Volume 61, Issue 3 , Pages 237-239, March 2008
Once upon a time and the timing of surgery in burns
Article Outline
The depth of injury is the major determinant in the management of the burn wound.1 The superficial partial thickness burn will invariably heal without surgery, the full-thickness wound, of any significant size, will invariably not heal without surgery. The intermediate depth burn can heal without scarring if cleaned and dressed with biological dressings.2 It is the deep partial thickness, or deep dermal burn that still causes some debate. There is the potential for such injuries to heal but the process can take several weeks during which time the patient is at risk of infection developing in the wound. Another very important consideration is the outcome as the risk of hypertrophic scarring does increase with delayed wound closure. Accordingly, in children and adults with functionally or aesthetically critical sites of injury the surgical management of deep dermal burns is to be strongly encouraged.
There is considerable scope for reviewing the merits of technique and timing of acute, excisional, burns surgery but this is sadly lacking in the contemporary literature. Even in the definitive reference work for burns care this topic receives considerably less attention than, for example, the metabolic consequences of burn injury that such appropriate treatment seeks to avoid.3 Reference is made to a recent meta-analysis of early excision of burn wounds, drawing attention to the hazards of increased blood loss.4 We did point out, however in a letter of response to that paper, that although the analysis was excellent, what was being analyzed was not, and, unfortunately a meta-analysis does not give a better analysis of poor data.5 Looking at the evolution of burns care over the last half century perhaps the single most significant advance in management, which has had the greatest benefit for the greatest number of burns patients, has been the introduction of the concept of the early tangential excision of the burn wound to create a surgical wound that can be immediately closed with grafts. This huge step in burns care did not happen overnight, nor did it happen in the richly endowed centers of excellence of burns research. This revolutionary change happened slowly, carefully and quietly in a place called Maribor. Maribor is now an urban municipality of Slovenia but in the 1950's and 60's it was in Yugoslavia, behind ‘the iron curtain’.
In September 2007, just 50 km north of Maribor, the European Club for Paediatric Burns (ECPB) held its 2007 Workshop in Castle Seggau, a former Bishop's residency, just outside Graz, Austria. The ECPB was formed in 1991 by four paediatric surgeons whose common mission was to raise the standards of paediatric burns care in Europe.(see www.ecpb.org) The ‘Club’ has now grown to a world wide association of friends and colleagues who share this mission for children around the globe. Every third year there is an International Congress and so far these have been in Zurich, Switzerland; Florence, Italy; Hong Kong, PRC and Cape Town, South Africa. In the intervening two years the club enjoys a retreat to a castle or some other outstanding location for a workshop. Hence, Castle Seggau, parts of which are over 1000 years old. The Castle is situated in wine growing country called ‘Styrian Tuscany’. The hostess of the workshop was Professor Marija Trop, a Paediatrician at the Medical University of Graz. Marija has a wonderful sense of drama and history and it was absolutely fitting that as a highlight of the workshop there should be a session called ‘Once upon a time’. This session began with an introduction to, and a personal account by, the very person who was the pioneer of early tangential excision and grafting, Zora Janžekovič. For all the delegates at the meeting it was a wonderful experience to hear the account of this extraordinary time and its aftermath and the account is printed in full in this issue of the journal as a historical record for all to enjoy.
In addition to Professor Janžekovič the delegates were delighted to hear from three other great pioneers of burns surgery, Dr Friedrich E Muller, Professor Radana Kőnigová and Dr S William Gunn. (Fig. 1)
Figure 1
Following their presentations the four elders acknowledge the standing ovation from the delegates: From left to right: Dr Friedrich E Muller, Professor Zora Janžekovič, Professor Radana Kőnigová and Dr S William Gunn.
