WRITING REFERENCE: Burns

Like any sensible writer (or someone just very nitpicky about their own writing), I like doing a ton of research into things, especially injuries (I love researching injuries) and the canon material, if I'm writing fanfiction. So when I was writing the beginning of Heathens, I had to do research on burns, because, well I've never experienced full body third degree burns, which I assume is what B got. Most likely it was fourth degree burns, but given he was able to live in prison...hmm.

(Let's be honest, Another Note is a huge mess that needs a ton of research to correct, so I took the liberty of adjusting a few things and in my universe, Mello was a) exaggerating when he was writing this or b) baked as hell.)

While I've never gotten burnt that badly, I have been through three fires so I think I'm a good source to ask for fire phobia, but I'm also one of those people who gets weird with their phobias to get over them, so, I guess I'm questionable. 

Anyway, I got fire phobia down, I know what it's like to be in a fire, so I only needed to tap into my own experiences for that. My problem for Heathens was how burns were treated, how long the hospital stay was, what does the patient eat while being hospitalized, what's PT like, etc. There's a ton of references online for that types of burns, but nearly none for the treatments, so I decided to scour through hospital pamphlets and websites and papers and compile them, and hey, while this may be incomplete, at least this can help a bit for anyone who wants to write for burn injuries.

(Note: this may be a little cluttered, but that's because I just copied down or paraphrased what I deemed important for me to know.)

BURNS

A burn is damage to body tissues caused by sunlight, heat, fire, electricity, friction, radiation, chemicals, hot water or steam. Burns are described by the damage they cause. A mild burn that affects only the top layer of skin, causing redness, is called a first-degree burn or superficial burn. A burn that is red with blisters and affects the top layer of skin and supporting tissues is called a second-degree or partial thickness burn. More severe burns that affect all layers of skin and supporting tissues, causing a white color or black charring, are called third-degree or full thickness burns. Full thickness burns that also affect the fat, muscle and bone under the skin may be called fourth-degree burns. Even burns that are not as deep may be considered severe if they cover a large area of your body. A person who is burned may also have damage to the eyes (ocular burn) with facial burns or to the airway (inhalation burn) from breathing in hot air, steam, smoke, or chemicals.

Did you know that third-degree burns hardly ever hurt at all, at least not initially? That's because nerve endings have been completely burned, and the brain hasn't yet received the painful message.

HOSPITALIZATION

You may need to stay in the hospital because:

• Your burn is severe or covers more than 10% of your total body surface area.
• Your burn affects your face, hands, feet, genitals, or large joints.
• Your burn has damaged your airway.
• You have a medical condition that is making your burn more difficult to treat.
• You have an electrical or chemical burn.

Burn Team 

- the ones who take care of you while you're in the hospital

• Plastic Surgeon - organizes your case, does surgery, may contact specialists if necessary
• Nurse - daily care
• Dietitian - organizes your diet, gives you vitamins
• Physiotherapist - plans your physical therapy, helps with stretching
• Occupational Therapist - helps you relearn to do daily tasks, helps plan your move back home
• Respiratory Therapist - is involved when you have breathing problems, especially with lung damage from smoke inhalation or a swollen burnt neck
• Social Worker - helps with your family, helps you plan to go home

(Obviously in Heathens, A skipped the social worker for B because he was already going to be under house arrest.)

Hospital monitoring:

•  You will be checked often by the hospital staff.
• Your heart rate, blood pressure, and temperature will be checked regularly.
• A cardiac (heart) monitor may be used to keep track of your heart rate and rhythm.
• Your blood oxygen level will be monitored by a sensor that is attached to your finger or earlobe.
• Your fluid intake will be monitored closely by keeping track of everything you eat and drink and any IV fluids you receive.
• Your fluid output will be monitored closely by keeping track of the amount of urine and bowel movements you produce. You may have a small tube (catheter) placed into your bladder through the urethra (the opening from the bladder to the outside of the body) to drain and measure urine from the bladder.

