# Spanked By ER Doc!



## Gbro (Sep 8, 2007)

I have been reprimanded by an Er Doc, It only lasted about 10 min, and he kind of ran out of breath, and left mumbling things we don't want our children to hear.
The call came in "2 year old pulled a deep fryer down onto himself"
This was 30+ miles north, and 1st responders are paged.(they usually never make contact, as they are from another county).
As we put ourselves "enroute"(10-8) I put in a request for a chopper, and requested it lift off ASAP. 
On scene, 1st responders had water jel dressings on the child, and he was just fussy. The burn was 50% of the chest, with some burns on the upper legs. 1st responders stated child was screaming upon their arrival.
We took the Water jel package as more of the jel was still in it, and transported the child on the mothers lap, This was to keep child from over cooling. The transport went well, good vitals and LOC, Reported again to ER, as we gave ER heads up about Chopper being launched  while we were enroute.
The chopper was just landing on the Pad when we arrived at the Hosp. We were just ahead of the flight crew bringing pt into ER. The response was like an "Ice Berg" We even heard comments like "don't you think we know how to handle burns". The ER Doc took his anger out on me.

"Who gave you the authorization to use an ointment on a burn?"
"Where in your training manual dose it say to put an ointment on a burn?"
I said, "Doc, It's Water Jel" He stated that that is an ointment???

Then he hit me with, "Where is your Protocol for its use?"

Ahaa, Baa, Ahaa, Doc, I don't know!(now i could have wimp'ed out and told him that the 1st Responders were the evil villains that put that crud on this boy), But not me, and we have been carrying water jel on board for 6-7 years, and used it numerous times in the past.
This went to the state. We were "WRONG" we had no protocol!
We then contacted the major burn center in our Region and did get a authorization for the use of Water based burn dressings.

Guess our Eye's and Tee's were not quite dotted and crossed.


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## certguy (Sep 8, 2007)

I'd like to hear some more on these water gel dressings . Though I don't agree with it , our local protocal is dry , loose dressings after the initial cooling . As a disaster worker , I could well see burn pts. with a long transport delay due to infrastructure damage and not enough resources . These could provide longer pain relief as long as they don't cause hypothermia .

                       CERTGUY


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## PArescueEMT (Sep 8, 2007)

I know I was taught to soak down a 5x9 with NSS or sterile H2O. i personally have never used water gel or other "burn dressings". Burn sheets and wet dressings are all i have used.


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## Ridryder911 (Sep 8, 2007)

There are times you have to pick your fight wisely. I would had told him to contact my supervisor, etc. I would had recommended him to read the ABA burn criteria as well. He made his point, that is all it should had been. 

Seems, unusual that an ER Doc would even want to deal such a mess.... since, he will have to transfer it later. I unfortunately have not always learned diplomacy, and after the first 5 minutes of arse chewing, asked if he would like to settle it outside. 

R/r 911


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## Airwaygoddess (Sep 9, 2007)

A point well said Rid!


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## Arkymedic (Sep 9, 2007)

Ridryder911 said:


> There are times you have to pick your fight wisely. I would had told him to contact my supervisor, etc. I would had recommended him to read the ABA burn criteria as well. He made his point, that is all it should had been.
> 
> Seems, unusual that an ER Doc would even want to deal such a mess.... since, he will have to transfer it later. I unfortunately have not always learned diplomacy, and after the first 5 minutes of arse chewing, asked if he would like to settle it outside.
> 
> R/r 911



*Grins wickedly* Sounds like me and you have the same prob Rid. My mouth works faster than my brain has time to stop it and I would have said the same with a few choice words (but I'm working on that lol).


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## Arkymedic (Sep 9, 2007)

certguy said:


> I'd like to hear some more on these water gel dressings . Though I don't agree with it , our local protocal is dry , loose dressings after the initial cooling . As a disaster worker , I could well see burn pts. with a long transport delay due to infrastructure damage and not enough resources . These could provide longer pain relief as long as they don't cause hypothermia .
> 
> CERTGUY



When I was at the oil refinery in KS we had them and used them very effectively for thermal, flash, electrical, and hydrofluroide (HF) and caustic burns. The smaller ones work very well for sunburns also.


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## Flight-LP (Sep 9, 2007)

Water jel is great, I've not heard of needing a burn centers approval for it though, must be a MN. thing. Yeah, the doc didn't have to be a di#$, but that could have been easily avoided. Just don't take the pt. into the ER and hand off care directly to the flight crew. Not only does it avoid having some doc in a box who probably isn't prepared for such a patient going nuts, it also eliminates the need to wait for a transfer, the flight crew can take the pt. directly there. Or meet the helicopter somewhere else. Either way, I would have never stepped foot into that ER. Also, and this is just a pet peeve of mine, NEVER transport a pt. on moms lap. There is no reason to not properly secure a child for transport. Should you have been involved in an MVA, that kid is now nothing more than a greased up projectile. Try explaining that one in court...................


