Burns: Medico-Legal Considerations

TASA ID: 1361

On October 6, 2011, at 2 p.m. ET, The TASA Group, Inc., in conjunction with Dr. Michel Brones, a Board Certified plastic and reconstructive surgeon, presented a free, one-hour, interactive webinar, Burns: Medico-Legal Considerations, for all legal professionals.

During this program, our presenter covered essential concepts in understanding burn injuries and their sequelae. Classification, types, mechanisms and treatment modalities were discussed to familiarize the participants with the current thoughts in this field. Medico-legal implications pertinent to the plaintiff and defense aspect of burn injury litigation were presented with a number of case examples.



If you are an Illinois attorney and would like to receive IL MCLE credit for viewing the archived recording, please click here.

About the Expert

Dr. Michel Brones is Board Certified in plastic and reconstructive surgery. Dr. Brones is currently in private practice after 17 years of experience (1981-1998) as a plastic and reconstructive burn surgeon at The Grossman Burn Center at the Sherman Oaks Hospital in Sherman Oaks, CA. Dr. Brones specializes in all areas of plastic/reconstructive surgery with special emphasis on burn injuries, hand surgery, and cosmetic/reconstructive procedures. Dr. Brones has more than 25 years of experience testifying for plaintiff/defense cases involving personal injury, product liability, medical malpractice, civil/criminal cases.

Transcription:

Matt: Good afternoon. Welcome to today's webinar, "Burns, Medico-Legal Considerations." During this webinar, our presenter will cover essential concepts in understanding burn injuries and their sequelae. Classification, types, mechanisms, and treatment modalities will be clearly discussed to familiarize the participants with the current thoughts in this field. Medico-legal considerations pertinent to the plaintiff and defense aspect of burn injury litigation will be discussed with a number of case examples.

The presenter for today's webinar is Dr. Michel Brones. Dr. Brones is a board-certified plastic and reconstructive surgeon. He is currently in private practice after 17 years of experience as a plastic and reconstructive burn surgeon at the Grossman Burn Center in Sherman Oaks Hospitals in Sherman Oaks, California. Dr. Brones specializes in all areas of plastic and reconstructive surgery, with special emphasis on burn injuries, hand surgery, cosmetic, and reconstructive procedures. Dr. Brones has more than 25 years of experience testifying for plaintiff and defense cases involving personal injury, product liability, medical malpractice, and civil and criminal cases.

Dr. Brones has asked that we make this presentation as interactive as possible. If you have a question that pertains to the subject matter that is being discussed, please use the chat feature on the right-hand side of the screen to submit your questions throughout the presentation. Dr. Brones will do his best to answer the questions as they come in. Approximately one hour after this event, we'll send out an email with a link, a follow-up link that will include the archived recording for this webinar. We do ask that you take time to fill out the survey that will appear on your screen after the webinar is over. And now, I invite you to sit back, relax, and enjoy. I'm going to turn the presentation over to our distinguished presenter, Dr. Michel Brones. Dr. Brones, the presentation is all yours.

Dr. Brones: Good afternoon or good morning to everyone, and thank you for joining us in this presentation. First and foremost, I know that this subject may be new to some of you, and sometimes the subject may be a little arid and a little bit difficult to understand. So I like again to re-emphasize that I'm more than happy and I think that it would be best for all of us, if you have any questions as we go along, please feel free to send the questions to Matt. He will type them into me so I can answer as we go along. Okay. And now, let's talk a little bit about burns. What I thought I would do is I would give a little perspective from a medical point of view first and so we can know the terminologies that we're talking, and then we'll go more into the medico-legal aspect of these type of injuries.

So let's start first with total body surface area burn, the rule of nines, the burn unit admission guidelines, and the fluid resuscitation guidelines. I'm sure that if you've seen any significant burn injury in your practice, you often come across with this total body surface area burn. What it means is what percentage of the body had been affected by the injury, and certainly, this has great implications, because the greater the area of the burn, of course, the greater the mortality and/or morbidity of the injury. In order to assess the total body surface area, we use a diagram, or quickly, we use the rule of nines that I'm gonna show you in another diagram. Also, I wanted to talk about some of the burn unit admission guidelines because this is one of the medico-legal areas in which some cases are seen as to when a case was or was not properly sent to a burn unit. And finally, we'll talk a little bit about the fluid resuscitation guidelines. Again, some of the cases of malpractice are involving whether or not the patient was appropriately treated by the referring facility, and in some cases, whether or not the patient was appropriately treated by the receiving burn unit. So all of these elements are important elements because they can be a source of malpractice actions.

