Why Burn first aid is as important as any advanced life support treatment and why US EMS stinks at burn first aid.

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Melbourne MICA

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Being disappointed at the response to my original post on this topic and quite willing to say I have an agenda I've decided to throw some sand around to get some attention.

US EMS is among the worst in the world at local utilization of an evidence based burn first aid model. At the same time US EMS is about as far away from a employing a default model regionally or nationally as you can get. Instead arbitrary caveats are applied, local "expert opinion" is often used to shape CPG's and the "lets not do anything that might cause even the teeniest bit of hypothermia" approach (including a treatment that has huge benefits for the pt).

For cash strapped local EMS or even larger regional health systems, a look at the dollar figures alone should surely create some interest or even an impetus to change practices particularly if you are one that employs hydrogel dressings and similar products. So some stats below are worth a look.

The first 2 show a rough break up of costs associated with the most common surgeries. The next 4 show a breakdown of burn related costs.



From an economic standpoint alone it remains a minor mystery of the universe that such a dollar driven country as the US has not immediately snapped up the burn first aid approach that most reduces endpoint costs. And there is only one that comes close to this and it involves cooling with water for 20 minutes for all thermal burns (yes even large ones). There is no other approach employed in the US that comes even close to the clinical benefits of water cooling or its economic value.

Now I realise the troops here don't make the big calls but my agenda is to pressure the process at all its interfaces. This includes people like yourselves. Given the feral reception given to the Weaver EMS/burns/hypothermia paper of 2014/15 there are plenty of paramedics and their services who are in denial. In the same way, unless your service employs active warming technologies (like barehuggers), you will have a tough time convincing anyone patients with large burns can be adequately warmed. So the approaches used in the US mostly don't work to reduce hypothermia incidence from burns let alone provide the most cost and clinically effective treatment for the patient.

And then there is the evidence a slab of which I provided in the original post if anyone wants to download it. There are about 10 papers, all current or relevant.

So even as a point of debate on a paramedic EMS forum like this I would enjoy hearing your views and what reason you would have for NOT approaching your own service to ask them why not 1 EMS service in the US employs a 20 minute water cooling model including your own, have not published a single paper or online article describing in detail how their alternative approach is supported by the literature (especially dry dressing and hydrogel dressing models) nor provided an evidence summary for your burn care model attached to the published CPG's of your service.

And please, "not all ambulance CPG's are supported by evidence" or "who follows what the state based guidelines say?" replies just don't cut it.
 

CCCSD

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Are you absolutely certain about your claims of “not 1...”? I’m glad to see someone actually spoke with every single EMS agency and company and provider in the US so they could come on here and lecture us.

Please provide documentation of your findings.
And please, don’t just say “because...”, that just don’t cut it.
 

GMCmedic

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Well my main reason for not approaching anyone is currently your condescending attitude.

I dont bash Australian EMS because frankly, its none of my business. Hint hint
 

NPO

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I read your post. Here's my problem with it:

It didn't tell me any of the following:

- What I'm doing wrong
- What I should be doing
- How to implement it
- Consideration of variables for availability of burn hospital care, transport times, level of service, etc...

If you can explain what I'm doing now, how and why it's wrong, and what I should be doing, and then tell me the limitations of that, I'm eager to hear it.

Do we do a 20 water cooling if we are 10 minutes from a burn center? Do we do it of we are 1 hour from a local trauma center with no burn capability, which will have to transfer another hour by flight another to a burns center? Does this apply to only thermal burns? How does the availability of active warming change things? (Yes, we have active warming.)

If you can present THIS information, I am open to listening. I'll even give you the first one:

My protocol is to apply dry sterile dressing and wrap in plastic wrap.
 
OP
M

Melbourne MICA

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Hello comrades. Well I'm a bit disappointed some of you found it so easy to take offense as I've not criticized any individual EMTLIFE poster nor the website itself, any specific US organisation, state, county, district or agency. I also noted the defensive response from EMS bodies to the Weaver paper that I could only categorise as "you've got to be kidding!?" How many papers detailing problems with pre-hospital management of hypothermia in trauma do we need? And I did note the absence of active warming technologies in EMS that is common everywhere. I would love to know how paralysed RSI'd airways burns patients are warmed without active warmers. I have also presented a brief list of the economics of burns to highlight how little emphasis has been placed in this area of clinical care relative to the economic burden and oblivious of the staggering effect of burns cooling on just about every outcome parameter of burn injury you can name.

