Learning micro-course

Burns

A Case Study

Background

William is an 84-year-old gentleman with a past medical history of rheumatoid arthritis, bladder cancer, and lung cancer. His cancers are unrelated. William has deformities in both hands due to RA. He has no original joints. A urostomy was created when William was diagnosed with bladder cancer. He underwent chemotherapy and radiation for the bladder cancer. His lung cancer diagnosis is fairly new and he decided not to treat the cancer. The tumor is very slow-growing and has caused no problems. William has fallen multiple times due to an unsteady gait and generalized weakness. He has a walker and scooter, but does not like to use either. He was recently hospitalized for septic shock secondary to a surgical wound from a lipoma removal.

Sulfasalazine, a DMARD causing sun sensitivity, was recently prescribed to William to help with the inflammation caused by RA. During drug education, the risk of infection was stressed, as well as the risk of Stevens-Johnson syndrome. Sensitivity to sunlight was listed as another side effect, but no time was spent on this information. William and his wife, Sandy, daughter, and son-in-law went to the beach shortly after William started taking sulfasalazine. Sandy recalled being told something about sun sensitivity because of the drug. William assured her he would stay under the beach umbrella during peak sun hours. He always wore a shirt to the beach because of his embarrassment of the urostomy. Why was this a bad idea?

Bill noticed his left leg was very red before going to bed. He put some aloe vera gel on the site, but didn't tell Sandy about his leg's appearance. The next morning, Bill's leg was redder and some skin was sloughing off. Sandy was concerned about the way his leg looked, so took him to Myrtle Beach Urgent Care. The provider told Bill to use vaseline on the site and leave it open to air. The provider assured William that the burn would look better in a few days. What type of burn does William have? Was the prescribed care appropriate for the burn? What would you do differently, if anything?

Within 2 days, William's burn resembles the picture. There has been no healing. The leg is becoming warm to touch and painful. William opts not to go back to urgent care and instead visits the PA on staff at his retirement home. The PA prescribes bacitracin ointment, covered with a nonstick dressing. She dresses William's wound and tells him to come back if it gets any worse. The next day the burn is very painful to touch. There are multiple blisters and it seems one has opened up every time William looks at the site. It also has a peculiar odor. Sandy adds more bacitracin and puts gauze around the dressing to keep it in place. William and Sandy drive to their daughter's home 3 hours away for the weekend. Their daughter is a nurse, so they plan to have her look at the burn when they get to her house. Did William get appropriate care from the PA? What would you do differently?

When William and Sandy arrive at their daughter's house, William can barely get out of the car. Sandy rushes in to ask for help. Their daughter, Lynn, runs out to help. William's color is gray and he is more unsteady on his feet than usual. He is having trouble putting any weight on the burned leg. Lynn gets him into the house and on the couch. She begins to unwrap the gauze dressing to see what the burn looks like. The smell of the wound is overpowering. The site is dark red with pockets of pus evident in the burn and red blistering. William is hypothermic and his blood pressure is 100/60. What is going on with William? What should Lynn do?

Lynn gets William in the car and takes him to the ED two miles away. The receptionist takes one look at him and runs into the back. A nurse comes out with him, puts him in a wheelchair, and takes him straight back to a bed. William's blood pressure is lower than at home. The provider comes in and asks what happened and how it has been treated. He mumbles under his breath about some people not being able to do this job. The ED provider treats the burn appropriately and admits William to a stepdown unit. How did the provider treat the burn? Why was William admitted and what interventions were done once he was admitted?

William was referred to the Burn Center at UNC Health in Chapel Hill after discharge. He was treated there for 6 months. He has some scarring of the leg, but has no other permanent damage. He does not go out in the sun without high SPF and clothing for protection. The manager of the urgent care in Myrtle Beach received a letter outlining the poor care received. There was no response. Lynn spoke with the PA at the retirement facility. He is afraid of her and hides if William has been admitted to the healthcare facility on-site at the retirement community. The picture to the right is the real William and Sandy.