So let's go a little bit into the area of burn and talk about what are the guidelines for a burn center referral. And as you can see there, hopefully, it is clear in your computers, what I was referring as the rule of nines. Each upper extremity is considered 9%. As you can see there, it's 4.5% for the arm, but that is for the front and back, 4.5%, so it will be equivalent to 9%. Likewise, the lower extremities, the entire lower extremity is about 18%, 9% for the front and 9% for the back. As you can see, the chest and abdomen is about 18%, the back is about 18%, and the face, the head, actually, is 4.5% for the face, 4.5% for the back of the head, so it's a total of 9% for the head, and 1% for the genitalia in order to complete the 100%. This becomes very important when you talk about you combine the percentage of the burn with, of course, the depth of the burn. It is not the same to have, let's say, a 50% burn that is only first and superficial second-degree burn, and we'll talk about those type of burns a little bit later on, than to have a 30% burn that is a third-degree burn or even a fourth-degree burn. In considerations of burns, we take in consideration the depth of the burn and, of course, the extent of the burn.

Now, what represents, according to the American Burn Association, an indication for burn center management? This becomes an issue when some institutions either do not refer or do not allow the patient to be sent to a burn center, or when there is a delay in referral to a burn center. So let's look at the guide. Any partial-thickness burns, any partial-thickness burn is a second-degree burn, that is more than 10% total body surface area burn would be an indication for burn center admission. Now, this area is a little bit gray as to whether the patient has to go to a burn center, but certainly, the patient could go. Any burns that, besides that, involve the face, the hands, the feet, the genitalia, perineum, or major joint areas are better evaluated in a burn center. Third-degree burns, electrical injuries, including lightning, chemical injuries, inhalation injuries, and circumferential, limb, or chest burns are better evaluated in a burn center setting. The reason for that is because, of course, the burn center is equipped with the appropriate modalities of treatment, with the appropriate diagnosis of treatment, and with the nursing personnel that would take care of these issues.

Let's talk about what are the common cases that I see in my practice and probably the common cases that most of you, I imagine, deal with. The number one injury that I see is related to scald burns. The setting is usually a child or an elderly patient. In both cases, issues of abuse, neglect, or criminal issues come into consideration. On many times, we are called to determine in case of children, whether the injury was purposefully inflected, whether it was accidentally inflected, and as I'm sure as many of you are aware, many of these scalding burns involve issues with thermostats, hot water heater, plumbing, and issues of that nature. Many times, I'm also called up on criminal cases in which there is a criminal investigation concerning children abuse. So those are issues that certainly happen very routinely. Other types of scalding burns, of course, involve hot tea and hot coffee. Many cases in which fast-food franchises are involved, of course, hot coffee, hot tea, Chinese restaurants with hot tea, oriental restaurants with hot tea. These are common sources of litigation. And certainly, showering and hot baths are also sources of litigation. Child and elder abuse, certainly, is an area that is ever-present, and certainly, immersion burns, the difference between what is accidental or not in immersion burn always comes into consideration. So I would say that scald burns and related injuries are probably the most common type of burn injuries that we see, certainly, represents the majority of any of the burn center admissions. By far, scalding injuries and hot water injuries or hot liquid injuries represent most of the injuries, and these are the areas that certainly we spend a lot of time. We are called many times to determine whether the temperature of the water that produced the injury was overly hot or whether it was an issue of duration of exposure, because here...

