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In 1968, Dr. Richard Fratianne, a young surgeon, was assigned to help open and work in MetroHealth Medical Center's Comprehensive Burn Care Center in Cleveland, OH. The center was one of only a handful of facilities/units dedicated to burn care at the time, and Fratianne along with his colleagues on the unit quickly discovered that if they were going to become burn care experts, they would have to do so on the job.
"There was no formal training [for burn care] then," he remembered. "We flew by the seat of our pants. We did not have the techniques or the knowledge that we do today." That flight, by the seat of his pants or not, sent Fratianne on a career path that led him to help develop the techniques and knowledge he speaks of, and to become a part of the American Burn Association. And today, nearly 50 years later and 10 years post-retirement, Fratianne is still at the MetroHealth Medical Center's Comprehensive Burn Care Center, now as the center's director emeritus.
 For many medical practitioners on burn units or in burn centers, working burn care is not simply a rotation or a job. It is a career choice, a passion and, for individuals like Fratianne, a lifelong commitment. Burn care, after all, is not your typical wound care.
Burn Care
Most commonly and simply put, burns differ from other wounds in terms of expanse. "When I am performing wound care on a patient, it is often to a localized area, often insensate or with limited amounts of tolerable pain with a goal of reducing the size of the wound to healing," described Mary Jo Bernard, MPT, a physical therapist at Johns Hopkins University Burn Center.
Burns, on the other hand, are less localized. "In the burned population," Bernard continued, "the wounds oftentimes cross one or more multiple joints and our goals are more for return to normalized movement and long-term function."
However, it's not just localization and placement of the burn that differentiates burns from other wounds. "A burn injury is the most severe, most stressful injury sustained by the human body," Fratianne explained. When a burn is sustained over 50 percent or more of the human body, every organ system in the body is forced to operate at its maximum capacity, he detailed. "If there is any weakness [within these maxed systems], the patient's life is at risk. . . It is an incredible experience, incredible."
And, since the burn does affect so much of the body, the first goal in burn care is not necessarily to heal the wound but to save the life. "That may take weeks," Fratianne stated.
"During that time, we have to preserve function: make sure that the eyelids open and close, that there is mobility in the face and [that the patient may be able to perform] various ADLs (activities of daily living) with their arms and legs," he provided by way of example.
Bernard agreed. "Our biggest goal is to return the patient to their prior level of function, return to work and for the developed scar tissue to not interfere with function. This begins at the day of admission. If the person is awake and able to assist in their care we begin with active range of motion, emphasizing that movement and strength are the key to keeping normalized function," she said.
This goal, however, leads to one of the most challenging aspects of burn care: pain. "We inflict pain," Fratianne said. "Physical therapists and occupational therapists inflict an incredible amount of pain as they move joints that are stiff [for example]."
To make matters worse, the pain the patient is feeling doesn't just stem from stiff joints being moved to preserve function. It starts beforehand.
"We all know how much it hurts to have a small burn that doesn't need hospital care or skin grafting," explained Bernard. "In this population, the patients are dealing with the pain from the initial injury, pain from dressing changes, psychological pain of disfigurement and now, in comes the physical therapist who wants to move and stretch your very painful injury.
"Developing a trust between the therapist and the patient is imperative. The patient has to trust that you aren't going to stretch beyond what they are capable of tolerating or create more pain than is necessary," she finished.
The Practitioner
Developing such a trust requires a unique individual. Burn care practitioners are medical professionals who know that burn care is not only something that they are interested in but something in which they wish to participate. As a result, at MetroHealth, for example, students interested in burn care-no matter their field-complete a rotation in the center to determine if they are a good fit. Should the students decide that burn care is for them, they usually don't waver. "We have practitioners who have been waiting for five, six years [for an open position at MetroHealth]," Fratianne said.
Bernard experienced a similar process, though with less of a waiting period. "I graduated from PT school in 2004 from St. Louis University. I have worked almost nine years since graduating and have been working primarily with burn unit patients for just under eight years. Through clinical rotations during PT school, I realized I had an interest in wounds and burn care that I previously didn't know I had. I was able to join the burn rehab team at Johns Hopkins Burn Center in a full time capacity and haven't left since."
Staying isn't the only requirement for being a burn care team member, however. The complexity of burn care and the many-membered medical team on all burn units also necessitate expertise-expertise first and foremost in how to handle the aforementioned pain and how to create rapport with the patient.
"On the one hand," Fratianne said, "the patients hate the therapists. [Many of the therapists, I work with] are sweethearts, but they are also mean as can be," he laughed. "And on the other hand, you see the same patients come back and just wrap the therapist in a hug. "That's the way it is. You have to be tough yet compassionate."
The Technique
With that balance of tough compassion, a therapist can embark on a complex, multi-faceted therapy regimen that encompasses many techniques.
"Often, the patient needs assistance to achieve full range in the form of manual, low load, prolonged stretching and positioning, including splinting, to maintain the functional range of motion," Bernard said. If the patients are sedated, manual stretching is still performed and splints and positioning devices are utilized to assist in keeping functional range during the healing process.
"Other techniques used in this patient population include serial casting, scar massage, myofascial techniques and contract relax stretching, just to name a few. We often use 'every trick in the book' to achieve our goals as the burned population presents with many co-morbidities and psychological issues that come along with the accident," she described.
The Team
Therefore, it is not only important that the individual practitioner be an expert but that the whole unit is one, as well. Burn care units require a group of burn care experts who are, as Fratianne puts it, more than a team. They are a family. "On our unit," he stated, "T.E.A.M. stands for 'Together Each Accomplishes More'." And that couldn't be more true.
"The collaboration with all members of the burn team is imperative in providing successful interventions and return to normalized function," Bernard said. "The most common daily collaboration [for physical therapists is with nursing. Nursing is one of the biggest assets to our team approach as we need them to be on board with positioning, splint wear schedules and assisting the patient in donning and doffing splints, and administering pain medications for therapy interventions.
"The therapist is often only seeing the patient one time per day so keeping the nurses informed as to the patients progress, available range, positioning, ability to feed themselves, how to set the patient up to succeed at self-care is the strongest collaboration we need to have within the burn team."
In addition to nurses and physical therapists, the team includes doctors, occupational therapists, dieticians, social workers, music therapists and chaplains. These practitioners work not only to heal the physical wounds but also the "interior self," Fratianne said, for the psychological ramifications of a severe burn can be as severe-if not more so-as the wound itself. Patients often see themselves as victims, at least at first. With a team of individuals such as Bernard and Fratianne that feeling may not last long, for, as Fratianne said: "We aren't finished until the patient is a survivor."
Sue Coyle is a freelance writer in Philadelphia, PA. Contact her at susanelizabeth.coyle@gmail.com.
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