Burns - Demand Letter - Page 5
Automobile Accident
Demand Letter
IV - MEDICAL PROOF REGARDING BURNS
Considering the extensive nature and severity of the burns suffered by Lee Lynette Waymond (85% TBSA), Wendy Germaine (52% TBSA) and Sally Waymond (45% TBSA) we anticipate at least three full days of medical testimony concerning burn injuries. Dr. Donald Parks, who will serve as our principal witness to educate the jury with respect to the horrors of burns, is a brilliant professor as well as practicing surgeon and is quite accustomed to lecturing on burn injuries. The reasonable value of medical services rendered to date to correct the burns to these three victims total in excess of One Million Dollars ($1,000,000). The total lifetime medical costs for the three victims will be approximately $2,000,000. Thus, we plan to fully educate the Texas jury with respect to the following elements of burns:
1. Burns
a. Etiology
The etiology and physiology of burns consist of the severity of the charred skin which is related to depth, extent, percentage of body surface burned, age, and parts of the body affected. The depth of injury is directly related to the temperature of the burning agent and the duration of contact with the body tissue. Below 112 degrees Fahrenheit, no local damage occurs unless exposure is for a protracted period. Between 112 degrees and 151 degrees Fahrenheit, the rate of cellular destruction doubles with each one degree rise in temperature. A full thickness burn may occur in as little as one second of exposure depending on the degree of the heat.
b. Burn Categories
Burns are classified in three different categories:
(1) Superficial partial-thickness burns (First degree): These burn injuries involve the top layer of skin, the epidermis.
(2) Partial-thickness burns (Second degree): These burn injuries involve the epidermis and upper portions of the dermis. Some of the dermal appendage may remain, from which the wound may spontaneously re-epithelialize.
(3) Full-thickness burns (Third degree): In these severe burn injuries, all layers of the skin and often the underlying tissues are destroyed. Grafting customarily is required to close the wound. Sally, Lee Lynette and Wendy all suffered from third degree burns.
c. Physiology
The physiologic reaction that occurs when skin is burned consists of adjacent, intact blood vessels dilating. Platelets and leukocytes begin to adhere to the vascular endothelium as an early event in the inflammatory process. Increased capillary permeability produces wound edema, with an influx of leukocytes and monocytes. With medical treatment, eventually new capillaries, immature fibroblasts and newly formed collagen fibrils appear within the wound and will support the regeneration of the epithelium. If this does not occur, surgical intervention is necessary. With the removal of the eschar tissue and the formation of granulating tissue, an attempt is made to accept a skin graft. All three of the burn victims in this case required escharotomies and skin grafting
d. Alterations in Body Systems
In addition to charred skin in the local burned area, there are major alterations and disruptions in the vascular and other systems of the body. The water vapor barrier for the body is the outermost layer of the epidermis and infections and severe reactions from fluid loss occur. Capillary permeability increases, permitting fluid and protein to move from the vascular space into the interstitial spaces and swelling results. With this reduced vascular volume, the burn patient goes into shock and can die within minutes. Other complications will result in death to the skin from rotting necrosis. All three victims in this case were life threatened by alternations in their body systems.
e. Complications Concomitant
Sally, Wendy and Lee Lynette were life threatened by the complications which accompanied their severe burn injuries. The primary causes of morbidity and mortality in burn victims are those related to skin infection and pulmonary problems. Therefore, intravenous antibiotics are given prophylactically to prevent gram-positive infection, and topical antibacterial agents are applied to help retard the proliferation of pathogenic organisms until wound closure occurs spontaneously or through surgical intervention. The complications which confronted Sally, Wendy and Lee Lynette included the following:
(1) Hemodynamics
There is lessened circulating blood volume which results in decreased cardiac output from the heart and increased heart rate. This results in inadequate tissue perfusion which causes acidosis, renal failure and burn shock.
(2) Metabolic demands
A breakdown of cells results liver and muscle glycogen becoming exhausted within the first few days.
(3) Renal effects
Glomular filtration is decreased and may cause complete renal shutdown and failure of the kidneys.
(4) Hematology effects
Thrombocytopenia, abnormal platelet function, and deficit in several plasma clotting factors occur, resulting in bleed outs and anemia from occult blood loss.