Okay, I'm gonna go and answer some of the questions. I get that I'm talking about...okay. I wanna talk a little bit about what is the first, second, third, and fourth-degree burn, and then there is a question as to what temperature would be required for hot water to result in second or third-degree burn. I'm gonna address the issue of the temperature once we go and see a diagram that I have that addresses that issue. But first and foremost, a first-degree burn is the most superficial of all the burns, and it's what we usually get when we get a sunburn in which our skin just turns maybe red but without any blistering. Once we have blistering, then it becomes a second-degree burn. A blister is typically a superficial second-degree burn. And then a deeper second-degree burn would be one that is really red, the skin has been lost, there is no blistering. And a third-degree burn is when all the layers of the skin have been burned, and the skin is typically leathery and either gray or white. I think that we can compare this to a tall building, like a 10-story building. In a first-degree burn, the uppermost one or two stories have been burned. In a superficial second-degree burn, the uppermost three or four stories have been burned. In a deep second-degree burn, the uppermost six or eight stories have been burned. And in a third-degree burn, the building has been burned to the ground. Now, a fourth-degree burn, we typically see with either chemical injuries or electrical injuries in which not only the skin has been burned but the underlying subcutaneous tissue and/or muscle has been burned as well. And then we're gonna talk about what is the temperature that is required for second and third-degree burns in a little bit.

Let's go to the next slide, and that is tap water scalds. And as you can see there, and I hope that you can see the chart well, but typically, as you may or may not know, the thermostat in a hot water heater should be...the recommendation is to be set at 120 degrees. Now, it is very, very common to find that the setting of this hot water heater is many times quite high, in the range of 140, 150, 155. The reason for that is because this unit, sometimes they serve a row of apartments. So in order to get enough hot water to all the apartments, the setting is quite high, and usually, that is what leads to problems. Sometimes, also because the setting is so high, there are some spikes of hot temperature that can injure the patient. But 120 is the recommended setting in most of the water heaters, and as you can see, at 120 degrees, you can have a deep second or third-degree burn in about 5 minutes. Now, as you can see in the chart, at 140, that gets reduced to about 5 seconds. So it happens very, very quickly. And at 155 degrees, the burn injury will occur in 1 second.

Now, these are tap water scalds, typically showering, typically hot water bath. And what happens in some of these cases is that even though the temperature is regulated for a shower or for a bath, sometimes flushing of the toilet or opening of another source of water, cold water, will introduce a spike in the hot water of the shower that may injure the client. So this is something we look for. Also, many of the units that are involved, I mean, apartment units that are involved, do not have anti-scalding devices, and according to each state, there are particular laws related as to whether units should or should not be equipped with anti-scalding devices. But in general, these anti-scalding devices are quite cheap, easy to place, but many, many buildings or institutions lack those anti-scalding devices. So this is something that commonly occurs that I'm commonly called upon to testify, not only up on the actual medical state of the patient but also from a forensic point of view as to whether the temperature of the water and the duration of exposure could have indeed caused the injury as alleged by the plaintiff.

So let's move on a little bit to our next topic. Besides the shower and the hot tub, food and beverages related scalds would be the next topic of consideration. Certainly, hot coffee and hot tea remain standard issues of litigation related to whether the coffee or the tea was served too hot and whether or not the patients were aware of how hot the beverage was, and issues of that nature that get related as to what is the standard of the industry, whether the franchise complied with the standard of the industry, and then issues related as to who was negligent are common causes of my expertise. Temperature and duration of exposure are the two elements that come across in all areas of litigations in which burns have been involved, what was the temperature and what was the duration of exposure, because that would determine what is the depth of the burn and sometimes what is the pattern of the burn.

Basically, this is a similar chart. It's a little bit busier chart, but it relates to food and beverages related scalds. And as you can see in the chart, and I hope that it's clear, there's also issues related to frying, baking, deep frying, not only issues related to hot water.

Preventive measures related to children and adults, this is always a topic that comes into consideration. When we talk about adults, I'm talking here about the elderly. Certainly, here, it's very popular to nursing homes or similar institutions that take care of the elderly or the disabled. And in case of children, of course, whether the parents are being negligent, and many of these cases, of course, involve foster families, sick parents, families that are not your typical family, and certainly, even institution where the children are placed. These are very, very common sources of injuries, very common sources of litigation. And the preventive measures have to be related, again, to the anti-scalding devices, to the setting of the hot water thermostat, to the presence of the attendant, to the presence of the person that is helping the elderly or the child towards the bath, and when hot food is served and hot coffee or tea is around, to the appropriate considerations. So that is very important.