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## Gbro (Sep 9, 2007)

> LP said;
> NEVER transport a pt. on moms lap. There is no reason to not properly secure a child for transport. Should you have been involved in an MVA, that kid is now nothing more than a greased up projectile. Try explaining that one in court...................



I agree with you,
 We have several pediatric immobilization devices in use today.
I will have to do some testing and see if this;
http://www.med-worldwide.com/product20951.html
devise could be used attached to mom. It is one of the devices we use today.



> Rid said;
> There are times you have to pick your fight wisely. I would had told him to contact my supervisor



Why, i can handle a bit of chewing, Like i posted we were wrong on past runs, to pass the buck isn't my way. It was then dealt with appropriately, However i felt good about what i did, except in retro, the securing of the little guy.



> LP also said;
> Either way, I would have never stepped foot into that ER.



We have done several Chopper runs and they almost always land at the Hospital. 
That Doc just reacted poorly and it infected the rest of the staff. We got over it, its behind us now.(that Doc moved on)(renta Doc).


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## Flight-LP (Sep 9, 2007)

Gbro said:


> I agree with you,
> We have several pediatric immobilization devices in use today.
> I will have to do some testing and see if this;
> http://www.med-worldwide.com/product20951.html
> ...




Yeah, the pedi-mate is a good device, but you attach it to the stretcher, not mom. Mom sits in a seat with a seat belt, preferrably up front. 

Just because you use a hospital LZ does not mean you have to go into the ER. In most cases going into the local podunk hospital will delay and can be detrimental to definitive care. Skip that ER go straight onto the helicopter, do not pass go, do not collect $200.......................

BTW, a chopper is a motorcycle.....................


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## Gbro (Sep 10, 2007)

> L P say's;
> BTW, a chopper is a motorcycle.....................



Gbro Say's;(wiki Say's also)
Chopper may also be used for:

Helicopter 
Thompson submachine gun 
The nickname of Ron Harris (footballer), a Chelsea footballer 
A member of the Lambda Chi Alpha fraternity 



> LP Say's;
> Just because you use a hospital LZ does not mean you have to go into the ER. In most cases going into the local podunk hospital will delay and can be detrimental to definitive care. Skip that ER go straight onto the helicopter, do not pass go, do not collect $200.......................



I'll pass on that one. The ER staff isn't Podunk, They just acted poorly on that one(in my opinion), We need a good trusting working relationship. Doing something like that would cause more animosity than what happened(Again IMO).
Still going to look into attaching Pedi-mate to Mom. Never know when it could be necessary. Remember, we can be an hour out, and transporting multiple Pt's is something we do often. 
Back when we had two swingers to add to the 1st 2. Only one time used and it was a mess.


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## Flight-LP (Sep 10, 2007)

It may not be podunk, but was it a burn center capable of handling a critical pediatric burn? If not, then the reasoning still stands. Animosity is irrelevant to proper care, there is absolutely nothing wrong with handing patient care off to an air medical crew and is usually more prudent and provides for the quickest access to definitive care. But to each their own...............


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## Ridryder911 (Sep 10, 2007)

I may add transfering multiple patients and as well as "swingers" (I presume, hanging patients) is usually never done except in MCI, if even then. I would hope those would be "stable". 

I agree with Flight, unless they are an accredited pediatric burn or trauma center they should had been routed immediately to the appropriate center without being seen in local ER. Why waste valuable time, for a tetanus shot? As well, once in contact with the ER, then they have to (by COBRA law) do a complete work up, intervention, then paperwork, then guess what... transfer the patient. While if the patient was met at the pad, valuable time would not be wasted. 

R/r 911


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## Gbro (Sep 10, 2007)

That is something to discuss with the Director and crew. But my concern here is with; It is a rare incident where the air ship would land before we could be in the ER, and i wouldn't what to even think about delaying transport to Er, with the intent of circumventing them. 
This run happened a number of years ago, and we didn't have intercept agreements then. Today we would be intercepting like a previous post where our crew had the 4 burn Pt. and had 4 air ships meet at the 2 closest ER's. both of them were 20 & 25 miles out.


