Advances in Industrial Burn Injuries

Note: This webinar was approved for CLE credit in CA, NJ and PA.

Disclaimer: Please remember that if you are applying for CLE credit you must attend for the full 60 minutes of the LIVE presentation, not the ONDemand version. If a participant is seeking credit in states we are not approved to issue credit and the participating party seeking credit incurs a fee to receive said credit, it is not the obligation of TASA to remit payment for such credit. It is the participant's obligation to remit payment to the state in which they would like to receive credit.

Program Description

On November 1, 2023 at 3:00 p.m. (ET), The TASA Group, in conjunction with cosmetic and reconstructive surgeon, Dr. Thomas Zaydon will present a one-hour interactive webinar presentation, Advances in Industrial Injuries, for all legal professionals.

Brief Description

Participants will learn the following:

• Degrees

• Mobility & Systemic Complications

• Assessment/Management

• Tools

Advances in Industrial Injuries from The TASA Group, Inc. on Vimeo.

About the Expert:

Dr. Thomas J. Zaydon, Jr. is a cosmetic and reconstructive surgeon practicing in Miami, FL for the past 25 years.  He is Board Certified by the American Society of Plastic Surgeons and is a Fellow of the American College of Surgeons, is an active member of the Aesthetic Society of Plastic Surgeons and a Diplomate of the National Board of Medical Examiners.  Dr. Zaydon is also an active member and leader in multiple Plastic Surgery societies and hospital committees. 

His credentials include Drexel University College of Medicine, Philadelphia, PA; Eastern Virginia Medical School, General Surgery, and Chief Resident at Louisiana State University. 

Dr. Zaydon holds active medical licenses in the State of Florida and the State of Louisiana.

He is the current Chief of Plastic Surgery at Mercy HCA Hospital in Miami, FL.

He is the former President of the Florida Society of Plastic Surgeons and the Miami Society of Plastic Surgeons.  He served as Vice-Chairman at the Miami Heart Institute and former Associate Chairman at the St. Francis Hospital.  He currently serves on numerous committees at Baptist Hospital and its Affiliates. 

Dr. Zaydon is available to assist you in performing evaluations, preparing reports, and serving as an expert witness regarding plastic surgery issues.  Where appropriate, he is available to manage and treat ongoing plastic surgery issues. He averages 60% plaintiff and 40% defense work.  Ninety-Five (95%) percent of his time is spent on patient care.  

He is known for being highly ethical and competent, as well as prepared and analytical.

Transcription: 

Ms. Davis: Welcome to today's presentation, Advances in Industrial Burn Injuries. The information presented by the expert is not to be used as legal advice and does not indicate a working relationship with the expert. All materials obtained from this presentation are merely for educational purposes and should not be used in a court of law, sans the expert's consent, i.e. a business relationship where she or he is hired for your particular case. In today's webinar, Dr. Zaydon will discuss degrees, mobility and systemic complications, assessment and management, and tools. To tell you a little bit about our presenter, Dr. Thomas J. Zaydon Junior is a cosmetic and reconstructive surgeon practicing in Miami, Florida for the past 25 years.

He is board certified by the American Society of Plastic Surgeons, and is a fellow of the American College of Surgeons. He's also an active member of the Aesthetic Society of Plastic Surgeons and a diplomat of the National Board of Medical Examiners. Dr. Zaydon is also an active member and leader in multiple plastic surgery societies and hospital committees. For attendees requiring our passcode, the passcode for today is INJURIES. Please remember that if you are applying for CLE credit, you must log onto your computer as yourself and stay for the full 60 minutes. You are also required to complete the survey at the end of the program. Please note that CLE credit cannot be given to those watching on a single computer.

Dr. Zaydon, the presentation is now turned over to you.

Dr. Zaydon: Thank you. Hello, everybody. I'm going to give a hybrid talk. It's gonna be partly medical and partly legal. As a board-certified plastic surgeon and active practice in Miami, Florida, I've had the opportunity to opine to both plaintiff and defense juries burn, not only educational information, but assessment information, and on occasion, liability. So, I'm gonna give an overview on what the attorney, my colleagues in law, need to know about burn injuries. This presentation will be balanced as best I can between the defense perspective and the plaintiff's perspective, and I'll put in medical knowledge that I think you need to have so you can evaluate a case and present it to a jury and/or judge. So, that being said, let's get on with the presentation.

