When I was a student in PA school at the University of Florida, I never imagined that I would work in a burn center. This was one of those medical subspecialties that was discussed but never truly covered in depth. By no means am I the first PA to work in this field; I'm just one more in a line of dedicated professionals striving to improve patient care in this challenging medical subspecialty.
I work at an American Burn Association/American College of Surgeons-verified regional burn center in Florida, where I treat all types of burn wounds. Many of our patients are referred to us from other hospitals, emergency departments, and physician offices. I work with a team of clinicians that includes an attending physician, a burn fellow, three plastic surgery residents, and an ARNP.
■ 5:30 AM
I arrive early and round on all of my patients for the day. I check the daily list of patients and see that we had some new admissions overnight. A 23-year-old white male who was burned during an airplane crash is in the burn ICU. He fell 200 feet and, amazingly, he suffered only a broken clavicle. His burns, however, cover 75% of his total body surface area (TBSA) and appear to be mostly full-thickness injuries with some circumferential burns on his extremities. I know that his wounds, fluid status, and pulses will have to be closely monitored for the next several hours to assess for compartment syndrome. After his wounds are debrided, I apply silver sulfadiazine cream and cover the burns with a dry gauze dressing. A sobering way to start any morning.
■ 6:30 AM
I meet with my team for pre-rounds prior to walking rounds with the attending physician. We discuss overnight events and how our patients are doing. The meeting is brief; then, we divide up the orders that need to be written, patients who need to be transferred or discharged, and the services we need to consult for our patients before entering the operating room.
■ 7:30 AM
Our first OR case is a 34-year-old white male who had attempted to burn some brush with gasoline and a lighter 4 days ago. The fumes ignited and caused a flash flame burn injury. He has a 10% TBSA burn to his bilateral upper extremities and hands that initially appeared to be a mix of partial- and full-thickness injury; through serial wound examinations, we determined that he would need skin grafting. After seeing the patient and checking his labs, we take him back to the burn OR. The patient is sedated with general anesthesia; and, after he is prepped, we begin the process of excising the burn wounds. I begin tangential excision on one arm while the burn fellow works on the other arm. Because these surgeries can be very bloody, we always make sure that we have cross-matched plenty of blood for our patients. We use a mixture of tourniquets, tight gauze wraps, and a thrombin spray to achieve hemostasis on the extremities. While waiting for this to occur, we use the dermatome to harvest skin grafts from the patient's thighs. A dermatome can slice an extremely thin layer of skin, about .010 to .012 of an inch thick. This patient has plenty of donor sites, so we can use a sheet graft instead of a meshed skin graft. Meshed skin grafts can leave a poor cosmetic result and may provide less wound contraction. After we finish, I help transport the patient to the postanesthesia recovery unit and inform the family that the surgery was a success.
■ 9:45 AM
The team is ready to begin our next case, a 42-year-old white female who was burned on the job. She is employed as an electrician and was burned when the wire she was working on ignited, resulting in a flashback of fire. She sustained partial-thickness burns to 12% TBSA on her face, right upper extremity, and bilateral lower extremities. She will undergo wound debridement and xenograft placement. Xenograft is a biological dressing, usually made from pig skin, that acts as a scab. It allows the wound to epithelialize, prevents the loss of moisture, and protects against infection; 1 to 2 weeks later, it is removed. Usually patients with a xenograft have less pain and are able to go home with minimal wound care in a couple days.