Dr Friedrich E Muller is regarded by many to be the Grandfather of Burns care in Germany. In 1967 he set up the first centre for the treatment of burns in Germany, at Bochum, which he directed. He contributed to the opening of other centers in other cities in Germany. He organized a network linking the various burns centers in Germany, with a view to the management of beds in the event of disasters. His studies have concerned all the aspects of the burn disease. He has taken a particular interest in burns shock and immunological and infective aspects, supporting the trend towards the use of early surgery in burns treatment. In 1998 Dr Muller was awarded the G Whitaker International Burns Prize. Dr Muller entranced the delegates with a recollection of his visit to Mainland China in 1978. This was the era of the opening up of China under the enlightened guidance of Deng Xiaoping. Dr Muller was part of a delegation under the auspices of the International Society of Burn Injury who crossed the border from Hong Kong with some excitement but also apprehension into the unknown territory of the Peoples Republic of China. Dr Muller described the initial disbelief but then admiring acknowledgement of how advanced the burns care was and the total dedication of the very labour intensive approach to the management of the most extensive burns. One aspect that he described that impressed the Western visitors was the Chinese approach to infection control. Each day the patient with an extensive burn would be moved into an empty room which had been completely ‘sterilized’ the day before. This is indeed an enlightened concept that would certainly turn the tables on the present onslaught of MRSA!
The third of the elders was Dr S. William Gunn now in his 9th decade and still going strong. A Swiss-based Canadian surgeon, Dr Gunn spent 35 years as the head of Emergency Relief Operations at the World Health Organization and as a United Nations consultant. Disaster medicine grew in scope and impact under the passionate guidance of this inspired man. After leaving WHO he worked as an advisor to the International Red Cross, WHO, the UN, UNICEF and many governments. He became president of the International Association of Humanitarian Medicine Brock Chisholm, an association named in honour of WHO's first director-general, a Canadian who died in 1984. Apart from medicine Dr Gunn has indulged in a lifelong interest in the culture of Canada's first nations and deeply cherishes his honorary position as chief of the Kwakiutl tribe which was one of the major tribes of the Northwest Coast of Canada. Dr William Gunn has a Kwakiutl name, Kwe-Kwala-Gila which means Saviour of Lives.
And last, but by no means least, Professor Radana Kőnigová. A leading figure in Czech medicine, Professor Kőnigová worked in the Department of Plastic Surgery of Charles University in Prague under the guidance of Professor Burion, from 1962. In 1969 she was asked to set up an intensive care unit for critically burned patients and in 1990 she became the Head of the new independent Department of Burns Medicine at the Third Medical Faculty of Charles University. In 1992 she was appointed Professor of Plastic Surgery and Burns Medicine and in 1993 awarded the G Whitikar International Burns Prize. On 28 October 2004 she was awarded the Order of Merit, presented personally by the President of the Czech Republic and commended for her lifelong medical, pedagogical and scientific work and as a living monument to Czech medicine and to its representation worldwide.
It is humbling to be in the presence of such giants but equally inspiring to witness their humanity, their compassion and their commitment. Long may medicine be able to draw upon such figures to guide, to teach, to lead for the benefit of all.
At the close of the Workshop a special ceremony was held when Dr Clemens Schiestl, Director of the Pediatric Burns Centre, Division of Plastic and Reconstructive Surgery at the University Children's Hospital in Zurich announced the creation of a new award. This award is to be called the ‘Zora Janžekovič Golden-Razor Award’ in honour of Professor Janžekovič. The golden razor is a symbol for Zora's improvisation skills, but also a symbol of her overwhelming desire to help, even at times with bare hands, more than half a century ago. It was felt fitting that the first award should be made to Zora Janžekovič herself (Figure 2, Figure 3, Figure 4).
Figure 2
Dr Schiestl and Zora Janžekovič read the transcript of the award.
Figure 3
Zora Janžekovič receives a bouquet from Professor Marija Trop.
Figure 4
Professor Zora Janžekovič read a short speech of thanks on receipt of the award. This is her handwritten transcript.
References
- . Allogenic skin in the treatment of burns. Clin Dermatol. 2005;23:376–387
- . Glycerolised allogenic skin: transplant or dressing? A medico-legal question. Burns. 2002;(Suppl 1):S34–S39
- . Operative wound management. In: Herndon DN editors. Total burn care. 3rd ed.. Philadelphia: Saunders Elsevier; 2007;p. 177–195
- . Meta-analysis of early excision of burns. Burns. 2006;32:145–150
- . Meta or better: analysis of early excision. Burns. 2006;32:662
PII: S1748-6815(08)00028-4
doi:10.1016/j.bjps.2008.01.002
© 2008 Published by Elsevier Inc.
Volume 61, Issue 3 , Pages 237-239, March 2008
