley Road Hospital (later City Hospital) in 1964. Administered by the MRC Burns Unit and under the direction of Lowbury, the laboratory assessed the number of infections in regional hospitals, determining causes when possible. Although the Accident Hospital closed its doors in 1993, the Infection Control Research Laboratory continues to exist in a new location. Many of its earlier recommendations for controlling infection are still in place today. With the laboratory celebrating its 50th anniversary this year, staff have organised a commemorative conference, and the History of Medicine Unit at the University of Birmingham has organised an exhibition on ‘the history of hospital infection’, which will be on display in the foyer of the Medical School until the summer.

Dr Jonathan Reinarz is Director of The History of Medicine Unit and a Reader in the History of Medicine at the University of Birmingham.

March, 2014

War burns and the birth of plastic surgery

Dr Jonathan Reinarz

The majority of historical research into burns has concentrated on the remarkable reconstructive work undertaken on burns casualties during the First and Second World War. In fact, some argue that plastic surgery as a specialty first emerged during the First World War. Soldiers in both wars sustained horrific injuries and dreadful deformities from high velocity missiles, explosives and burns, many of which would previously have defied repair. A young ear, nose and throat (ENT) surgeon from New Zealand, Harold Delf Gillies, began the war in a surgical unit at the Cambridge Hospital, Aldershot. Alarmed by the number of face and jaw reconstructions he was having to perform, Gillies visited two plastic surgeons in France before setting up a larger surgical unit in 1917 at Sidcup, where he brought together a team of specialists, including ENT colleagues and dental surgeons. Gillies is best remembered for the tubed pedicle, a flap of skin which was harvested from the arm or chest, for example, stitched into a tube, so as to retain a blood supply and gradually migrated to the area where it was required. By the end of the war, Gillies had developed many other surgical techniques and performed over 11,500 operations. Many of these are included in his best known publication, Plastic Surgery of the Face (1920), which, along with Gillies’s archives, has recently been digitised and made available online as part of activities to mark the centenary of the First World War.


From Airman’s Burns to Hiroshima

In one of those accidents of history that historians have become used to over the years, many severe burns in the Second World War were placed in the hands of another young surgeon, Archibald McIndoe, who happened to be the cousin of Harold Gillies. Unlike most of the casualties seen by cousin Harold, McIndoe treated primarily flame injuries that largely resulted from a decision to relocate the petrol tanks of fighter aircraft in front of the cockpit and pilot. The consequences of placing 48 gallons of fuel in the nose of a Spitfire rapidly became apparent during the Battle of Britain in 1940, when burn casualties mounted and the medical community defined a new injury, ‘Airman’s Burn’. Nearly 400 Royal Air Force (RAF) crew sustained serious burns to their face and hands in 1940 alone, Richard Hillary becoming perhaps the best known due to his memoir, The Last Enemy, in which he described his injuries.

‘I looked at my watch: it was not there. Then for the first time I noticed how burnt my hands were: down to the wrists, the skin was dead white and hung in shreads: I felt faintly sick from the smell of burnt flesh.’

While the smell of burn victims and high fatality associated with serious burns had led many to be isolated, removed or even excluded from nineteenth-century hospital wards, Hilary was lucky to be treated in a specialist burns unit by one of only four plastic surgeons operating in Britain at this time (including Gillies who would spend his second war at Park Prewitt Hospital in Basingstoke). Appointed civilian consultant surgeon to the RAF, McIndoe became responsible for Hillary and many other air-force casualties at a surgical unit which was established in a cottage hospital in East Grinstead, 40 miles outside of London. Here, he treated hundreds of burned airmen and developed surgical techniques in order to improve on existing plastic surgery techniques, which often left much to be desired. According to Mcindoe, in these early years of reconstructive surgery ‘the end result seemed to convert the pathetic into the ridiculous’. Rarely satisfied with his first attempts, McIndoe worked 12-hour days and frequently subjected his patients to more than a dozen operations. He rapidly became recognised as the authority in the field, influential in developing new operations and discarding older treatments, such as the use of tannic acid to coat burns injuries. He hosted many visiting surgeons at East Grinstead, which had trained 60 surgeons by 1943, and secured his reputation in 1944 when 50 North American plastic surgeons attended his unit for ten days to train in preparation for the D-Day landings. He also increased the levels and training of nurses on his wards and introduced saline baths into burns treatment.