I think the basics, probably everybody on this call remembers the basics. You have different levels of burns. We used to call them first, second, and third, we don't do that anymore. We use the anatomy. It's a superficial epidermal burn, it's a mid-dermal burn, or a full-thickness burn. It should be noticed that juries understand, as doctors do, that burns are painful. A full-thickness burn may not be initially painful, but the treatment tends to be painful. In general, a superficial epidermal burn, what we used to call first degree, does not leave a scar. In order to have a scar or require any sort of medical treatment, you'd have to have involvement of the dermis. The dermis is the layer underneath the epidermis.

But the main goal of this slide is to tell my colleagues in law that we no longer classify first, second, third degree, we are defining burns by the extent of involvement. And by knowing the extent of involvement, we can better counsel the patient on the best course of treatment and explain to the lawyer the patient's diagnosis, prognosis, and make an assessment. I am frequently asked, "Can I correlate temperature with the depth of the burn?" And I'll get into that later in the presentation. I have a little teaser for you. And my teaser is PRP, most of the audience is aware of the role of PRP in orthopedic injuries, well, we use it a plastic surgery. Let's define our words. Plasm is the blood, the liquid part of the blood. A platelet is in the blood.

As it turns out, platelets are a very rich source of growth factors and they rejuvenate skin. So, as I will get into the presentation, I'm gonna be able to give the audience information about the value of platelet-rich plasmin PRP in the role of burns. So, it's not just for orthopedic conditions, it's for burns as well. Every day, we're getting more and more indications for the use of PRP, even longevity. So, some basics. Skin burn treatment, obviously, with the exception of a few chemical burns, the first thing you wanna do is hold it under cold water. I will say that some people sometimes don't remove clothing fast enough, so the clothing acts as a thermal keeper. It keeps the burn going longer. That's why it's important when you have a burn from a fast food location, that you hold onto the garment that the liquid may have gone through because this can be important in determining the temperature.

Obviously, we wanna use an antibiotic ointment. If they're allergic to ointments, aquaphor can be used. You want to do the opposite of hot, you wanna use cool, and of course, you apply aloe. Some things you don't do, we don't use toothpaste, egg whites. We don't pop blisters, we like to keep those blisters intact, and we don't ice burns anymore. We can use constant cold water, just some basic ABCs. So, when do we like to see the patients? Well, obviously, as quickly as possible. As a practicing plastic surgeon, I see burns acutely, and I see burns a week later, and I see burns years later. And we used to say that the burn had to undergo complete healing and maturation before we intervene. And as I'll get into this talk, I'm gonna explain about the earlier interventions that have evolved in recent years.

We are finding that if you can control healing, you're gonna get a more optimal outcome. So, regardless whether it's a partial thickness or full-thickness burn, I would enclose it, recommend an early referral to plastic surgery or a burn specialist. But basically, the idea is to control the healing to get the best possible result. Tools that we can use. We like to use early compression. We know that this helps remold the collagen and line it up in a more linear manner. I talked earlier about PRP, what we're doing here. You have a burn, it's maybe a couple weeks later and a great deal can be done. What you wanna do is you penetrate the burn scar with a needle. And then when you do so, you, we create the burn. And by doing so, you can introduce the PRP.

In the United States, we typically get the PRP from the patient's own fat. We tend to get the PRP from fat, and then we spin it in a centrifuge and extract the growth factors. So, that way, we're not worried about cross-contamination, and we stay in line with FDA recommendations. Offshore, PRP is available from outside sources, but the United States, we use the body's own tissues, certainly safer. So, our idea is to recreate the burn wound, bring it back to an area where it was before you saw the patient, and restore healing in a controlled manner. And we talked about the use of a Dermapento do so. Now, not all burns are thermal. Some of these burns I'm showing are from a seatbelt, or some of them are from an airbag deployment, often overlooked that there's release of noxious chemicals from the airbag. And this nauseous chemical from the airbag deployment can create a burn-like injury on the face. But the treatment is essentially the same.