Testing:

• Arterial blood gas (ABG): A blood test to measure the levels of oxygen and carbon dioxide in your blood.
• Blood, urine, or other tests to check for fluid and electrolytes, infection, or organ function.
• Tests to look for abnormalities inside your body, which may include:
• X-rays: Pictures of the inside of the lungs to check for damage.
• Bronchoscopy: A test in which a slim, flexible, lighted tube called a bronchoscope is passed through your mouth and down into your lung to check for damage.
• Electrocardiogram (ECG): A test that measures and records the electrical activity of your heart.
• Endoscopy: A test in which a long, flexible tube and tiny camera is put into mouth, down your esophagus, into your stomach and into the upper small intestine to look for damage if you have swallowed chemicals.

Surgery

Some full body burns may need 10 - 15 surgeries.

First Surgery

• Cut away all the burned material
• First two to three weeks, you’re completely asleep on the ventilator
• Get all the burned tissue off in the first five days
• Temporary cover-on (cadaver skin)
• Skin grafts

Debridement - removing dead or infected skin cells

Dermabrasion - lessens appearance of scars from a burn injury

Skin grafts take 1 - 2 weeks to heal.

How long does it take for burns to heal?

Superficial burns (first degree) —3 to 6 days.

Superficial partial-thickness burns (second degree) —usually less than 3 weeks.

Deep partial-thickness burns (deep second degree) —usually more than 3 weeks.

Full-thickness burns (third degree) —heal only at the edges by scarring without skin grafts. A skin graft is a very thin layer of skin that is cut from an unburned area and put on a badly burned area.

Treatment

The treatment for a burn depends on its cause, how severe the burn is, how well you respond to treatment, your overall health, and any complications you may have.

• You will have a small tube (IV catheter) inserted into a vein in your hand or arm. This will allow for medicine to be given directly into your blood and to give you fluids.
• You will receive oxygen through a small tube placed under your nose or through a mask placed over your face. In very severe cases, you may need a tube put into your windpipe to help you breathe.
• You may have a tube put through your nose down into your stomach, called a nasogastric or NG tube. The tube may be used to give fluids or medicine, or with suction to help relieve pressure from air or fluids in your stomach and intestine.
• You may need treatment to remove the burned tissue. Your provider will choose the best debridement method.

DEBRIDEMENT METHODS

Surgical: The burned tissue is removed with a sharp surgery tool or laser.

Chemical: Medicine is put on the burned tissue to help remove the burned tissue.

Mechanical: Dressings or a stream of water is used to remove the burned tissue.

Autolytic: A wet or moist dressing is put on the burned tissue to keep the burned tissue moist and allow your body to grow new, healthy tissue underneath it.

You may need surgery to treat your burn. Surgery may include:

• Escharotomy or fasciotomy: Surgery to cut through the burned skin, fatty tissue, and connective tissue (fascia) to relieve pressure from swelling in the area of the burn.
• Skin grafts: Surgery that uses skin taken from another area of your body, a donor, or an animal to cover the burned area after the burned tissue is removed to help new skin grow.

Your provider may prescribe medicine to:

• Treat pain
• Treat or prevent an infection
• Control your blood pressure
• Replace or supplement nutrients, hormones, or other chemicals that your body may need to recover from the burn
• Reduce the workload of the heart or treat any abnormal heart rhythms
• Help relax your airways
• Reduce swelling in the airways

Dressings are usually changed at around 8 pm to 9 pm.

You may need physical or occupational therapy to help prevent complications and improve your recovery. Most rehabilitation programs include:

• Physical therapy to help prevent scars and muscle contractures and regain muscle strength
• Occupational therapy to help you relearn ways to do the tasks that you did before the burn

PT usually lasts until 1 pm in hospitals.

Alert your healthcare team if you have:

• Trouble breathing
• Bluish color of your skin below the level of the burn
• Numbness in your feet or hands below the level of the burn
• Chest discomfort (pressure, fullness, squeezing or pain) that lasts more than 5 minutes or goes away and comes back, or chest discomfort that goes to your arms, neck, jaw or back
• Fast, slow, or irregular heartbeat
• Increased pain at the site of the burn
• Increased drainage from the burned area
• Increased thirst and dry mouth
• Depression

Duration of Hospital Stay

How long you stay the hospital depends on many factors. The average amount of time to stay in the hospital with a burn is 4 to 9 days.

