Rising skills down-under
In 2008, Ian Mackie flew to Australia to develop his abilities in the treatment of burns
"A simulated disaster exercise involving all three emergency services and all major metropolitan hospitals, allowed me to experience first-hand how disaster plans work"
In January 2008, I began a 12-month fellowship based at the Royal Adelaide Hospital (RAH) and the Women’s and Children’s Hospital in Adelaide, South Australia. This was performed as Out of Programme Experience, following completion of the UK FRCS(Plast) examination in the final year of my higher surgical training programme. The aim of the fellowship was to build upon and refine the skills in burn management I had gained from my UK plastic surgery rotation and to equip me with the skills necessary to provide first-class burn care as a consultant in the NHS.
It was with mixed feelings that we departed from Manchester in mid-January, knowing that we would not be seeing the UK for a further 12 months, and that we would be having little contact with our close friends and family. Neither my wife nor I had been to Adelaide before and, apart from email correspondence, did not know anyone there. Following a short stay in Singapore, we arrived in Adelaide and were greeted by Dr Greenwood at the airport. We must have been easy to spot – two very tired and disheveled adults pushing overstuffed suitcases while trying to keep track of two over-excited small children.
The next few days were a bit of a blur; mostly because we were trying to come to terms with the vicious heat and jetlag, but also because I spent a great deal of time trying to sort out registration, banking and all the things that we take for granted in our life back in the UK.
Finally, the fateful day arrived and I wandered in to work at the RAH, knowing that whatever the first impressions were, I would be working there for the next 12 months. The scale of the unit, and of the job at hand, immediately surprised me. This well-regarded international unit comprising ‘only’ eight burn beds, functions as the main adult burns unit for the central one-third of Australia – covering a population spread over 2.4 million km2. In the UK, while we are well versed in dealing with populations greater than in Australia, our populace is typically concentrated in a small area around our cities. The geographical scale of Australia and the distances that patients were happy to travel never failed to surprise me, and it was not until the end of my fellowship (after I had the chance to explore the red interior of Australia) that the size of the country really hit home.
While the majority of the fellowship was spent at the RAH, working with a well-established team, I also spent time attached to the paediatric burn unit at the nearby Women’s and Children’s Hospital.
From a purely professional perspective, I was exposed to all aspects of burn care, burn practice development and also undertook a small degree of research. Despite the small population, the RAH unit admitted 458 burns in the calendar year 2008. Although the majority of burns dealt with were small in size, each one was dealt with using the best intentions and finest care. Cleaning and dressing burn wounds is known to be painful, even with copious amounts of analgesia. However, it is obvious that if we are to encourage rapid healing we need to remove all dead and devitalised tissue and apply an appropriate dressing. In the RAH, a zero tolerance approach is taken to this aspect of burn management and a comprehensive set of treatment protocols developed. No patient is expected to experience painful stimuli on the ward, and therefore there is a very low threshold to take patients to the operating theatre to cleanse and dress wounds. This allows accurate assessment of burn depth and permits the administration of the definitive surgical procedure at the same time. I was able to improve my abilities in diagnosing the depth of burns and also develop decision-making processes which allow for the initiation of appropriate treatment. While the mainstay treatment of many burns surgeons is to ‘watch and wait’ and then skin grafting at a later date, the Adelaide approach offers a viable alternative. The first-line treatment for all burns is a trip to theatre, general anaesthesia and scrubbing of the burn. Following this aggressive approach, obvious full-thickness areas of burn are excised and primarily grafted. Partial-thickness burns and areas of ‘dubious’ viability are dressed with a skin substitute (Biobrane) and then antimicrobial dressings. The aim is to complete this phase of patient care within 24 hours of the burn injury, and in some cases we were able to definitively debride and graft the burn less than six hours after the injury.
By getting the initial management correct and not cutting corners, it is presumed that all future dressing changes are much simpler. The protocols in practice at the RAH, and their eventual outcomes, confirm this presumption. Additionally, thorough debridement in theatre allows for the use of skin substitutes as a primary treatment modality rather than alternative therapies. My observation of the use of these substances was that post-operative patient discomfort was reduced and that dressing changes on the ward (traditionally performed by nurses) were much simpler and quicker.
Although most of the fellowship involved the acute management of burn patients from a huge geographical area, all patients were followed-up in the out-patient department in Adelaide. Coming from the UK, where we do not expect our patients to travel for more than is strictly necessary, it was surprising to see patients take a flight to see us for what amounted to no more than a few minutes in out-patients – and to be quite happy about it! Nothing less than cosmetic and functional perfection was accepted by the clinical staff, and patients were added to the operating lists for seemingly minor revisions if it was felt it would be beneficial. I had the opportunity to use different plastic surgery techniques to revise scars and release contractures. In addition, I explored the effectiveness of resurfacing techniques to improve the cosmetic outcome of both the burn itself and its treatment.
Research projects I was involved with included basic science work that had previously been set up in the laboratory (attached to the unit). A simulated disaster exercise involving all three emergency services and all major metropolitan hospitals, allowed me to experience first-hand how disaster plans work and where the pitfalls and perils lie. The exercise had been developed to stretch local resources and to initiate ‘Ausburnplan’ – the Australian National Burns Disaster Plan. After debriefing, the exercise was considered to be a relative success. However, from a local burns perspective, we felt that we would have been completely overwhelmed and patient care would have been sub-optimal. I was fortunate to be involved in the refinement and planning of the South Australian burn disaster/trauma plan. Building upon the outcomes of our simulated exercise, we have adapted our local plan and aim to have this tested at the next simulation.
The fellowship was concluded in great style. After receiving requests from two aboriginal healthcare centres for burn education, a team was dispatched from Adelaide. This comprised a senior nurse from the RAH, the aboriginal burn co-ordinator and myself. We flew from Adelaide to Ceduna, where we collected a 4x4 and, after hours of ‘off-roading’, reached Oak Valley, the most remote aboriginal settlement, and educated the local healthcare staff (all three of them). The following day we ‘off-roaded’ through the Nullarbor desert and drove the coastal route along the Australian Bight to reach Yalata for another education session. All work completed, we headed to the beach for fishing and sand-duning and an opportunity to network with the local healthcare staff. These last few days showed me another side of Australia, demonstrating fantastic but occasionally bleak scenery and helped change my ideas about ‘distance’. From a healthcare perspective, the remote centres are exceedingly well-supplied and, with education programmes and close interpersonal links such as that developed by the centres in Adelaide, well-trained. It was useful to also see the conditions that some of the population live in, and to also appreciate why, sometimes, burns present late and not within the first few hours, as we would all prefer.
It was with sadness that we left our new friends in Adelaide, having made the city our home for the preceding year. We spent the final days at a local beach resort amid temperatures of 35oC and were shocked when we arrived in Manchester to see snow and ice on the ground, with temperatures of 2oC ! Professionally, the experience that I have gained over the past 12 months has certainly refined and changed my practice and hopefully improved outcomes for all future burn patients that I will treat in the UK. Like most people who do fellowships, I wish that I had taken more time to travel around Australia. However, this year has served as a good taster and I would certainly like to return.
I am grateful to the Ethicon Foundation and the RCSEd in supporting my fellowship to Adelaide and to the staff of the RAH for making my stay so enjoyable.