What we're trying to avoid is a keloid scar. The word keloid, you may be familiar, I think most people are familiar, has to do with an objectionable raised scar. The healing process tends to go outside the zone of trauma, and it's raised. It's a response to a burn or in response to a road burn, an airbag, a thermal burn, a chemical burn, electrical burn. And the idea is to control the healing by restoring the injury and then controlling the healing process. There's two words I like to mention. One is a hypertrophic scar, and the other is a keloid scar. They're quite different. Hypertrophic scar stays within its own border, it doesn't go outside the zone of trauma. What we all dread is a keloid scar. A keloid scar goes outside the zone of trauma and requires a bit more intervention to manage and treat, and the results are more unpredictable. But that is the definition between a keloid scar and a hypertrophic. Both are the body's responses to burns.

And this shows the utilization of a Dermapen, those that are watching it. We are basically recreating the injury, having a fresh, open wound, and restoring it with PRP. Burns need to be mobilized. And when we assess a burn, we look at range of motion. Burns cause damage to not only the structure, but frequently to the adjacent structures that are not burned. The reason being that a burn tends to contract, the more severe the burn, the more severe the contracture. The contracture is due to the shortage of healthy, supple skin. So, it's important that early mobility be established and every effort be undertaken to preserve range of motion.

When assessing wounds, it's important that you measure mobility, because very often, mobility's overlooked, but it's an important part of the function in the impairment rating. Typically, the burn expert will not give you these measurements. On catastrophic cases, it's important to have somebody who's familiar with these measurements, who's familiar with the patients hesitations to cooperate, that's an expert in their field give you exact numbers. These numbers often can be improved by plastic surgical procedures, which I'll discuss shortly. Physical therapy is important not only early on to prevent contractors, but in the treatment. When looking at a life plan for somebody, it may recommend in a bad burn, a catastrophic burn, the ongoing care of a physical therapist.

And my colleagues in physical therapy try to keep the burn wounds supple by early intervention, even in an open wound. We tend to do everything we can to overcome the contractile forces. Good communication between the lawyer, the doctor, the physical therapist, the entire team can provide an optimal outcome. I think that your best physicians, your best case practices have optimal communication going, frequent communications on the patient's diagnosis, prognosis, and recommendations. This very busy slide just talks about the types of intervention. They vary slightly depending upon the depth of the wound. But this is a more simple slide. And basically, I wanted to go back to showing the audience, first degree is superficial. It could be a sunburn. They tend to be painful. The skin gets dry, but it goes on to heal in three to seven days.

We call it superficial. There's no dermal involvement, therefore, almost always no scar. Scar requires a partial thickness involvement of the dermis. Typically, if there's a blister, there's gonna be some dermal involvement. That's our second degree. And then you could break it down to superficial and deep and full thickness being all the way through the skin, the dermis, right down to the muscle. Now, full-thickness burns are not painful in the beginning, but the treatment can be painful. And then you have subdermal, which we'll briefly talk about later. It has to do with lightning strikes and electrical injuries. Not all burns are from hot liquids. You can have a road burn, it's an evulsion injury. The principles are exactly the same. You want to recreate the wound by bringing in healthy uninvolved tissue.

So, not all burns are from hot liquids or flames, but the treatment is essentially the same, the measurement strategy's the same, the assessment's the same. Stem cell treatment is...look at this young girl. It looks devastating, catastrophic injury. We were able to restore her to some sense of normalcy by restoring the skin. Now, it should be emphasized that the skin is an organ. It's not just aesthetic. It's not just something that's not pleasing to the eye. The skin has a functional duty. It has the mechanical duty to protect the body against being bumped against the external object, to protect the body against viruses, protect the body against bacteria. It has the duty to keep the skin supple. It has a duty to thermal regulate.

The skin is more than just a covering. It is the largest organ, a functional organ of the body. And it should be emphasized that an injury that is considerable in its extent is gonna have an impact on the body's ability to reach its maximum potential. We've also used in the past, and we continue to use hyperbaric oxygen for acceleration of healing. But as we get more and more into rejuvenative medicine, hyperbaric oxygen is not used so much down the road. It's sometimes used in this acute or subacute stage, but the extra oxygen is probably less important now in the more mature stages. It definitely has hyperbarics. Hyperbarics is good for decreasing edema, enhances healing, it's antibacterial. It's an early rejuvenative technology that we plastic surgeons utilize to achieve an optimal result.