After the 1945 atom bomb attacks on Japan, the attention of doctors turned to the impact of modern warfare on both military and civilian casualties. McIndoe himself argued that burns would likely outnumber all other injuries in future wars. McIndoe’s colleagues similarly promoted such ideas, suggesting that ‘atomic flash’ burns necessitated whole hospitals be transformed into burns units, arguments reinforced in the aftermath of Hiroshima and Nagasaki and during the Cold War. Many more units like that at East Grinstead were established in the 1950s, and McIndoe continued to work in his 50-bed Burns Centre at East Grinstead until his retirement in 1959. In a lecture to the Royal College of Surgeons in 1958, he comprehensively outlined his views on reconstructive surgery and paid homage to ‘the greatest plastic surgeon of all times’, Harold Gillies. McIndoe died in 1960, aged 59. A statue is being planned to recognise his work; if realised this will be one of only three existing British public monuments in England commemorating surgeons.

Dr Jonathan Reinarz is Director of The History of Medicine Unit and a Reader in the History of Medicine at the University of Birmingham.

March, 2014

Burns: A riot in the body

Dr Jonathan Reinarz


You can imagine, as a medical historian, much of my research centres on ‘Saving Humans’. When I was asked to contribute to this blog, though, one particularly timely subject immediately leapt out: burns. I began researching burns last year in the British context for the years 1800 to 2000, and, in that time, the public has been reminded of the subject with regular reports of acid attacks, house fires, wars, suicides and revolutions. More than many other subjects I have researched, burns are both timeless and very timely. In June 2013, the Burns Collective was launched in Birmingham, creating a national centre for burns research linking hospitals in London, Bristol and the ‘Second City’. I attended the inaugural conference and instantly found myself fascinated by papers outlining current practices, research and priorities. Though the history of burns remains to be explored, they should also be familiar to all of us. Unlike many diseases and accidents which will thankfully remain a mystery to most of this blog’s readers, we have all experienced burns. However prevalent or timely, burns are also particularly suited to a blog managed by the University’s Institute of Advanced Studies. Like the IAS, which aims to bring together scholars from across the University of Birmingham’s various academic disciplines, burns are unique in the way they bring together people from across medicine’s many specialties. 

In a previous project, I had the opportunity broadly to explore the medical, social and cultural history of the skin. At its most basic, a burn is an injury of the skin, the body’s largest organ (though some now call it a ‘multi-organ’). Addressing burns and scalds only in passing, the project reminded us that burns are prominent in the cultural imagination, and have been so for hundreds of years. Neither are they confined to the realm of the dermatologist. Besides contributing significantly to the way in which we conceive of ourselves and others, the skin has many essential functions: it regulates the passage of fluids in and out of the body; it helps synthesis vitamin D, while shielding the body’s interior from ultraviolet radiation; it is a barrier that prevents disease-causing organisms from entering the body, while simultaneously receiving sensations which it passes on to the brain via the nervous system. As a result, when the skin is burned, whether by hot tea, a sunburn, or following more serious flame, electrical or chemical accidents, we experience pain, and much else that is more than just skin deep. The skin’s many features and functions are invariably compromised by burns, and people’s identities may be changed forever. The more serious the burn – anything larger than 10% total body surface area is considered a major burn – the more violent the body’s response. It is for this reason that burns have been described as ‘a riot in the body’. All bodily systems potentially respond to serious burns, especially if the victim also experiences smoke inhalation.

What is a burn?

The immediate aftermath of a severe burn is shock and suffocation, both related to a lack of oxygen. Plasma normally circulating in the blood surges to the tissues, leaving the blood thicker and prone to clotting. During the 24-hours following a burn, the affected area grows progressively more swollen; this is the period when blisters form. Fluid must be replaced to restore circulation and dilute the toxins being expelled in greater amounts by the kidneys (one formula used to help calculate fluid replacement was developed by Basil Pruitt, who attended the Birmingham congress). In the nineteenth century, the oozing appearance of burns might have led doctors to introduce treatments which only encouraged dehydration. As a result of these physiological changes, the body is less able to regulate temperature and shock ensues. One by one, the major organs are compromised by the loss of liquids. When the respiratory system is effected, breathing becomes difficult and the body deals with lower cardiac output by pumping more blood. The additional effort required to do so sends the body into a hypermetabolic, or catabolic, state, and it begins to break down tissues, burning protein as well as fat. As body mass decreases, the patient becomes more susceptible to infection and wounds also heal more slowly. The destructive increase in metabolism, on the other hand, is countered by feeding the patient amounts of food that might ordinarily be regarded as excessive. And, importantly, the whole process is not over in a day or two. Burns are an acute illness that lasts weeks or even months. Treatment of burns patients therefore becomes an intensive life-saving process, which these days extends beyond the immediate survival of the burned individual, and aims for full psychological recovery, involving psychiatrists, physiotherapists and social workers, among many other specialists and professionals. It is for this reason that victims of severe burns are treated in burns units. According to the British Burns Association, there are currently 27 specialised burn units in Britain. In the 1930s, more than half of major burns cases in this country might have died from their injuries. Today, 97% of approximately 16,000 people hospitalised for burns each year survive this ordeal.