Concerning the issue of pain, there is a question as to the difference in pain, okay, and the recovery time. The issue of pain, certainly, is an issue that is ever-present in burn litigation, because many of the allegations surround the issue of pain and suffering, and I know that, according to different states, the issues of pain and suffering are differently from a legal point of view. But I've been involved in several cases in which the patient ultimately died from the injury, but the area that was the source or the major area of the source of litigation was how much pain and suffering surrounded the injury and how much pain and suffering was related to the daily dressing changes and treatments that the patient underwent in the burn center setting even though the patient ultimately died.

Second-degree burns are theoretically more painful than third-degree burns. As a matter of fact, one of the distinctions between a second and third-degree burn is done as to whether the patient has or does not have pain. But the fact is that a third-degree burn will then go to surgery, and once we do surgery, of course, and the skin is removed, then the area would be quite painful. Burns, in general, are associated with a great degree of pain. Morphine or a similar medication has to be given, IV, practically, around the clock. Many of these large burn injuries are placed in an induced coma-like state in order to take care of them because of the pain and other considerations. So there's always a great amount of pain surrounding this experience, and concerning the recovery time and pain, I would say that once the burns are covered with a skin graft, once all those raw nerve endings are covered, then the pain decreases dramatically.

And then, according to what is the area that is affected on the particular patient, certainly, there will be a decreasing amount of pain. Pain will continue later on, of course, after the patient is discharged, and many of these patients do require pain management once they are discharged. It's a little bit difficult to answer, what difference will it make in the patient's recovery time? It would depend upon the extent of the body that was burned and the type of burn that was sustained, and of course, upon the surgery that was done in the patient.

There is another question concerning as to whether the age of the burn victim will affect the healing and scarring. The answer is yes. Typically, people at either extremes, whether you're too young or too old, our skin is much thinner. Consequently, a burn that would only be a second-degree in an adult may easily turn to a third-degree in a child or in an elderly. And also, typically, the older you are, the less scarring you will produce. Consequently, young people and middle-aged people will tend to scar much more aggressively, will tend to develop hypertrophic scarring and/or keloid scarring much more aggressively. And the older you get, the advantage of having a less [inaudible 00:25:49] scarring is that even though you will not heal as fast, certainly, the healing is not as bad. Hypertrophic scarring is not present, and keloid scarring is also not present as well, or not commonly present. So consequently, the older you are, you will have a better scar.

Let's move on a little bit to... This is a very good chart that shows about second and third-degree again and the time. Time and the temperature is very important. Again, 120 degrees, 5 minutes, 140 degrees, 5 seconds. Now, if you think about it, five seconds is not that long. So if you have a patient that is exposed for five seconds, then you would have a deep second and third-degree burn. And certainly, as we go higher than 155, it takes a second or less to produce a very severe injury. Many times, there are issues that are related as to, well, if the patient has been exposed to such temperature, why is the patient still exposed? Why doesn't the patient leave the shower, in the case of a grown-up that can do it? Many times, there are some other issues, and there are issues related to burn shock that do not allow the patient to quickly exit the area. Again, this is very, very important because it's what always comes up in litigation, how long was the patient exposed to the injuring agent and how hot the injuring agent was.

Let's talk a little bit about the different types of burns beside the scalding burns that we also commonly see in a burn setting, and those are electrical burns. Electrical burns are either work-related burns or are related to people doing work around the home. There's a difference between a flash electrical burn and a true electrical burn. In a flash electrical burn, what happens is that there is a production of heat, and the patient gets burned by that heat production secondary to the flash. But in a true electrical burn, the current will go through the body of the victim. Those, of course, are much more severe. Many of these injuries will end up in either amputations or will end up in immediate death. So these are very, very severe injuries that require immediate attention.

Going to chemical burns, again, most commonly occur in a work environment. These are very, very tricky burns because some of these burns do not manifest themselves right away and involve in many cases in which the initial plant in which the injury occurred that showered the worker, did not think much about it, and then the patient goes to the emergency room later on that day or the next morning with a severe burn injury. So these are extremely tricky type of burns. Traditionally, alkali burns, they go deeper than an acid burn. They may be more severe, and these are burns that require, most of the time, burn center management, and they have to be appropriately treated.

Contact burns are those that are produced with either cold or hot devices, and many times, people will have ice applied, particularly after surgery, and some injuries may or may not occur related to the icing. Other forms of contact burns may occur when the patients use a heater, either room heaters or massage and heating devices. And of course, frostbite, for people that live in cold climates, is another injury that is treated in a burn center environment, because basically, a cold burn is like a burn injury and it is treated as burn injuries. All of these type of injuries are commonly seen in a burn center and commonly causes of litigations. So these are areas that we have to be quite aware.