What I did do is state at the outset I had an agenda, described what it is, pointed out current issues generally, pointed readers several times to my previous post on the same topic (December) and mentioned I had uploaded no less than 10 papers on this specific topic but it would seem few have opted to read them. I will upload some of my own personal renderings and have included two screenshots of my "burn projects" contributions as well as my base archive of burns studies including the property sheet. There are about 30-40 burns projects to which I have contributed, around 60-70 organisations I have lobbied regarding establishing a standard burn first aid model, untold numbers of e-mails and my archive of studies numbers about 1750 papers - I have read about 90% of them. Thanks you NPO for at least asking for some information. I will provide more here and point you to all my burns posts going back I think to about 2014 or so. If it comforts those offended I will say Australia EMS in this area of practice also sucks - and I have written to every ambulance service in this country to tell them this. My particular beef is hydrogels and the snake oil salesmen who still try to pass this dodgy product as the new revolution in burn care. So for some files to read. Recall the 10 I already posted from December for starters - they are all PDF's for download. Others see attached below. NPO I will get to some detail soon. I have just come off a 14hr night shift and need some snooze time. Thank you all for responding.
 

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Aprz

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I think the problem is that you come across as very condescending rather than just simply presenting information. It may not be intentional, but there is a tone I am at least reading when I read your posts.
 

DesertMedic66

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I am also reading it with a tone of “you guys are all really stupid for this and I am better than all of you”.

I’m all for information but the 2 threads you have created about this same topic have both had this exact same tone. If you are wanting to get information across, this is not the way to do it. You can make another post in 6 months but if it’s in this same tone, you are going to get similar results.
 

silver

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Based off of my quick read of the studies from prior post, I honestly couldn't find any of them with "strong" methods or evidence to change practice. In addition, I didn't see much in way of how cooling changes outcomes regarding patient morbidity and mortality (which is the only important thing for a medical intervention). It's hard to convince someone to change practice without a reason why.
 

Tigger

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So even as a point of debate on a paramedic EMS forum like this I would enjoy hearing your views and what reason you would have for NOT approaching your own service to ask them why not 1 EMS service in the US employs a 20 minute water cooling model including your own, have not published a single paper or online article describing in detail how their alternative approach is supported by the literature (especially dry dressing and hydrogel dressing models) nor provided an evidence summary for your burn care model attached to the published CPG's of your service.

And please, "not all ambulance CPG's are supported by evidence" or "who follows what the state based guidelines say?" replies just don't cut it.
Frankly your delivery sucks. This is not how you go about talking about EBM, when you lead off with "I'm right, you're wrong," you don't exactly leave much room for discussion. Sure you didn't attack any individual, you just said we all suck. Which you're probably right about, but that's not exactly how change get's affected. You want buy in? Perhaps seek to find out why things are the way they are and go from there.

Also, my guidelines are just that, guidelines. I'll cool burns down and dress them in whatever fashion that the burn centers want. Perhaps that deviates from our published guidelines, no one cares. If I can defend my actions, there is no issue. If practicable for relatively smaller burns (and usually it is), I'll cool burns with water and then apply a non-adherent dressing. We don't carry fancy burn dressings.

I am not sure how logistically feasible it is to cool a larger surface area. The last guy's house was on fire so his bathtub wasn't too useful.
 
OP
M

Melbourne MICA

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Thanks all for the replies. I appreciate the interest and don't mind getting a razz from comrades. You can tell me where to get off if you feel that way. See, I've been pushing this barrow for 9 years now and am well acquainted with all manner of ways to tell me I'm an idiot, not worth being listened to, don't know what I'm talking, have all the facts arse about, and best of all of course, that I'm just a pleb paramedic.

That was the case with certain hydrogel company aligned members of a prominent UK burns association who first decided to portray me as a loser interfering paramedic with the gall to suggest a new approach then threatened the association with legal action if they published the hydrogel position statement myself and another colleague had taken about a year and a half to write for their body. As it was we did manage to write their burn first aid guidelines. The executive made no attempt to defend my position and instead pulled the document despite something similar already used by ANZBA since 2012.

The cold shoulder is the most common response -just ignore them and they will go away, another form of denialism. For example I have written to the ABA (American Burn Association) 3 times now and been ignored 3 times, written to private charity groups, first aid bodies, the military, even had published a criticism of the ERC's burn first aid recommendations who promptly told myself and my associate we just didn't understand grading tools for recommendations. And no I didn't spit invective, accusations or arrogant claims about how wonderful I am.