And this shows the chamber. Some chambers are small for just one person, but we can have chambers that are size...this one that have about, you can take 14, 15 people in the chamber, and they go in and they can all talk to each other. And it does take away some of the fear that people have when they go in by themselves. And this is just a type of illustration I would show to a jury to illustrate the differences of burns. Again, the second degree burn impacts the protective soft tissue appendages, it affects the pigmentary cells, it affects the cells that make the skin supple and protective. A first degree burn tends not to do that, and a third degree burn is full of thickness that basically makes charred or charcoal, I like to say, of all the areas.

Again, we can correlate to some extent the depth of burn with the temperature and the type of offending agent as long as we have a sense of the time of contact of the agent with the body and we have a good idea of what the protective cover was and how long it was in place. Laser has a wonderful, wonderfulrole in the treatment of burns. This is a burn scar that, you know, obviously has, you know, cosmetic issues. Pardon me a second, I'm getting a question. And laser is very beneficial in ameliorating the inflammatory process. The inflammatory process, if we can control inflammation, then we can get a better outcome for the burn.

And this is well known. The idea is to lower the inflammation to get a more optimal result. Lasers can be different types. One is a pulse dye laser. This is a laser with a very favorable risk-benefit ratio, very little risk, very high benefit. But sometimes you have a more difficult scar that you wanna take a bit more risk. So, there is a less favorable risk-benefit ratio. There's more of a risk because you're recreating the wound and you never can predict 100% how it's gonna come out. But the CO2 laser, which we call an ablative laser, does have a role in the more difficult wounds. So, I'm not gonna repeat this, but this basically is a recap. No longer, first, second, third, we define burns by their anatomical layer. And again, it's important that your expert have these slides available. They're very easy to create. You don't have to outsource it. The juries tend to enjoy the educational part.

Actually, when they give me a deposition, I enjoy having selected photographs and exhibits to show the extent of the burn or what could be done. Because, you know, we don't always say in words concepts that are best shown in images. So, we'll got past a lot of material. So, let's talk about body surface area. Now, burn surgeons need to estimate the extent of the burn. And there's many different ways of doing it. In general, take the patient's age and the extent of burn, that gives you an idea how significant the burn is. So, obviously, a burn in an older individual has more impact on the impairment rating than a burn in a younger individual. And then we use something called the rule of nines, which is basically that we break the body up to various zones. I'm not gonna bore the audience here how we calculate this, but we do have a method to our measurement of the body surface area of a burn. And we use the rule of nines or the rule of palms.

This shows when you look at the medical records, how you might come up with the extent of the burn. Look at the arm, about 4.5% for each arm, and 18% for the chest. But again, I emphasize that as you get older, you can almost say that age plus the extent to burn is a good idea of the mortality. It's a little bit sad, but it is borne out by our research. And if you want a more simple method, roughly a palm, if you take a palm, your palm is...the size of your hand, I should say, is roughly 1% of the body surface area. You will have mixed situations where you have partial thickness and full thickness in the whole person. But we do add partial thickness and full thickness when coming up with total body surface area.

Now, burns, they not only wreak havoc on the skin, they wreak havoc on the body. We talked about the havoc burns wreak on the skin, its ability to thermoregulate. In more significant burns, it can affect the fluid shifts. And in a really deep, full-thickness burn, you can actually have dead and innatured skin. For both the plaintiff and defense, there are recognized guides that have actually correlated jury verdicts with the patient's age, extent to burn, and the type of burn. And juries do recognize that burns are painful, but first degree burns don't tend to be painful after they're healed. Third degree burns, as I said, are painful when they're being treated, but they're not painful in the beginning. But juries recognize that and they get an idea where something may settle for mediation. There are many, many sources on the database that show the amount of burn correlating with a specific verdict.

Burns do cause complications. The greatest risk is infection. A bad burn can because a release of myoglobin, which can cause organ failure. As I mentioned, your preexisting age and health are special factors, but they're not within the control of the patient when they're injured. We do see nursing home patients that are involved in burns for one reason or the other, I'm not gonna get into details, but we have to keep in mind that the elderly and the infirm, as well as the young, we should keep our radar open for signs of physical abuse. I'll repeat that. When you have a patient who is elderly, infirmed, or very young, burns warrant some investigation for signs of physical abuse. Factors that are within the control of the patient, we do know that comorbidities such as smoking and diabetes do have prolonged healing period.