(5) Immunologic effects
The loss of the skin barrier and presence of eschar, dead rotting skin, favor bacterial growth. An abnormal inflammatory response after a burn injury causes a decreased delivery of antibodies, white blood cells and oxygen, hypoxia and acidosis, thrombosis of vessels in the wound area and impairment of the body's resistance to bacteria. All three of the burn victims in this case, Sally, Lee Lynette, and Wendy suffered from burn wound sepsis.
(6) Burn wound sepsis
Colonization of the burn wound by bacteria, subeschar and intrafollicular colonization develop and invade subadjacent nonburned tissue, seeding bacteria from the wound. This colonization will give rise to systemic septicemia.
f. Treatment of Burn Complications
Prevention of infection and pulmonary damage and rehabilitation are of major consideration, such as, hemodynamic stabilization, metabolic support, wound debridement, use of topical antibacterial therapy and biologic dressings and wound closure. Vital important measures follow:
(1) Burn wounds must be cleansed initially and daily with a mild antibacterial cleansing agent and saline solution.
(2) Nonviable tissue (eschar) is removed through enzymatic, mechanical or surgical debridement. Burn eschar will begin to separate from the underlying viable tissue by a natural process of bacterial growth, which causes a lysis of protein at the viable - nonviable tissue interface. Eschar is also removed through daily dressing changes with forceps and scissors during wound cleansing.
(3) Removal of nonviable tissue down to a viable base, then covering it with a biologic dressing, heterograft, homograft or autograft from the victim.
(4) Topical antimicrobials have medication applied to cover burn areas and reduce the number of organisms. However, some of the gram negative bacilli become highly resistant to the antimicrobials.
(5) Split-thickness grafts are harvested either from human cadavers or other mammalian donors such as pigs.
(6) Allograft is a graft of skin taken from a person other than the burn victim (skin bank) and applied to a burn wound temporarily (a cadaver is the most common source). The grafts are applied to the skin and held with staples and gauze until they grow into the skin.
(7) Broad spectrum antibiotics are necessary to combat systemic gram positive and gram negative infections and sometimes fungal infection which may appear. Critical diagnostic parameters include the following:
(a) qualitative wound inspection and biopsy
(b) bronchial inspection and biopsy
(c) blood culturing
(d) sputum cultures
(e) temperature monitoring
(f) changes in behavior, hallucinations or confusion
(8) There is a high index of suspicion for smoke inhalation injury. It is imperative to have an evaluation by a chest x-ray, blood gas levels, and bronchoscopy to confirm mucosal erythema, hemorrhage, ulceration, edema, presence of carbonaceous particles, or soot in oropharyngeal passages or production of dark gray sputum.
(9) There is impaired gas exchange related to carbon monoxide poisoning, upper airway obstruction, smoke inhalation and/or edema of the lung.
(10) Prolonged intubation connected to mechanical ventilation may be necessary for adequate exchange of oxygen and carbon dioxide.
(11) Bronchial suctioning may be required to flush out toxic sputum which harbors bacteria.
(12) Septicemia signs, including changes in mentation, tachypnea, and decreased peristalsis, increased pulse, decreased blood pressure, increase or decreased urine output, facial flushing, increased temperature, or malaise are serious warning signs of septic shock.
(13) Ambulation and physical therapy are necessary to prevent contracture of the scarred tissue and webbing between the fingers and toes.
(14) Itching is common and scratching will inhibit the growth of newly epithelized tissue and damage skin grafts.
(15) Depression and severe grief over the loss of sense of self and negative disfiguring body image should be treated with appropriate psychological counseling and therapy.
2. Sepsis
a. Etiology
Sally, Lee Lynette, and Wendy all suffered from bacterial invasions which caused severe, life threatening problems. Gram negative infections are bacterial invasions caused most frequently by Escherichia coli, Staphylococcus aureus, and Klebsiella. The bacteria can invade the bloodstream and the burn victim can rapidly decline into septic and circulatory shock. These bacilli are not invasive in normal persons, however, they are opportunistic bacteria that become infectious in burn victims with diminishing defense mechanisms.