The other area that is very common is areas related to flame, flash flame, and of course, smoke inhalations. Apartment, building, structures do go up in flames, and of course, the issues are related as to how did the burn start, was it a faulty electrical device, was it electrical wiring, and of course, litigation proceeds from then on. Other areas of concern are related, of course, to appliances and burns that are related to appliances, either to the stove, sometimes to microwave, and certainly, anything that is related to gas. Gas line explosions and issues of that nature are also commonly seen in this consideration.

Smoke inhalation. Smoke inhalation is many times the cause of the injury. Many people do not die from the burn injury, but they die from smoke inhalation. Certainly, the lungs are affected. Patients need to be intubated, put on a ventilator, and managed. They may require several bronchoscopies, and again, people that sustain severe smoke inhalation are insidious for infection. Then the smoke inhalation will go into pneumonia. And ultimately, many of these people die, not so much from the burn per se, but from the smoke inhalation, and also, of course, sometimes there's no burn, it's only smoke inhalation that leads to either tremendous injury or death.

First, second, third, and fourth degree, we discussed those. Sometimes it's very difficult to make a differentiation as to what is what, and even in a burn setting, we may require a few hours or days till we can determine for sure, what is the nature of a burn.

Superficial and deep partial thickness. The reason why there is a difference between those two is because a superficial second-degree burn, which is basically a blister, many times is treated conservatively, while a deep partial-thickness burn or deep second-degree burn, for all purposes, many times is treated as a third-degree burn or also known as a full-thickness burn. Consequently, there is not that much difference between a deep partial-thickness and a third-degree or full-thickness burn, and many times, they are treated likewise. So these are all the initial considerations when we talk about burns.

And let's talk a little bit about skin grafting, because that is what you will see in many of these clients, and then we'll talk a little bit about what happens with many of these patients. The treatment, the acute phase when the patient is admitted to a burn unit is the resuscitation. Many of these victims would die from shock, and that was commonly 20, 30, 40 years ago, in which we did not understand exactly, what was the mechanism of the shock. But basically, what happens in a burn injury, in a severe burn injury, is that, basically, the gates are open, the doors are open, and water basically pours out of the individual. The patient goes into what we call hypovolemic shock, meaning that there's a tremendous loss of water and fluid, and the resuscitation means we have to give a lot of fluid back into the patient in order for him to keep his blood pressure up. Dressing changes are done in order to avoid infection and in order to control the pain, and they have to be done under pain control because they're quite painful.

Skin grafting, of course, is the only way that we can treat these injuries. We do not quite yet have a true artificial skin. We still have to use the patient's own skin, is the best material to skin graft this area. Homografting is cadaver skin. Before we can put the patient's own skin, which is called autografting, many times we will take the patient to surgery, remove the area that is burned, and do a temporary covering with homografting cadaver skin, and then bring back the patient to surgery, remove the cadaver skin, and put the patient's own skin, what is called autografting.

Physical and occupational therapy is part and parcel of the recovery because patients have a tendency to contract. Consequently, the joints will become less supple. They're not able to move the joints, they cannot raise their arms, extend their elbows, or bend their knees. So it's very important, that physical and occupational therapy. And certainly, psychological and psychiatric intervention, during and after treatment, is required because these patients are, of course, left with tremendous emotional trauma, and these are the type of injuries that not only are internal injuries but are external injuries in which the patient has a daily reminder that he has been injured. Rehabilitation, of course, in an outpatient, depending upon the extent of the burn injury, but certainly with severe large burn injuries, is part of the procedure.

And let's not forget about pressure garments. Pressure garments are given to most burn victims that have been skin grafted, and basically, they are custom-made garments that the patient will need to wear for about 2 years, 23 hours a day. The reason for the pressure garment is to avoid hypertrophic scarring, to avoid keloiding, and to produce a scar that is nicely molded to the patient that is as soft and supple as possible without hypertrophy. The pressure garments do this by applying, like the name implies, pressure, and then we use silicone inserts, which are like jelly silicone, underneath some of the areas in which we wanna apply extra pressure. Ultimately, for those patients that have sustained facial burns, we have face masks that are custom-made. They are plastic, and the patient wears them, again, 23 hours a day, and the reason is that pressure needs to be applied in order to make the scar smoother and softer. So these are all the elements that a burn victim will have to deal with. Of course, there'll be medications that will also accompany, and of course, their recovery is lengthy, particularly in those large burn injuries.