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## Flight-LP (Sep 10, 2007)

Gbro said:


> That is something to discuss with the Director and crew. But my concern here is with; It is a rare incident where the air ship would land before we could be in the ER, and i wouldn't what to even think about delaying transport to Er, with the intent of circumventing them.
> This run happened a number of years ago, and we didn't have intercept agreements then. Today we would be intercepting like a previous post where our crew had the 4 burn Pt. and had 4 air ships meet at the 2 closest ER's. both of them were 20 & 25 miles out.




But you wouldn't be delaying care. If you wasted time by going into that ER which is not capable of treating or stabilizing a critical burn pt, then that would be delaying care. Please re-read the previous post. What the ER thinks about your decision is irrelevant, you do what is right for your patient. I don't know what kind of ties you have with that particular hospital (political, financial, etc.) but I still see no reason what so ever to stop there. I would think that they would thank you for not inundating them with a patient that they couldn't handle. Not to mention the potential money grubbing lawyer who gets a hold of one of these "specialty" cases. 

PLANTIFF LAWYER - "So, Mr. EMT, tell the court again why you failed to provide appropriate care to my client by delivering him to a facility that is not capable or designated to handle such a case?????"

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ - Out of companies pocket
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ - Possibly out of your pocket


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## Ridryder911 (Sep 10, 2007)

Gbro said:


> That is something to discuss with the Director and crew. But my concern here is with; It is a rare incident where the air ship would land before we could be in the ER, and i wouldn't what to even think about delaying transport to Er, with the intent of circumventing them.
> This run happened a number of years ago, and we didn't have intercept agreements then. Today we would be intercepting like a previous post where our crew had the 4 burn Pt. and had 4 air ships meet at the 2 closest ER's. both of them were 20 & 25 miles out.




What decade does your EMS live in? Does your state not have Regional Trauma Guidelines, as directed by your state Trauma System, and then regional area guidelines? All states were to be compliant by the year 2000. (yes a federal regulation) By-passing the local lower level ER is for the * good* of the patient. The old addage, _ transporting the patient to the nearest hospital versus transporting to the most *appropriate* hospital_, has been gone for decades. There is nothing a local ER can do for a major burn patient that a flight crew or ALS crew can do except a tetanus shot. I know I worked as a burn nurse in the 2'nd largest burn center in the U.S. 

The same as in trauma, the reason for air ships is even there is rapid transport. By entering a local ER can cause potential harm. Remember, once the patient has entered thier "system" all work up and treatment has to be started, such as a CT scan, x-rays, lab's, etc. awaiting for results, and initial treatments are nothing more than delays to the patient, since they have to be repeated. There is no way, they could be ready and transported before the flight team could transport. 

Remembering, they have to perform such or they (hospital) will be in violation of COBRA violation, hence the reason why by-pass destinations and diversions are performed daily. 

I highly suggest your service and local medical community get onboard with current medical regime. Not doing so may lead for us to read about your community on the local new cast. 

R/r 911


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## medicdan (Sep 10, 2007)

Ridryder911 said:


> Remembering, they have to perform such or they (hospital) will be in violation of *COBRA* violation, hence the reason why by-pass destinations and diversions are performed daily.



I am not getting involved in this discussion, but what do you mean by a COBRA violation. 
COBRA, as I know it is a law that guarantees employees health insurance after they leave a job. Is there another law I dont know about.


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## Arkymedic (Sep 10, 2007)

ridryder 911 said:


> I may add transfering multiple patients and as well as "swingers" (I presume, hanging patients) is usually never done except in MCI, if even then. I would hope those would be "stable".
> 
> I agree with Flight, unless they are an accredited pediatric burn or trauma center they should had been routed immediately to the appropriate center without being seen in local ER. Why waste valuable time, for a tetanus shot? As well, once in contact with the ER, then they have to (by COBRA law) do a complete work up, intervention, then paperwork, then guess what... transfer the patient. While if the patient was met at the pad, valuable time would not be wasted.
> 
> R/r 911



This not only would involve COBRA but also would drag out the ol EMTALA laws also...


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## ffemt8978 (Sep 10, 2007)

emt-student said:


> I am not getting involved in this discussion, but what do you mean by a COBRA violation.
> COBRA, as I know it is a law that guarantees employees health insurance after they leave a job. Is there another law I dont know about.



Same law, just a different part.


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## Gbro (Sep 11, 2007)

Ridryder911 said:


> What decade does your EMS live in? Does your state not have Regional Trauma Guidelines, as directed by your state Trauma System, and then regional area guidelines? All states were to be compliant by the year 2000. (yes a federal regulation)* By-passing the local lower level ER is for the  good of the patient. The old addage,  transporting the patient to the nearest hospital versus transporting to the most appropriate hospital, has been gone for decades. There is nothing a local ER can do for a major burn patient that a flight crew or ALS crew can do except a tetanus shot.* I know I worked as a burn nurse in the 2'nd largest burn center in the U.S.
> R/r 911



Why do you shoot our Er's in the back?
They are both listed as trauma centers.