Other bodies have argued they employ fully evidence based approaches and careful analysis despite not even referencing any current evidence. Others get money from commercial bodies like the hydrogel companies so find ways to squeeze the product line into their recommendations. Others portray themselves as champions of the burn sufferers but are actually using their operations as fronts to make money via grants and donations.

I love journals who have their own special ways of selling BS as well. One high profile UK paramedic journal was upset when my colleague and I criticised their integrity and independence when a clearly commercially biased item that wreaked of conflict of interest was published. It was written by a dodgy operator who not only works for a hydrogel company, has never actually treated a burn patient in his life, sells himself as a guru of burn first aid speaking at industry gigs as an expert but has no qualifications of any kind and was even on their editorial board and placed an advert for his companies product smack bang in the middle of the article. Strangely enough the same guru has never appeared at an international burns conference to demonstrate his expertise.The chief editor then wrote a canned response to the 2 separate letters myself and my colleague wrote to the journal not realising we both knew each other. His response was breathtaking. The same journal then had a full front page spread and article by the same fraud featuring the same hydrogel company on display at a trauma conference.

The response from a certain doctor in a very prominent US EMS journal was also a doozy. BTW this journal loves flogging commercial products on their front pages with accompanying articles. On this occasion the doc wrote an article on the most used hydrogel in the US that could quite easily have appeared on the companies home page as a cut and paste despite saying he had no conflict of interest or connection with the company. I wrote to him with the facts, even linking his commentary to sections appearing on the hydrogel companies website he decided not to reply. So I wrote to the journal editor once again and received a curt reply about how high their editorial standards are.

From paramedics I generally receive a collegiate initial response, some curiosity but often ambivalence as just about everyone sees this area of practice as a boring, simplistic non-event.

So I am truly sorry you feel aggrieved - you are my colleagues and have my respect as such. So now you have put the ball in my court by accusing me of being smug, arrogant and a know it all. Good. Now read the multitude of articles I have provided, the links to websites, organisations and information and then come back here and tell me I'm wrong. Tell me why US EMS approaches to burn first aid don't stink and why we as paramedics don't have a responsibility to challenge orthodoxies founded in BS irrespective of whether or not you like the way I have framed my current posts. I will post more information shortly for those interested.

 

akflightmedic

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So you want us to debate a topic which many of us do not have consistent exposure to in our careers, a topic which you have apparently studied and researched for many years now, and for all intent and purpose a topic you would be classified as a SME in?

Anything we say or propose would immediately be pounced upon, rejected and shredded (based on your previous posts). At no point would I feel welcome suggesting something contrary to your position. I am content to follow local protocol as currently dictated and wait you out...you will only yell at the wall for so long before you find another forum to present in.

Generally speaking, rallying soldiers is awesome and effective when you have a cause, however the soldiers usually need to share the same or some of the same passion as you do. I simply fail to see that taking place here. And according to your last post, it seems it has failed in other venues as well. You simply may be years ahead of us all in the treatment of burns...until that day comes, you will simply have to keep banging the drum, advocating for change. And when change does occur, you can then sit back and smugly reply "See? I told you so!".
 
OP
M

Melbourne MICA

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Thanks akflightmedic.

Appreciate your candor but really don't understand the responses I have read here. From the outset I have put all my cards on the table and asked for nothing in return save some honest remarks about the problems with US practices, understanding at the same time I have broached this topic with equivalent bodies OS and in my own country and made this known as well. You can't address a problem until it is recognized. My goal and that of my colleagues is simply to see a standard model of burn first aid introduced internationally, a goal mirrored by any number of authors and experts in the burns community.

Unfortunately, "I am content to follow local protocol as currently dictated" seems to be the fallback position of those few who even took the time to construct an argument rather than just fling derision and insults in my direction. Similarly, if anyone bothered to look at my previous posts and those more recently they would see I have done all the things you declare I would not do. Provided information and content, addressed queries openly, conceded points well made and yes, noted weaknesses and errors as well.

And have I reciprocated with insults and derision as well? Have I done so in this reply to you?

As for your comment: "I simply fail to see that taking place here. And according to your last post, it seems it has failed in other venues as well".

You bet there have been failures. But successes too. The BBA in the UK now has the most up to date, accurately referenced and detailed set of burn first aid recommendations in the world in my view. But for commercial interference from inside the same body and threats of law suits we would also have a model for managing hydrogel burn dressings, a document I worked on for nearly 2 years.