Electrical injuries and chemical burns are a special situation, and this includes taser injuries and so forth. As a reminder, I hope you never encounter this. If someone you know is involved in an electrical situation, the first thing you do is you turn off the power. You don't go try to pull them away from the electrical situation, you'll become part of the problem. Lightning strikes, keep in mind that, in Florida, especially, I don't know who's in Florida on the call, I do see victims of lightning strikes. And lightning not only causes burns, but it can cause damage internally with the heart because the current goes, you know, you make a complete circuit and the body's in the middle of it, and it takes a beating.

Now, this is interesting, body's response to burns. Regardless of the burn, the first thing that happens, if you remember from high school biology, fight or flight. There's a release of catecholamine. If it's a partial-thickness burn, there's pain, there's tachycardia, the heart beats fast, there's obviously anxiety. The second stage, which is half a day later, is you have an inflammatory response. That's the redness I showed earlier. And you have edema, which is swelling. So, our goal as a burn surgeon is to control the body's response to the burn during that fluid chip stage. And we do that with the tools that I showed you, including early mobility, compression, lasers, and the like.

The evolving medicine burn science is that earlier intervention is helpful. We used to wait till the person was completely healed then intervene. We're doing earlier interventions now. And then you have the hypermetabolic stage where the body really gets cooking with gas, and then the body would tend to need more nutrition. And we know that nutritional support is important. And then we control the resolution phase where we deal with the scar, we do the rehab I talked about, and get the patient back to the best normal we can. Keep in mind that the smaller the point of contact with an electrical burn, the more concentrated knee injury. I'm gonna skip over electrical burns, interest of time.

This shows you have an entrance and an exit wound in this slide for those that can see it. And our goal is to treat the whole patient. And keep in mind that these patients in the burn unit have psychological issues. They may have difficulty sleeping, they may require pain, so that is outside of the scope of this talk, but plastic surgery literature is quite clear that burn patients, whether it be electrical, chemical, thermal, flame are enhanced risk for psychosocial sequelae, therefore evaluation by a colleague with the appropriate expertise and the psychosocial sequelae of burns may be of some benefit.

And this just gives you another example of an electrical burn entrance and exit site. And what happens is it's a full-thickness situation and the skin is homogenized by that. All the cells, all the layers, everything kind of comes together and you get for lack of a better word, a mix smasher. You get a homogenization. Let me skip over that for interest of time. So, taser burns are treated the same way as any burn, and we have to keep in mind that if it's a taser burn, that it may require a more aggressive approach, which we sometimes do, is we excise the burn.

And you may see that where we actually do early burn excision, followed by resurfacing. Occasionally if a burn is obviously full thickness or devastating like some of those electrical burns I showed, early excision and revision is an evolving concept in our literature. So, we have several questions, so I'm gonna release some time here. Let me answer some of them first. One case... We already have a lot of questions. Okay, thank you. I do wanna mention that your plastic surgeon should work with a life care planner. Give me one second. I wanna have my producer write down all the questions.

I'm pleased to have all the questions, I just wanna get some... Can you write down the 35 questions for me? All right. Here we go. If it's a catastrophic case, I think that a life care planner should work closely with your plastic surgeon. Now, it's important when making a life care plan that it is a believable plan. And sometimes in the plaintiff's plans, the plastic surgeon burn expert will overreach. So, it's important to have not only a defense, but a plaintiff burn expert working, it doesn't matter what side on these cases because we have in our field, recognized terminology to describe plastic surgery fees.

We have recognized terminology for the codes and the extent of surgery. And I think it's important that the jury only be exposed to codes that are reproducible and scientific. This is no longer a situation where we have people just opining upon codes and fees and just making their best guess. This is become more of an exact science. Okay. All right. Writing the questions down for us. I apologize. So, we're sometimes asked, when do you have to clean a burn? Sometimes we see a burn, for example, after a road rash, and the patient has been exposed to external forces on the road, and they have a lot of debris. So, they come in to see the burn expert, and they're already healed.