This incident happened some years ago, I think i pointed that out. 
We do have hospitals out here that are not trauma centers, Like community Memorials and such. We do our best to not transport to them.
Incidently that young boy was on that air ship in under 20 min. 
I had a chance to talk to an Aunt of the boy just 2 weeks ago and he did very well, Very little 3rd Degree burn. In fact that is what caused me to bring it up.


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## triemal04 (Sep 11, 2007)

Gbro said:


> Why do you shoot our Er's in the back?
> They are both listed as trauma centers.
> 
> 
> ...


So you're saying a trauma center is a trauma center is a trauma center right?  Wrong.  There are (or can be, definetly should be everywhere in my book) multiple different levels.  Here it's 4.  There will be a huge difference between a local hospital that can produce an ER Doc, 2RN's, has a surgeon in house and everyone else on call and a regional hospital that can produce multiple ER Docs, RN's of various types,RT's, anesthisiologists, neurosurgeons, surgeons, and chaplains in just a couple of minutes.  Just because a hospital get's itself classified as a trauma center doesn't always make it the best choice; I don't know how Minnasota does it, but maybe you should look into that.  Not to mention the fact that a trauma center is definetly not always a burn center; often they can be two different things entirely.  That kid needed a burn center, not a trauma hospital.  So unless it happened to be both...straight to the bird with him.


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## Arkymedic (Sep 11, 2007)

triemal04 said:


> So you're saying a trauma center is a trauma center is a trauma center right?  Wrong.  There are (or can be, definetly should be everywhere in my book) multiple different levels.  Here it's 4.  There will be a huge difference between a local hospital that can produce an ER Doc, 2RN's, has a surgeon in house and everyone else on call and a regional hospital that can produce multiple ER Docs, RN's of various types,RT's, anesthisiologists, neurosurgeons, surgeons, and chaplains in just a couple of minutes.  Just because a hospital get's itself classified as a trauma center doesn't always make it the best choice; I don't know how Minnasota does it, but maybe you should look into that.  Not to mention the fact that a trauma center is definetly not always a burn center; often they can be two different things entirely.  That kid needed a burn center, not a trauma hospital.  So unless it happened to be both...straight to the bird with him.



Well let me tell ya'll this if you can just go to a trauma center consider yourself very lucky. We have one level I trauma center in Little Rock at the University of Arkansas Medical Services (UAMS) about 3.5 hours from here, a burn center at Arkansas Childrens Hospital same place, and very few other level trauma centers scattered throughout Arkansas. There are also trauma and burn centers in Memphis, TN, Tulsa and OKC, OK, Springfield, MO, and Shreveport, LA. Consider yourself very very fortunate to have that option. We are also one of the few states that has a designated trauma system. I consider myself fortunate to have the choice between two good hospitals that are progressive. http://www.bizjournals.com/memphis/stories/2007/03/26/daily11.html?b=1174881600%5E1438099


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## Ridryder911 (Sep 11, 2007)

There are multiple levels of trauma center designations. The most common is accredited by the American College of Surgeons (ACS) Level I and Level II. The main differential is sponsorship and participation in research and residency and publications. There of course is much more.. I was on the ACS acreditation and review, when I worked as a Trauma Systems Specialist. Most of the criteria is chart review and surgical intervention and rehabilatation. Not as much in regards to the true physical building nor the ones in the center. 

Level III and Level IV are usually state appointed (albeit some states certify all levels) and these can be varied in requirements. Such as some states do not even require a physician to be present .. Yes in a trauma center (level IV).  So, just because one advertises or announces that they have a trauma center does not impress me or convince me that they are capable of providing the required care. 

There is as well differential in Burn Centers and Burn Units. Burn centers are usually accredited through the American Burn Association (ABA) and have to meet strignet requirements set forth by their accreditation committee. 

Technically, the ACS does not regard burns as _ trauma_ rather as enviromental injuries. 