Back to work issues. These, many times, are, of course, a source of litigation related not only to back to work but to permanent and temporary disabilities. These are always sticky issues in cases in which the injury has occurred during work and in cases that involve large injuries, like in oil fields or particular plants in which they deal with chemicals, cleansing agents, and in which burns are extensive, third-degree burns affecting a large part of the body. Most of these patients have a hard time going back to work, and if they do go back, they go back to a modified duty, or they have to go through a retraining and job rehabilitation program.

Permanent and temporary disabilities related to burns, these patients should not be exposed to the sun, because the sun will produce a hyperpigmentation, meaning you will darken the scars. So we commonly tell these patients not to be exposed to the sun. If they need to be exposed, then they have to wear either protective clothing or a sunscreen, 25 or above protection. And disabilities, also, they should not be exposed to extremes of temperature, no hot or cold exposure, because these patients do lose the ability to control their body temperature. Again, I'm talking about large burns. And usually, these patients also lose the ability to sweat, because the sweat glands have been injured during the third-degree burn, so they cannot control their temperature.

Common complaints are related to itching. I would say that most, if not all, burn victims do have itching, and that is related to dryness of the skin. Certainly, when we skin graft, the sweat glands and the oil glands do not get transplanted. Consequently, the skin of these patients is always dry and itchy, for which we recommend creams. That is, again, part and parcel of the treatment. Burn camps and support groups are attached to most burn centers, and we feel that they should be part of what patients undergo. The support groups, of course, are free. The burn camps, it's a minimal fee, but do help particularly children to deal with their injuries.

Let's talk a little bit about the forensic issues that I'm involved with and maybe the type of cases that you may be involved in. The forensic issues relate as to whether the story that the plaintiff presents is or not in agreement with the injury, that it makes sense if the story that's been told, the story that will indeed produce this type of injury, that it makes sense what the duration of exposure. Was the agent that produced the injury, an agent that could have produced this injury? Many times we see injuries in which there is a particular branding, meaning there is a specific area that is clearly demarcated that has been burned so we can determine, what is the agent and whether the injury was accidentally produced. Other forensic issues related as to, what was the temperature of the water? Was the attendant present at the time of their injury? How did the injury occur? What was the length of time between the injury and when the patient was removed from that area?

Splash versus immersion burns, intentional versus accidental. Immersion burns, which is an area that is commonly seen in children abuse cases and elderly abuse cases, typically, you will have a clearly demarcated line, the line of immersion. If you were to have splashing, then that would either represent that there was a patient under a shower or that there was some fighting going on or that water was running at the time. So we look for splash marks. Duration and temperature of exposure, as we've discussed before.

Arson. Certainly, together with the people that will investigate the scene, we are called upon to see whether the elements, again, fit together. And again, we're not as concerned, at least on my point of view, as to the mechanical wiring, but we are concerned as to whether there was some flame injury, whether the injury was a flash injury only, and we can tell that the type of burn as to what was the area that was exposed and what was the mechanism of injury per se, whether there was a direct exposure of the skin to flame or whether it was a heat-related type of injury.

Cases of assault, they're always interesting cases, many times. They would be cases in which patients are sprayed with either acid or alkali, or cases in which hot coffee or hot water is being thrown a victim, and these are particular cases that we're also called up on.

Pain and suffering, like we've discussed, is one of the issues that always come into consideration. And certainly, depending upon the nature of the procedures that were performed and the nature of the healing, we can determine as to whether the pain and suffering that the patient is experiencing, of course, even though there are individual variations, but whether the pain and suffering will fall between the commonly seen range of patients with similar injuries.

The past and future treatments is certainly something that I'm always called upon to determine. I do review carefully the costs that were incurred before the litigation has started, the costs that are incurred as the litigation continues, and certainly, what are the future treatments and costs associated with these injuries. Either from the defense or the plaintiff's point of view, some of these costs can be exorbitant, depending upon the injury and depending upon who's recommending what. And it's very important that appropriate expertise is used in order to determine what are the future costs, because certainly, many times, the future costs may be more than the cost and what's incurred up to that point.