The diagnostic treatment procedures, such as indwelling catheters, intravenous tubes and oral airways result in disruption of the usual protective barriers normally provided by the skin and mucous membranes. The loss of the skin's protective barrier decreases the body's natural immunosuppressive resistance to bacteria. The emergence of antibiotic resistant bacteria add to the extreme difficulty of resolving the infection.
b. Identification
It is imperative that the identification of the appropriate source of the infection is determined. Blood cultures should be taken to identify the etiologic agents. Bronchial washings and sputum should be acquired for pulmonary complications. Tissue cultures should be obtained to identify the differing bacterial agents. When identified and isolated, the antimicrobial agents should be given promptly to determine the effectiveness of the drug against the bacteria.
c. Manifestatio
Sepsis and septicemia are recognized by the symptoms of fever, chills, flushed skin, deteriorating mental status due to reduction in the oxygenation of the cerebral flow, Tachycardia, tachypnea, clammy skin, decreasing pressure, decreased urine output, vascular collapse.
d. Treatment
Monitoring the pattern of the most commonly occurring agents should be noted by all health care workers. When possible, catheter tubes, indwelling intravenous and arterial lines, and oral airways or foreign objects should be removed to cut down on the avenues for infection. Wounds should be dressed and cleansed frequently to advert the presence of the organism.
Careful details of the burn patient's tissue and organ perfusion should be made and charted regarding the central venous pressure measurement, left ventricular filling pressure noted through the Swan-Ganz, serum electrolyte levels, urinary output, and deteriorating mental status. Administration of blood or saline for volume expansion will combat vascular collapse. Antibiotics specifically tailored to combat the gram negative infections should be administered intravenously.
V - SALLY WAYMOND
A. PERSONAL INJURIES AND MEDICAL SEQUELAE
After the accident which killed her husband, son, and niece, severely burned her daughter and niece and severely burned her, Sally was airlifted by LifeFlight to Lakeside Hospital under the care of the trauma team and burn team headed by board certified plastic surgeon, Dr. Donald Parks. In an interview, Dr. Parks states that Sally was in an extremely critical condition, yet fully awake and alert. (DP 1) The emergency room professionals began immediate life support measures and determined she had sustained burns to 45% of her total body consisting of third degree (all layers of skin are completely destroyed) and second degree burns (upper layers of skin are destroyed) and the following personal injuries:
- Burned to the bone - Fingers of the right hand
- Third degree burn - Left hand and arm
- Third degree burn - Right hand and arm
- Second degree burn - Back
- Second and third degree burns - Both knees
- Second and third degree burns - Both calves
- Second and third degree burns - Both thighs
- Second degree burns - face
- Toxic inhalation lung injury
- Right lower lobe lung laceration
Dr. Parks reiterates that in order for Sally to survive this horrible injury, for the first few days, numerous surgical procedures would have to be performed. (DP 2) In a heroic effort to save Sally's life and to deal with the complications that followed her throughout her hospitalization, the following procedures were performed:
- Escharotomies
- Eschar skin excision and grafting surgeries x 5
- Viable skin excision and grafting surgeries x 5
- Chest tube insertions x 3
- Swan-Ganz cardiac catheterization
- Bronchoscopy for visualization of lung x 2
- Bladder catheterization
- Nasogastric tube insertion
- Blood transfusions
- Left thoracotomy with repair of left lower lung lobe
- Oral intubation connected to mechanical ventilator
- Insertion of arterial line
- Insertion of intravenous line
- Antibiotic infusion
- Application of silver sulfadine dressings
- K-wire pinning to four right interphalangeal joints
- Surgical debridement of wounds
Victims of burn injuries and inhalation damage face numerous complications due to the fluctuation in blood and fluid volume, infection rate due to the protective layer of skin missing from inhaling toxic burn fumes, and major trauma from the impact of the accident. Sally endured numerous complications including:
- Grafted skin rejection
- Necrotic and lost grafts on right hand
- Adult Respiratory Distress Syndrome
- Right pneumothorax
- Pulmonary infiltrates
- Left tension pneumothorax
- Webbing between fingers
- Colonization of antibiotic resistant infection
- Depression
- Grief
- Massive scarring
- Loss of fingernails