R/r 911


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## EMTmetzger (Sep 12, 2007)

Ridryder911 said:


> There are times you have to pick your fight wisely. I would had told him to contact my supervisor, etc. I would had recommended him to read the ABA burn criteria as well. He made his point, that is all it should had been.
> 
> Seems, unusual that an ER Doc would even want to deal such a mess.... since, he will have to transfer it later. I unfortunately have not always learned diplomacy, and after the first 5 minutes of arse chewing, asked if he would like to settle it outside.
> 
> R/r 911



id probobly do the same thing, i'v been know to mach attitude w/ attitude (mostly to the realy cocky teachers)


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## njcoldone (Sep 12, 2007)

*spanked by er doc*

You are not alone when it comes to arse chewing. I'll give you my scenario- we were called for a difficult breather (which is an als dispatch protocol in my area) on arrival my findings were actually minor injurys from a domestic with no difficult breathing- I immediatedly canceled the als unit . obtained pt.vitals and assessed to find pt.admitted to drinking a bottle of wine and taking her dose of    anti-depressants for evening. pt. presented as being under influence -slurring, could not focus , and in a state of anger at times . Law enforcement on scene sorted thru mess of he said she said . During course of pt. interview pt. stated that we didn't have to worry she wasn't going to committ suicide that nite (?)In any case pt agreed to be transported to er for evaluation and pt. insisted on ambulating to stretcher outside of her door once we reached stretcher pt.claimed to have panic attack and in a matter of seconds appeared to go unconscious , I tried to verbally arouse pt. w no response while maintaining airway , a sternum rub also did not prompt any response so I asked for ALS to be dispatched (as per protocol ) for an unknown loc , pt regained consciousness within 1 minute and als was within 30 seconds of our location. Oh boy were they angry and questioned why they were "bothered with this call " after they were initially canceled. I responded that protocol dictated their dispatch and pt. status had changed -- Now get this 1 medic confronted pt. with anger and neither medic of the 2 even listened to my report. The only assessment they provide was a check from outside of rig of pt.current a+o which was 3 at that time . Pt. became infuriated unbuckled and jumped from rig where she was again confronted by  mighty medic #1 , hence pt.was placed under arrest by pd  the omighty duo left scene and later spouted that I never should have "bothered them " sorry my advocacy is for my pt. not the sleep of 2 medics !


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## Gbro (Sep 12, 2007)

What you did/went through/deal with in a metro setting that screens calls ALS vs BLS, has to be a frustrating thing. One would doubt his service/self much more than a BLS in my setting.
We get everything. And we request ALS when its needed/and by guide lines.
Our rig transports the PT. and through it all we are still part of every call.

EXCEPT 1.
The sister of one of the EMT-P's from a nearby ALS system requested that service for her husband. It was in our PSA and the dispatch properly dispatched that unit, but also dispatched us. Of course we were on scene much sooner, and got to here all about how wonderful her brother was and how she would only trust her husband with the service he was with.
It was quite the seen!, How glad we were to have them come through the door.
They did deserver each other! LOL


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## Gbro (Sep 12, 2007)

*Trouble with a smile*

Call for a 10-52 Motorcycle VS Deer, 2 
1st responders gave us a update, 2 pt's one uncon/unrep. head injury, other back pain, good CMS.
We did a load -N- Go with the head injury, but left one attendant on scene.
Radioed to responding ALS unit that we would grab a medic off there unit and they could continue and one of our attendants was still on scene. 
We did the intercept and all, BUT the ALS unit only had one medic on-board. the driver was EMT-B, just like us. 
So here is an ALS unit on a scene with 2 Basics with it.
When we arrived at the ER, the supervisor of the ALS unit thought he was going to give me a chewing over this. 
The smile never left my face!, The Pt's were my focus, We did our job. all the rest is just nit-pic parade. 
"I am smiling now".


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## Corl-Grove (Sep 18, 2007)

*Water Gel is awesome*

Whether or not your state appoved the use of water Gel from a burned patient perspective this :censored::censored::censored::censored: is great...

My brother had a truck that was overheating and he was attempting to remove the radiator cap when it blew off covering his chest and neck with screaming hot antifreeze/water. My truck responded to the call and found him screaming (wimpy Paramedic b.t.w.) we took him to the local ER which of course prescribed silvadeen (sorry not sure of spelling) and it did nothing for him. I aquired some Water Gel from the volunteer squad I ran with and told him to try it. Because of the Lidocaine his pain quickly subsided. I truly believe that as a tx for burns this needs to be investigated thoroughly.

Take care, and Be Safe


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## VentMedic (Sep 18, 2007)

Corl-Grove said:


> him screaming (wimpy Paramedic b.t.w.) we took him to the local ER which of course prescribed silvadeen (sorry not sure of spelling) and it did nothing for him. I aquired some Water Gel from the volunteer squad I ran with and told him to try it. Because of the Lidocaine his pain quickly subsided. I truly believe that as a tx for burns this needs to be investigated thoroughly.



Silvadene is a sulfa medicine used to prevent and treat bacterial or fungus infections.  It is not a pain killer but can prevent serious complications from  infection.


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