Most of the big burn injuries do have a life care plan attached to them. They're usually produced by nurses, life care planners, in which the input of all the specialists that are involved in the care of this patient is put on. I feel that it's very good to have the life care plan either from the defense or from the plaintiff's point of view because we can't put in one document the totality of the future costs, and in that way, we can present our case from either side and appropriately either pursue or defend the case. I wanted to also say that, as of late, many of the cases that come up on my desk are related to the use of medical technology, particularly lasers. Many of the newer modalities of laser treatment do produce burn injuries. Some of those cases, of course, do have merit, some of them do not. But just as an additional area of potential litigation, the increased use of laser, either during hair removal, particular treatments, skin treatments, particularly liposuction treatments, and particular laser use that is being widely applied now, we see more and more litigation coming from that.

I wanted to give you just a few brief examples of the cases that I've been involved with, and then I would like also to leave some time for more questions if you may have those. The typical child abuse cases that I see, they are two types. The cases that come from the public area are usually cases in which either the public defender or the district attorney is involved. Many of these cases are from broken homes, or from foster homes, or children that are in an institutional type of setting. And most of them involve, certainly, neglect, and many of them, I would say most of them, are accidental, but certainly, some of them are clearly abuse cases. Also, there is a small number of cases that do come from the private area in which parents that are usually going through a divorce setting are suing each other because of some type of burn injury that was sustained by the child while in the care of the other parent. That is a common source also of litigation. And those would be the two most common areas that I deal with.

Elder abuse has to do with nursing homes. And nursing homes, at least in California, are undergoing a number of cases, a number of lawsuits, and elder abuse, typically during a bath or showering, are the ones that I'm involved with for either side in order to determine whose fault it was, whether the attendant was present, whether it was the elderly's fault, and things of that nature.

Product liability and personal injury are most of my cases. I do a great number of product liability cases, and those have to be related...some of them are medical, some of them are not medical products, but those have to do with sometimes lack of appropriate safety mechanisms in the device, lack of appropriate temperature settings, or the unsafety of the particular device. Lasers would be one example. Heaters would be another example, either room heaters, floor heaters, other type of heaters, and certainly, let's not forget the propane explosions, and things of that nature. And then personal injuries, certainly, my second most common type of involvement. Any type of accident, car accidents, accidents at work, accidents at home, in which there is flame, flash, electrical injuries, certainly, very, very commonly to be involved in those type of cases.

Medical malpractice represents a smaller part of my practice but a growing part of my practice. There are a number of cases in which patients do inadvertently get burned during surgery, either because, during surgery, it is common to use the electrocautery. Surgeons, we would use the electrocautery in order to try, of course, to stop the bleeding. And many times, what happens is that there is oxygen around the field, and there may be an explosion with the oxygen and the electrocautery. So it is not uncommon to see burn injuries surrounding surgical episodes. Also, because many times patients do get cold during surgery, so it's not uncommon for particularly longer surgeries to have some type of a heating device underneath the patient, which can lead, in cases of malfunctioning, to burn to the patient's bodies. So these have been cases in which I've been involved. And certainly, cases in which hot water is used to either irrigate some areas or hot water bottles are placed next to the patient to warm up the patient that have led to this type of litigation. Other types of medical malpractice that involve the electrocautery and the laser are also, again, very common, and we see more and more surrounding this type of injury. The usage of chemical peels also may produce burn injuries and certainly something that we see in our practice as well.

Ultimately, there are a great number of these cases that come across my desk. I hope that I've helped you all in dealing or at least understanding what we deal with burns and what we see from a medical point of view and from a legal point of view. And if any of you have any questions or any concerns, please feel free to ask them now. Otherwise, I think that we're about finished with the presentation.

Matt: Okay, excellent. Thank you, Dr. Brones. I do have some questions that have come into me, and we'll just field kind of right down the list here. Going back a couple slides, what's the purpose of inducing a coma in a burn patient?