So, we obviously don't wanna leave the debris there because it's gonna leave a permanent tattoo. So, we have multiple ways of approaching that. One is you can do tattooing, which I do not recommend. Tattooing is a static intervention. It doesn't change as the body grows, it doesn't change as the pigmentary cells change, it becomes very unnatural. It's like a tattoo, it evolves. So, I do not recommend camouflage strategies for burns. Other things that could be done, as I mentioned, lasers of various energies and types, the pulse die of inflammation, the CO2 for ablative.

We do have the ability to introduce microdermabrasion, which is basically recreating the burn and recreating the PRP. And then when we create the burn, we can abrade or do a dermabrasion on the skin. And by doing so, we're able to get a lot of the foreign debris out. Even with airbag injuries, we sometimes see foreign debris from the actual contents of the airbag deployment. Let's get another question. Thank you. We're just trying to get everybody's questions. Now, these are great questions, everybody. Thank you. Can the burn expert provide a qualitative description of the intensity of pain from a burn?

Well, telling lawyers, this is obvious that the best person to describe the burn is a person that is experiencing the burn. I mean, that is, there's no substitute for that. However, we can state that burns are painful, and we can state typically how long a first, second-degree burn is painful. And we can state what types of environmental stressors can cause a burn to become painful, for example, going out to direct sunlight, or clothing against the burn wound. But in terms of the subjective number, the patient can give us a number, but we can only say that the patient's description is consistent with the anatomy, but it's hard for us to know how much pain someone is having, but we can opine.

Obviously, if someone has a 200-degree soup poured in their leg, that is gonna be extremely painful because that's a deep second-degree burn. And we could opine if someone had a sunburn, they're having pain three weeks later, that was probably more than a sunburn and there's some sort of disconnect. We can give general guides, but we can't talk about how the pain reflects their activities of daily living. When I see a burn patient, no matter when, I ask them, what can't you do that you could do? And then I ask them, why can't you do it? I don't engage them in a debate, but I would put it into the record what they told me. And if it's consistent, I'll say it's consistent. If it's unusual, I'll say it's unusual. That's the goal of an ethical expert. And I encourage you to pick somebody that subscribes to the ASPS, the Society of Plastic Surgeons Expert guidelines, which are part of my website.

And I think a good question to ask your burn expert, do they subscribe to these ethical guidelines? This will keep them from opining about factors that are beyond their expertise. I was asked, what type of aloe do I recommend? Aloe is very soothing. We use aloe frequently. I'd rather use aloe than antibiotic ointment. Antibiotic ointments tend to have issues with cross-reactivity and allergies. And I would say, maybe for the short-term antibody ointment, but as soon as the short term has passed, when things are well on their way, I'd convert to aloe.

I was asked, how soon after a burn should they see the expert? As a plastic surgery expert and treating physician, I'm asked to see patients at all stages, and it's important that I reach out to the lawyer and ask him or her, in what capacity in my treating the patient? It may cross over, I may start as an expert and become a treater, or I may start as a treater and become an expert. But in general, I think the sooner the better. I think the days of waiting until it's healed are well gone in my opinion. This is a self-serving question, Does Dr. Zaydon perform defense IMEs? Yes, I'm pleased to say it's part of my ethical code that I perform both plaintiff and defense IMEs.

It's always interesting to see when I give a deposition that I see the lawyer on one side that was on the other side, or now they're on this side and the other side, and it actually makes me feel very comfortable with my opinions that I very often know the lawyers on both sides of a case. I think when some hints for defense, and I know a plaintiff will be listening, is that you want to look for dishonesty. Dishonesty is obviously never good. You wanna look for inconsistencies. You may find that in the deposition, you may find that in talking in conference with your expert.

If you find one inconsistency or one untruth, it really opens the door tremendously to the credibility of the rest of the situation. So, obviously, if you're the plaintiff, tell the truth. Obviously, that's our go-to word here, tell the truth. But if you're looking to see what the truth is on either side, look for just a little hint of something that is not quite there. I was asked about pressure cooker burns. Pressure cooker burns, obviously, we're dealing with explosive forces, we have very hot steam. They tend to be in general deep second and not third degree. They do tend to leave some sequelae. You have to also look at the contusive force.