Providing content for the 2019 consensus paper on pre-hospital burn care for the Royal College of Surgeons Faculty of Pre- Hospital Care was another success. A number of UK EMS have also changed their guidelines as a result. My own service has re-written its CPG's and I have received assurances other aussie ambulance services will be reviewing their CPG's as well. St John Ambulance in Australia now recommends the 20 minute water model and I have also had correspondence from African, European and some US agencies including NASEMSO who were very open to further discourse on the topic. Incredibly one of the posters here opened his reply to me by suggesting no-one cares what NASEMSO says anyway.

So everyone does whatever they feel like doing, what the local doc or burns unit says to do or basically makes it up as they go along. Do you ad others see this as a problem? How does this support better patient care?

What I and my colleagues have brought to the table is the first detailed analysis of all aspects of this element of pre-hospital burn care including the inconsistencies and flawed models currently used by responders and those recommended by expert bodies and I have published any number of articles on this particular facet if only colleagues here, like elsewhere would actually take the time to read the items I have provided. Hence my focus now on US practices.

Insults are easy. So is going to your own service clinicians and asking why you are not using the model of burn first aid best supported by the evidence. The next question after that - "what evidence?", starts the whole thing going as it did for me.

PS If people wish to see what projects I have worked on they simply need to look at the 2 JPG screenshots of my burns folders I posted above. I have some ideas on using street fire-hydrants for use in mass casualty burn/terrorist/explosion events for example amongst a number of others. I am happy to discuss/get ideas to improve on any and all these projects from colleagues here.
 
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DrParasite

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I haven't read anything you said, or checked out any of your sources, but you're saying (or first aid) we shouldn't be flushing the burned area with copious amounts of water (doesn't matter from where, as long as it's cleanish and running), to stop the burning process? and from an EMS side, IV access with pain meds and fluids (to replace what was lost in the burn), and cover with whatever is available, and transports for the burn center for treatment (and any covering will be immediately removed, as the burn center will do doing their own thing)?

BTW, I am not trying to thrown insults at you, but I can only do what my medical director approves me to do. He's more educated than me (that's why he has MD after his name), and I trust that he consulted our local burn center for how they want burns treated (again, they have MD after their name, and only work on burns, so I am assuming they are experts in how to handle burns). So I can bring new information to him, but at the end of the day, I work under his license, and my job requires me to do what he directs me to do.

So you telling me how horrible of a provider I am because I follow my boss's directions, and how all US medicine sucks, isn't going to get me to either listen to you or change the way I do things.
 
OP
M

Melbourne MICA

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Hi Dr Parasite.

No I'm suggesting the exact opposite and seriously can't believe posters here are finding it so easy to feel offended despite the fact I have called no-one a "horrible provider" or that "all medicine in the US sucks" or anything close to such a ridiculous standpoint. And why would I? What I have said is we should all feel responsible enough to our patients to question the underlying premise of our CPG's. Is that not the very idea behind websites like this one? As it turns, duties I had in 2011 eventuated in a lit review of the evidence for our hydrogel dressings. And what I found was there was none of any worth. All the marketing was just that - marketing, no facts. As a secondary finding I also discovered there are no pre-hospital studies of any type on burn first aid. And here we are nearly 10 yrs later and many agencies, not just US ones still employ consensus or expert opinion based models. For those familiar with hierarchies of evidence these are the lowest there are.

For whatever reason the widest variance in opinions seems to be in the US, among the burns agencies and particularly in EMS. Do readers here know the American Burn Association, the CDC and the AHA all publish burn first aid recommendations - and all 3 are completely different. I sampled 24 EMS agencies and found around 20 different approaches.

So in 2 presentations at the ANZBA international burns conferences, 2011 an 2018, I decided to present evidence showing the problem was even bigger than people realized (or were prepared to admit). Since 2011 there have been some good advances. The 20 minute model is now the most widely accepted because the evidence base is the strongest. This has had the side benefit in that this has encouraged research to see where that model goes. Now we have, experimental, animal, observational, case series and even human studies including 1 RCT ALL verifying the benefit of the 20 minute cooling period.