Dr. Brones: Okay. The reason why we induce coma is because many of those patients, like I told you, do suffer smoke inhalation. They have to be placed on a ventilator. And many times, it is best if the patient goes under sedation, under what we call induced coma because we can manage the settings of the ventilator much better, and the patient does not fight the ventilator. Besides, there's a great amount of pain that is involved with the dressing changes and because those patients really need to have the dressings done at the bedside instead of the whirlpool where we commonly do them, we have to medicate the patients quite heavily. So it is much more convenient to have the patient fully anesthetized for the duration so we can do the ventilatory care, the pulmonary care, the dressing care without disturbing the patient and allowing us to do what we need to do without undue pain.

Matt: Okay, excellent. We have another question here. How long after discharge does pain management continue for? Do burn patients continue with pain management for a lifetime?

Dr. Brones: No. The answer is no. But this is what happens. Certainly, as you can see from the presentation, there is a really, a very...the gradient between a superficial second-degree burn and a third-degree electrical burn or even chemical burn is quite great. People that have electrical burns and chemical burns may have pain and discomfort for a long time. People that have the most commonly seen type of burns, scalding burns and flame burns, do not, but it depends upon the individual and depends upon the extent of the burn. Is it a 30% burn? Is it a 50% burn? Is it an 80% burn? Are the joints involved? And is the skin graft in a reconstruction that was done of such nature that the skin grafting that was provided, provided good coverage? Sometimes, particularly when the burns are extensive, the skin coverage that is produced with the skin grafting is very flimsy. So patients do complain of discomfort and pain. But in most of the cases that I've seen, and I've seen thousands of cases, burn pain subsides with time. It is rare to see that a patient will need pain medication for life. Very rare.

Matt: Okay. Thank you so much, Dr. Brones. We have another question here. What are nares, N-A-R-E-S?

Dr. Brones: I think it's a hair removal cream.

Matt: Okay. And then we have another question here that says, "How effective are the ointments that you talked about?" Are there any new topical medications that are out in the market right now that our audience should be aware of?

Dr. Brones: No. The only reason why we use ointments, like we've previously discussed, is because the skin is dry. So the only purpose of the ointments is to moisturize the skin. So any type of cream that has a moisturizer, and we try to use fragrance-free creams, these creams with no alcohol. So basically, aloe vera cream, vitamin E cream, any type of Nivea cream, any type of cream that has a good moisturizer base, with no alcohol, is the one that we'd recommend. There is no new cream that is better than any of those.

Matt: Okay, excellent. I don't see any other questions from the queue, so we're going to wrap up this afternoon's presentation. Dr. Brones, on behalf of everyone here at TASA and all the attendees, thank you for a great presentation, which probably you took a lot of time to put it together, and that you are truly a subject matter expert on this. So thank you very much.

Dr. Brones: Matt, there's a question that I wanna answer in one minute. There is a question as to whether pain and suffering is totally subjective.

Matt: Go for it.

Dr. Brones: The answer to that, whoever asked that question, is that the answer is no, but it is partially subjective. It is not totally subjective. That is the reason why we're telling you that I'm called many times to determine whether the pain and suffering that the patient is experiencing is between the range of what other patients have experienced or whether he's out of the range. It is partially subjective, but we can tell when we evaluate the patient as to whether the pain and suffering does or does not correlate with the objective findings. So there is a range that we allow the patient, but we can also determine whether the patient is out of range. That's it.

Matt: Okay. Thank you so much, Dr. Brones. We're just gonna wrap things up here very briefly. We've had a great presentation this afternoon, and we thank you, Dr. Brones, for all the time and effort that you've put into it. If you'd like to speak to Dr. Brones about [inaudible 01:00:26], you can contact us here on TASA. Our number is 800-523-2319. We'll be sending out a link to the archived recording of this webinar tomorrow morning. The archived recording will also be posted in the Knowledge Center of TASA's website. Just go to tasanet.com and click on the Knowledge Center tab found at the top of the page, and you'll be able to navigate to our previous webinars.

Our next client-focused webinar will be "The Role of Event Data Recorders in Accident Reconstruction," and that will take place on October 11th. If you have any follow-up questions or comments, please email them to me. My email address is found on the screen at experts@tasanet.com. All your comments are taken into consideration. They help us to produce better programs. With that, I'm going to end this afternoon's webinar. There'll be a survey that appears on your screen after you leave. We do ask that you take a moment and fill that survey out. It will help us to produce better programs in the future. Thank you so much and we look forward to seeing you at future TASA events.