Patient care is a burning issue

Patient care is a burning issue

It is a tug of war between Akhilesh Singh and a doctor who sprinkles a whole bottle of disinfectant on the badly burnt leg of the 13-year-old boy.

While the doctor firmly holds the leg from one end, Akhilesh grabs his own thigh to numb the pain. But it doesn't seem to work and his screams can be heard even two floors above his ward.

This is the burns unit at Lok Nayak Hospital.

“Son, I am trying to keep it as painless as possible. You just hold on a little longer,” whispers the doctor to him. The screams continue unabated, even as bits of flesh and skin are pulled out wth the old bandage, exposing the naked bone.

“Keep quiet or we will have to amputate your leg,” the doctor says loudly.

The threat has its impact on Akhilesh, who bites his lips to suppress the pain.

The whole process of removing the old bandage, using disinfectant and wrapping a new bandage takes less than 15 minutes.

The doctor later while he often uses the threat of amputation to keep patients still during treatment, in Akhilesh’s case, it may actually be required because of the kind of infection that has crept in.

Hailing from a village in neighbouring UP, Akhilesh has been occupying a bed at the hospital for over a week. Though he may be accommodated for much longer, most other patients admitted to the burns department — available only in a few government hospitals in Delhi — are not that lucky.

“Ideally, we need to admit burns patients for long, but we are forced to discharge most of them within a week to accommodate new acute patients. We lack the workforce and infrastructure to deal with the burden of patient turnover,” says Dr Karoon Agrawal, director of burns and plastic surgery department at Safdarjung Hospital.

The central government-run hospital is the largest burns unit in the world as far as patient turnover is concerned. The 114-bed department gets between 5,500 and 6,000 burns victims annually, but is able to admit only 1,700-1,800. Apart from Safdarjung Hospital, only Dr Ram Manohar Lohia Hospital and Lok Nayak Hospital in central Delhi, Deen Dayal Upadhyay Hospital in west Delhi and Guru Teg Bahadur Hospital in east Delhi provide treatment to burns victims.

But apart from Lok Nayak Hospital, which has 100 beds, none of the burns departments in the other hospitals match Safdarjung Hospital in terms of bed strength. While RML Hospital provides only 26 beds, DDU and GTB have 28 and 22 beds respectively.

In terms of patient turnover, the burden on Safdarjung Hospital can be gauged from the fact that RML Hospital, the other major central government-run hospital, gets just 500-600 patients annually.

Not all the beds are reserved for burns patients. Since the burns and the plastic surgery departments go hand in hand, almost half the beds are reserved for plastic surgeries. Apart from reconstructive surgeries, the burns departments also cater to trauma patients with exposed bones and joints and faciomaxillary trauma.

“We have to keep 50 beds for acute burns patients. The other 50 are for plastic surgery and burns related surgeries,” says Dr R B Ahuja, head of burns and plastic surgery department at Lok Nayak Hospital.

Outstation patients

But what really burdens the already crumbling infrastructure at these departments in the capital is the fact that most of the burns patients are from outside Delhi, with patients coming from states as far as Bihar, Rajasthan and Madhya Pradesh.

“Only 40 per cent of the patients we receive are from Delhi. The lack of facilities in other states and lack of confidence in existing facilities there send these patients rushing to Delhi. Once they reach the capital, Safdarjung Hospital becomes their preferred destination,” says Agrawal.

The outstation patients also pose another problem. “Hospitals and clinics at smaller towns in neighbouring states refer patients to us at odd timings such as 2 am without even calling us first. Since only the emergency department works at night, we are forced to admit even routine cases as emergency cases at the cost of admitted patients,” says Dr V K Tiwari, professor and consultant at the burns department of Safdarjung Hospital.

The situation is such that the hospital is forced to adopt a rotation policy. “While we try to admit all patients who need treatment, we discharge them as soon as possible and then call them back repeatedly for different surgeries. The dharamshalas outside the hospital come in handy for outstation patients, who are not in a condition to make repeated rounds,” says Dr Vishwa Prakash, senior plastic surgeon at Safdarjung Hospital.

Any specialised burns unit comprises a burns intensive care unit, burns operation theatres, specialised facilities for dressing of wounds and wards.

Unlike other hospital departments, where two or more patients are often heard sharing one bed, in a burns unit, a bed can’t be shared under any condition.

So, in an emergency situation, such as during Diwali — when 100 to 300 patients turn up at each of the hospitals — or when a group of people are injured in a gas cylinder blast, the situation becomes unmanageable.

“Often, in an LPG cylinder blast, five to six patients in critical condition are brought at once. The patients who are already admitted suffer as space has to be created to accommodate new victims,” says Dr V K Tiwari, professor and consultant at the burns department of Safdarjung Hospital.

According to authorities, mere renovation — which three operation theatres at Safdarjung Hospital department are undergoing — or increasing the workforce will not solve the issue.

“Renovation does not add space. We need many more beds, operation theatres, intensive care units and increased timings of the OTs. In fact, even if another similar burns unit came up in Delhi, it will be insufficient,” says Tiwari.

A separate hospital specialising in burns is not a solution either. “The burns department necessarily needs to be a part of a bigger hospital. A hospital specialising only in burns treatment will not succeed as these victims need care of all kinds. We need the services of child specialists, ENT specialists, neurology department and many other departments,” says Agrawal.

Because of the burden, aesthetic plastic surgery, the facilities for which are available at the department, is discouraged at Safdarjung Hospital. While it is still provided at Lok Nayak Hospital, at Safdarjung Hospital it is performed rarely and only to train medical students.

Crowd control

The large turnover of patients and their relatives, apart from posing a great risk of infection, is also a threat to doctors.

“A large crowd not only threatens care, it also compromises our safety. Since many of the burns cases are critical cases, we are often attacked by relatives of patients who fail to survive. They don’t see reason as they think the patient was brought walking and talking but died a week later,” says Agrawal.

As for burns patients, who face severe rehabilitation and psychological problems after accidents, the heavy rush results in denial of services to them. The priority is to save as many lives and limbs as most burn cases are emergency cases.

“Once burnt, burnt for ever. However small the burns may be, the scars remain forever. This results in great problems when it comes to earning a livelihood, getting married or finding acceptance in society. It poses major rehabilitation and psychological problems for victims,” says Agrawal.

In a burns patient, the skin that acts as a safety valve, is lost, thus exposing the internal body parts to infections.

“A burns victim suffers more pain than patients with other kinds of wounds. Extra care is required in their treatment as infection is received even from the patient's own body parts,” says Dr Tiwari.

New procedures

The only encouraging factor is recent medical advancements in this sector. Earlier, before performing surgeries, dead tissues were removed by using bandages for 45-60 days.  However, now they can be operated upon in as little as three-four days after the injuries are sustained.

“The dead tissues are now removed early through surgery itself. The early operations greatly decreases the risk of infection and hence the mortality rate,” says Dr Prakash.

Better antibiotics to deal with infections, the possibility of operating two large burn wounds at once and much improved secondary surgeries too have helped to bridge the gap caused by overburdened infrastructure.

According to Dr Agrawal, while the central government is making every effort to increase funding and improve infrastructure, the only solution to the problem is to create proper infrastructure at the state level so that patients are not forced to rush to Delhi.
“If we restrict the beds to only patients coming from Delhi, the services provided will be much better. But any number of bed is not enough for the crowd that comes from other states,” he says.

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