Dr Jonathan Reinarz is Director of The History of Medicine Unit and a Reader in the History of Medicine at the University of Birmingham.

November, 2013

‘A chance to cuddle babies!’ by Fiona Cross-Sudworth, Midwife at Birmingham Women’s Hospital

‘How lovely’ is often the reply when I say I am a midwife; ‘a chance to cuddle babies!’ they often add. While I agree that this is definitely a bonus, I don’t often mention the other side of my job: the privilege of also caring for mothers who don’t get to cuddle or take their baby home. 

Death of a baby whether a stillbirth or neonatal death is upsetting for the healthcare professionals involved and must be unbelievably difficult for the parents concerned. The Stillbirth and Neonatal Death Charity have calculated that 17 new families a day in the UK are grieving. The UK actually has one of the highest stillbirth rates in the developed world. 

Some of the risk factors contributing towards stillbirths and early neonatal deaths are known including intra-uterine growth restriction, poverty, infection and maternal medical conditions. However, there is still a raft of information even about the known risk factors that are not understood well, making further research into the cause and prevention of stillbirths a pressing need. 

In addition, we as healthcare professionals still have lots to learn about how and what we communicate from current research to pregnant women. Women must be able to look after themselves and their unborn babies as well as understand what warning signs to look out for (such as reduced or absent fetal movements).

Effective, research-based care will be what reduces our stillbirth rates. Here in the West Midlands this rate has reduced year on year. This is considered to be as a result of a multi-disciplinary approach to identifying intra-uterine growth restricted babies; arguably one of the most significant risk factors in stillbirth. That’s finally some good news.

Further links:

CMACE Reports

November, 2013

‘Don’t throw the baby out with the bath water’ – the importance of training in a low resource setting, by Miss Sadia Malick, Consultant Obstetrician and Gynaecologist & ammalife trustee

Training in the management of Obstetric emergencies is essential to prevent unnecessary disability and death in women. It is very important that all training is tailored and targeted for the group of healthcare workers being trained. All skilled birth attendants in the UK received skills updates every year.

In Pakistan, this is often not the case. There are three main groups of maternity healthcare providers. Firstly the trained doctors who are not working in hospital settings and do not take part in mandatory Clinical professional development programmes. These doctors remain on front line duties facing Obstetric emergencies all the time but unfortunately do not initiate or are part of programmes where they have to keep their knowledge up to date. Some NGO’s are involved with this cadre to improve and update skills with an aim to reduce maternal mortality and morbidity.

The second group are the trained nurses or midwives who provide midwifery care to women. These health care professionals usually work in district general hospital or smaller hospitals where they do not have the support of trained doctors’ majority of time. They have their experience and knowledge of working in obstetrics for many years but unfortunately have no formal training programmes to either update their skills or to learn new skills which would help them improve their care for the women they deliver. Some NGO’s are also involved with improving skills of this cadre.

The third group is that of the traditional birth attendants. This group is largely controversial and due to their lack of regulated training is blamed by the above mentioned group for the majority of the complicated cases that arrive too late in the hospitals, and present in a moribund state. The reality is that the services offered by TBAs are the most commonly used healthcare provider used by women, particularly in rural areas. This is due to many reasons, such as social (many women are not permitted to attend hospital to give birth for fear of exposure), financial (expensive, unaffordable healthcare, financial bribes by staff, or costly transportation to hospital) and a lack of any other service available (an absence of healthcare staff at the facility, as there is a global shortage of nurses, midwives and doctors).

Published research (Wilson et al, 2011, BMJ) suggests that engaging more with this group, by training and supporting them to detect and refer women experiencing signs of obstetric complications can improve outcomes for women and their babies.

Until societies decide that saving women is an absolute priority (economically and socially) and increase the numbers of skilled birth attendants to allow every pregnant woman to have a skilled birth attendant, like here in the UK. We should look to TBAs to fill the gaps. Evidence has shown that they can be effective, we should not ignore this. If there are interventions that work then we should use them. We cannot not ignore evidence; we should support TBAs until we have the optimal intervention to reduce maternal death – a skilled birth attendant such as a midwife or a doctor.

Useful links:

WHO maternal death

MME org

Pakistan maternal mortality

Maternal info world bank

Perinatal deaths

Obstetric care Pakistan


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