If your burn was severe or you have complications, you may stay in the hospital longer. You may need to go to a rehab facility to continue your burn recovery program before going home.

How long do grafts and donor sites take to heal?

Although the healing process may vary with each individual, skin grafts typically heal in about two weeks. Donor sites also usually heal in about two weeks, providing they do not become infected.

VISITORS

(this area was researched for A) 

 Items visitors can bring:

• personal care items (hairbrush, toothbrush, etc.)  Families can assist loved ones with personal care, grooming and feeding if needed. 
• slippers / running shoes
• photos / cards / books
• no valuables
• no cellphones or wireless communication devices in patient care areas; if used in lobbies / public hallways, keep them a meter away from the patient's IV pumps
• MP3 players, iPods and iPads are allowed to comfort and support the patient

When visiting:

• Do not visit if you do not feel well.
• Wash your hands before and after visiting.
• Do not use the patient's washroom
• Follow directions about infection control when posted on the patient's room door.

POST-BURN CARE

Hypertropic scarring

- when skin heals in a bumpy, raised, uneven pattern. Can result in uncomfortable scars and decreased movement in joints.

Scarring can be helped by putting pressure over the area, which is done by wearing custom pressure garments that flatten the scars. They need to be worn 23 hours a day. To prepare your skin for pressure garments, you will be made to wear tensor bandages while you're in the hospital. 

You may need to wear pressure garments for as long as six months to two years; you need to wear them until the scars are no longer red but pale. 

Other products to help flatten scars include plastic inserts, massage and gel sheets.

Splints

Splints are made of hard plastic that does not bend. They are worn over a joint to stop the joint from losing movement while the skin heals. Splints can be worn over joints in the arms, legs or neck. Some of them are custom made for each patient. Usually worn for most of the time after a surgery. Therapists will also give you a schedule of when to wear them. 

Bathing

Soaking in a bathtub is not recommended. Test your water temperature before getting into the tub or shower. Your new skin is sensitive to extremes of hot or cold and may be injured easily. Using a clean, soft towel and gently washing instead of vigorously rubbing will lessen any discomfort of bathing. Soap should be scent and dye free.

Dry Skin

The dry, scaly appearance of your skin results from damage or destruction of the oil-producing glands. Some of these glands will begin to function again, but until that time you will need to use some artificial lubricant. Avoid lubricants that contain lanolin and alcohol as they tend to create blisters in the healed skin. There are many lotions available or you may use mineral oil. Water-based lotions are recommended. (There's a recommendation for Nivea here...)

Itching

Itching usually accompanies the dry, scaly, healed skin. Avoid vigorous scratching because this may break your delicate skin and leave open areas to heal. Reapply lotion or mineral oil as needed. 

Bruises

Now that your burns have healed, you have a new layer of skin that is thinner and more sensitive and delicate than the rest of your body. These areas will bruise easily and must be protected against burns and sharp objects. Don't wear tight clothing or shoes that can cause pressure and blistering. Your body needs time to build up skin that can withstand pressure. The length of time will vary with each individual. For some it may take several months and for others a year or more. Gradually, as your skin thickens and toughens, it will become less sensitive. You will be able to go about your normal routine with less fear of bruising.

Blisters

Blisters commonly occur in healed or grafted areas and are no cause for alarm.  Don't break a blister if you get one. If they break, keep them clean and expose them to air to promote healing. If you get a blister under your pressure garment, put a bandage over it and keep wearing the pressure garment. If it doesn't heal, call a doctor.

Friction from linen, rubbing and bumping against objects will cause blisters. Standing for long periods of time without appropriate support may also cause blistering. Some people tend to form blisters more readily than others. This tendency decreases as your new skin thickens.

Sun 

Your new skin will be more sensitive to sunlight and will tend to sunburn in a very short time. Avoid direct contact with sunlight at all times (at least six months). Protect your skin by wearing light clothing to cover the areas that have been burned. Wear a large hat if your face and neck have been burned. Apply a sunscreen to protect your skin during the warm summer months. Your skin will remain sensitive to the sun for at least one year. After this period, you can test your skin by exposing small areas at a time to the sun.