Your burn expert usually will not be involved in the liability piece of a pressure cooker, but we can help with the zone of impact. We can help you in case there's a question about, well, where was the pressure cooker located? Was the person inebriated when they were injured by the alleged pressure cooker incident? We can help you with the zone of trajectory, how far away they were from the zone of trajectory. We can help you to some extent with temperature, and we can help you to some extent with the patient, what part of the patient was, you know, mostly impacted?

Was asked about barbecue burns. We don't usually opine upon the etiology or the liability. I don't think we ever opined about that. But we do want to talk about the fact that these types of burns are flame burns and they can be full thickness, because a flame burn is different animal, so to speak, than a thermal burn. A gas station explosions and oil tanker explosions are important because they typically are multiple trauma. Highly recommend that they be evaluated by a multidisciplinary team. In these types of cases, it may be worthwhile to summarize the records by a professional because they tend to be extensive. And it's important that your expert, whether it be plaintiff for defense, stays in the wheelhouse.

Again, I was asked about airbag burns. Again, it's a combination of the contuse of force from the airbag which causes a chemical type of burn. As an aside, airbags can impact the patient's body. And by doing so, let's say, for example, they have a breast implant or a cardiac pacemaker, or even a orthopedic prosthetic device, it may have been impacted and not recognized by the explosive force. I have authored some papers called "Unrecognized Issues in Plastic Surgery." And these issues very often have to do with the realm of burns because burns are not recognized as being a functional issue. Even the patients sometimes think, "Well, it's just aesthetic, it's just cosmetic."

Clearly, it's reconstructive even though the procedures are considered elective, meaning the patient can do them when they wanna do them or not wanna do them, they are considered medically necessary. Just because they aren't done immediately doesn't mean they aren't medically necessary. Elective means that they can do them as a non-emergency. And so don't let the other side tell you that this is quote-unquote "cosmetic." Anybody who's a victim of trauma, a victim of a burn has a reconstructive indication. Give me a second. I'll look at some of the types of questions.

So, how do you find a burn expert? Now, obviously, there's many referral sources, there's listing guides. You can go into the database and see who's testified on burns. There's a lot of different ways, but there's no substitute, what I call the venting call. That's my description of when they have a meeting of the minds between the plastic surgery or the burn expert and the particular lawyer. Whether it be defense or plaintiff. You want to be sure the person that you're dealing with actively is involved with burns, that they take care of burns currently, that they currently have not been...the usual questions.

And it's time for frank talk. And if there's any experts that are on this call, I would encourage you to tell the truth, just like you'd want your patients to tell the truth, just like we want the people in the courtroom to tell the truth. If there's any hangups, any disqualifications, any license sanctions, if you're retired or not doing burns, you haven't done a burn in years, be honest. Ms. Davis, are there any other questions that you see there? Give me a second. I'll see if there are more.

Ms. Davis: No, there isn't. We are good.

Dr. Zaydon: Should we call it... Okay. All right. I'm gonna wrap it up and I want to thank everybody for being on the call. TASA has my information. I really enjoyed speaking with you. I hope I can speak to some of you on potential cases in the future. I've known TASA for many, many, many years. They're good people. They're ethical. Whenever there's any sort of bumps in the row with the experts...I'm not getting paid to say this incidentally, any bumps in the road with the experts, they always intervene and they tend to be very good in negotiating bumps in the road. Well, thank you everybody. Take care.

Woman: Dr. Zaydon, can you go through the other slides that you have?

Dr. Zaydon: Well, I can go through them. If anybody wants to stay in the call, I'll just give you some presentations. This is an example of a type of case that we may encounter. A male who had a dispute with the wife and they poured a cleaning agent onto the head while they were asleep. This is obviously not a personal injury, this is a criminal case. Occasionally we get involved in criminal cases and we're asked to opine upon the body surface area. I told you how we came up with the body surface area, and we opine upon the patient's comorbidities having to do with the cleaning agent.

And so, the goal in a criminal case is to help the jury understand the extent of injury. A cleaning agent, obviously is a very different animal than a boiling pot of water. And a cleaning agent has more caustic ability to cause issues. So, the burn expert may be necessary in either defense or the pursuit of a criminal case. Keep in mind that unfortunately, the other specialists may be needed, the ophthalmologist may be needed, the nasal area may need ENT. And this slide is very, very, very interesting. A little bit outside the scope of the talk, the financial impact of burns.