SO the model I am now lobbying is that all thermal burns should have 20 mins of gentle cooling with running tap water or nearest equivalent. Studies show this is the clinical sweet spot for cooling and remains beneficial for up to 3 hrs after the burn event. Hypothermia risk is of course a mitigating factor that can be accommodated by slightly raising the water cooling temp (e.g. in the shower) or reducing the duration of cooling where signs of hypothermia develop. Sensitivities include children and the elderly as you would expect. The most important element is however to realize not what cooling should be done but who should do it and when. And believe it or not it doesn't need to be nor ideally should be, ambulance.

I will post more.

Cheers

MM
 

Tigger

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So I am truly sorry you feel aggrieved - you are my colleagues and have my respect as such. So now you have put the ball in my court by accusing me of being smug, arrogant and a know it all. Good. Now read the multitude of articles I have provided, the links to websites, organisations and information and then come back here and tell me I'm wrong. Tell me why US EMS approaches to burn first aid don't stink and why we as paramedics don't have a responsibility to challenge orthodoxies founded in BS irrespective of whether or not you like the way I have framed my current posts. I will post more information shortly for those interested.

There's nothing I like more than being told I am offended, when I am most certainly not.

Also I don't think anyone here is really telling you that you're wrong. So there's that. Would it make you feel better if I told you that there's lots of things that I don't like about my guidelines? That we do challenge them at the level that gets them changed (locally, since they are region specific)?

We get it, you know more about burns than we do. Not sure what we are supposed to do with this. Posting screenshots of how much research you have to support your position is of absolutely zero use to me. Once again, if you want things to change, you need to create buy-in. The best ideas presented poorly end up in the garbage.
 

DrParasite

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No I'm suggesting the exact opposite and seriously can't believe posters here are finding it so easy to feel offended despite the fact I have called no-one a "horrible provider" or that "all medicine in the US sucks" or anything close to such a ridiculous standpoint.
first off, I'm not offended at all. I''m not sure why you think I'm so offended. Maybe I was unclear? I mean, it takes a lot to offend me; and I can assure you, I'm more offended that you told or inferred that I was offended, than me being offended in the first place. But I can assure you, I won't lose sleep over it.
SO the model I am now lobbying is that all thermal burns should have 20 mins of gentle cooling with running tap water or nearest equivalent. Studies show this is the clinical sweet spot for cooling and remains beneficial for up to 3 hrs after the burn event. Hypothermia risk is of course a mitigating factor that can be accommodated by slightly raising the water cooling temp (e.g. in the shower) or reducing the duration of cooling where signs of hypothermia develop. Sensitivities include children and the elderly as you would expect. The most important element is however to realize not what cooling should be done but who should do it and when. And believe it or not it doesn't need to be nor ideally should be, ambulance.
That's what I have been doing for the past 20+ years..... ok, so maybe not for 20 minutes on the dot, but I recall in the late 90s being told to that you can put a burn patient in the shower to get all that cool water on them to "stop the burning process." Didn't need to be sterile water, just running water. Can even be a firehose (albeit with a lowered pressure than 100psi at the tip.....) if you are at a house fire....

I think the last burn patient I had was a kid who was "helping" mom in the kitchen, who had a pot of soup fall on them. 2nd degree burns to her back, neck and chest. maybe even her arms, it's been a while. I do remember picking the kid up, and running her under the sink for 10+ minutes with cool water, to "stop the burning process". Yes, she was soaking wet afterwards, so we covered her in sheets and blankets (and had mom grab a change of clothes for when she was finished in the ER).

oh wait, that was my second to last patient: my last patient was my 2 year old son, who pulled his mom's coffee cup down onto him. threw him into the sink too, hosed him off, and took him to the pediatricians office (it was closer than the burn center). Again, running water from the sink was what we did.

So I think your first aid treatment is more common than you think.
 

CCCSD

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I’m betting the OP is trying to sell a product. In the meantime, I’ll defer to my Burn Center, .MIL Docs, etc who have more training and experience than just about all the EMS providers: they deal with it daily.

I have yet to be taught NOT to cool with water for 15-20 minutes. Perhaps the OP isn’t understanding our protocols.
 

Tigger

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I’m betting the OP is trying to sell a product. In the meantime, I’ll defer to my Burn Center, .MIL Docs, etc who have more training and experience than just about all the EMS providers: they deal with it daily.

I have yet to be taught NOT to cool with water for 15-20 minutes. Perhaps the OP isn’t understanding our protocols.
I think of all the things he is trying to do, selling things is not it. Pretty much all the evidence I am familiar with specifically emphasizes the futility of using fancy bandages or salves. Essentially a non-stick and bacitracin is the consensus of most burn forums.
 
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