Cold

Because your new skin is thinner, it will be more sensitive to cold. Slight tingling and numbness may be experienced, especially in hands and feet, when the weather is cold. This sensation will gradually decrease as your skin toughens. You can decrease your discomfort by wearing warm clothing and avoiding exposure to the cold for long periods. You will need to protect your skin for at least a year.

Appearance

Your healed burn will continue to change over the next several months. You can expect some discoloration and scarring in the normal course of events.

Discoloration

The skin discoloration you see in your healed areas is a result of the normal healing process. It may appear light to deep pink, brown, or a grayish color. Discoloration varies with each individual, depending on your natural skin coloring. Natural color may return to superficial burns and some second-degree burns in several months. Other areas may take much longer and some discoloration may be permanent in burns of greater depth.

Discoloration of Extremities

If your arms or legs are involved, you may notice more discoloration after walking or having your arms down. You can help relieve this problem in your legs by sitting with your feet up on a chair. You may find that you experience less discomfort if you walk rather than stand in one place. Standing still for long periods allows the blood to pool in your feet and legs causing swelling and discoloration. Exercise in moderation will also improve your circulation in these areas and will decrease your discomfort. 

Exercise

As your skin heals, scar tissue will develop and your skin will tend to contract, causing tightness of muscles. You may notice a stiffness and slight pulling in the joints upon rising from sleep or after being inactive for long periods during the day. You will find that movement of the joints gradually decreases the stiffness. Regular exercise helps prevent arms and legs from becoming fixed in a rigid position.

Three types of exercises the physiotherapist will plan will be:

• stretching
• strengthening
• cardiovascular or endurance

Prior to discharge, the therapist develops a home exercise program for the patient and instructs the patient and the family in its use. The therapist also works with the patient and family to obtain necessary exercise equipment and arranges for out-patient physical therapy.

Diet

(also applies while still in the hospital)

High-protein foods such as:

• meat
• chicken
• fish
• eggs
• cheese
• peanut butter
• nuts
• milk
• legumes and beans

High calorie foods such as:

• cream
• milkshakes
• chocolate milk
• juices
• desserts
• margarine and butter
• sauces
• gravies
• salad dressings and dips
• dried fruits
• puddings
• ice cream

(When still in the hospital: tube feeding is for when you are unable to eat enough.)

Notes on how to write fire trauma (for those who've never been in a fire; note, that this is how I reacted and it's different from person to person):

• You're gonna hate the smell of smoke
• I mean really hate it
• Like a few days after the latest fire I was in (which was - what, two years ago? January 2016?), I smelled smoke from a candle, froze, and then immediately went to go see where the hell the fire was to put it out because hell no not again
• Some people just freeze and cry
• My great grand aunt yelled at some kids who were lighting matches because she was so freaked out
• If it's like night time, or if you're somewhere dark, and you see something bright when it shouldn't be bright? You're gonna freak the fuck out.
• The 2016 fire happened at like midnight for me and it started from my great grand aunt's apartment unit and it was right next to my room, so all I saw from my windows were bright orange 
• And I hated that goddamn color for a while
• Will not recommend going into the school theater while still scared of seeing orange in dark places because, well, incandescent colored lights had me scared for a while
• Definitely fire-based nightmares
• Paranoia and constant planning where to run in case wherever you are suddenly goes up in flames
• Fire-proofing everything you own
• I packed like a couple of emergency bags in the first few months post-fire just in case
• Hearing a siren gets mixed feelings because on one hand I associate it with yes, thank you, help is here, but also just oh there's a fire, please don't be our house, please don't be our house, please don't b
• Being terrified of matches/lighters and then later deciding to be a daredevil in an attempt to conquer a trauma and lighting a match and watching it burn down to your fingers
• Sense of sick triumph when you hold it without flinching
• Sense of sick triumph when you touch heated metal and burn your fingertips a little without flinching. But really, don't do that. It was just a weird thing I did to stop being scared of fires and heat I guess.
• Lmao I'm still terrified for everything burning but I'm good with small fires now
• But the first few weeks? You're gonna bolt when you see even small fires.