Once the patient is hospitalized for a burn, and this is documented ABA information, once the patient is hospitalized, I mean, I'm not talking outpatient, hospitalized for a burn, almost always their care, including their future care, exceeds half a million dollars. So, when working with the life care planner, if you have an inpatient burn, almost by definition, you're dealing with a catastrophic situation because you have a lifelong need for follow-up, the lifelong need for surveillance, for laboratory, for ointments, for camouflage clothing, physical therapy, additional operations. And this has a marked impact.

Again, these are all patients that were hospitalized, marked impact on the ability on their living, on their productivity, and on the disability cost. So, burns are a big part of the medical costs that we pay in this country, and it's often overlooked because if they have a guy outta the hospital, that's it. Well, that's not it. This is just a reminder that not all chemical burns are treated the same, acids are treated differently than alkali. So, with the exception of chemical burns, water is your go-to treatment, not ice. You have to see if you're dealing with a chemical acid or a chemical alkali because the treatment is different for each.

This shows the impact of a chemical burn on the skin that's no longer supple. It's dry, it's prone to breakdown. There's all the descriptions I've given you previously. And chemical burns tend to be more severe caustic and full thickness. And chemicals are everywhere. I mostly see in the workers' compensation patients, and the majority of them are people that are not using the safety equipment that's been provided to them. And this is very frustrating because majority of these injuries are preventable.

And this, again, shows the impact of a chemical burn, loss of motion. You see the thumb there that can't move or that could move. Shortage of soft tissue, contractures, tendency toward breakdown, instability. But the treatments is the same as I previously illustrated, physical therapy, compressive garments, consideration for laser, consideration for various microdermabrasion, we do the medicine. And sometimes, sometimes we have to do plastic surgery. Sometimes we do something called the Z-plasty. What the heck is the Z-plasty, Dr. Zaydon? Z-plasty is just a way of shifting the skin where it's in short supply and bringing in skin that is adjacent.

So, you basically bring in healthy skin by making a Z. You make a Z shape cut, size it down, and then you flip, if you will, the unhealthy tissue with the healthy tissue, and all of a sudden you have more range of motion. That's a Z-plasty. I show you this slide, but it took me a while to understand it and I'm a plastic surgeon. But that's one of the things that we would do later. Another thing that we would do later is something called tissue expansion. Again, this is where we expand the uninjured skin and one operation by using a balloon, an expansion balloon, let the skin expand for months, go back to the operating room, remove the balloon, and then you would do this very large Z-plasty of a lot of expanded skin.

You flip it, you take out the old burned area, put it anywhere you want, and then you bring in the expanded healthy skin to the side of the burn. Again, electrical and chemical burns tend to be on the catastrophic size. And I hope you don't have to face this, but before you throw water on a chemical burn, be sure you're dealing with an acid or an alkali because the treatment's different. Like dry lime, if you put on water over dry lime, you're gonna have a heck of a reaction. But phenol, you can use lots of water. All right. I think that's pretty good. I think we're close to time. Okay. Yes, I have... Thank you for another question, "Have I had chemical burns from salon hair treatment, and can you talk about the different ways to treat hair loss?"

Great. Love this question. Absolutely, we've had chemical burn cases from hair treatment and obviously, you can have hair loss, and I can clearly state on the record that hair loss can be treated with the same technology, the same exact technology that I described earlier, the dermapen and the PRP. So, alopecia is being treated more and more now with regenerative medicine and hair transplants are falling out of favor. And yes, unfortunately, we've seen burns from waxing studios, burns from laser hair removal. They're very common, but most often, these burns are from people that are new or untrained. And so, that's a whole different topic.

I think the best thing to do is find out the training of the person, and obviously, their licensure. Some states have different licensure requirements. That's a whole separate topic. And sometimes liability may be a lot easier than you think because the person administering the offending agent may not be licensed and/or qualified. And then you can do discovery on what training they had and what guidelines they have and do they follow on guidelines. All right. Well, I think that's it. Thank you so much for attending. And I hope I can meet some of my fellow lawyers on the phone. And TASA has my contact information. Thank you. All right.

[00:54:54]

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