Pod Insights This Podcast Will Kill You Ep 213 Burns Part 2: It’s like sci-fi but real About this episode At the turn of the 20th century, a severe burn was often a death sentence. Today, that is no longer the case. Over the past eighty years, burn care has undergone a profound transformation thanks to crucial advances across diverse areas of medicine, such as skin grafting, antiseptic technique, and fluid balance. In this episode, we trace how those pieces of the puzzle were integrated to bring new hope to those with severe burn injuries. But this revolution in burn care is far from over. As we discover, thrilling research in this area is blurring the lines between science and science fiction. Bioengineered skin? 3D-printed skin scaffolding? Nanoparticles? Tune in for all the exciting details!
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Transcript 10,478 words · 7 speakers
0:01 Speaker 00 This is exactly right.
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0:51 Speaker 01 Visit okeefescompany.com today. That's O-K-E-E-F-F-E-S company dot com for guaranteed relief. O'Keefe's Working Hands. Yeah, it works.
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1:33 Speaker 03 This episode features descriptions that some listeners might find upsetting. Please listen with discretion.
1:41 Speaker 04 Hi, I'm Emma. In May of 2020, I was working at my job as a bookbinder when a machine error caused my dominant hand to be crushed and burned inside a machine used for stamping foil designs onto book covers. That day, I went to the ER for treatment where I also got to have my first COVID test. About a week later, I had my first surgery. The first procedure was extensive wound abridgement that couldn't have been achieved while I was awake, and the application of homograft, which is essentially a very fancy Band-Aid that's cadaver skin. A couple of days later, after allowing the wound site to calm down a little bit, the homograft was removed and something called BTM,
2:24 Speaker 04 or biodegradable temporizing matrix, was placed on the burn site. BTM is an incredible innovation. It's basically a sort of foam that acts as a structure for the body to rebuild tissue into over time. Over a period of several months, the BTM then dissolves, leaving just the newly grown tissues. After the BTM was placed, I went home for about a month to allow the sites to mature. During this time, I had to rinse the wound and the BTM every four hours with Dacan's solution, which is a diluted bleach concoction that's been in use since the Civil War for wound care. After a month, I went in for my third and final surgery. My surgeon took a skin graft from the right thigh and applied it to the matured BTM.
3:07 Speaker 04 Watching the grafts heal and adhere to the healthy tissue around the wound site was really incredible and honestly felt miraculous. I eventually was made custom compression gloves and got to attend hand therapy. And about three months after my injury, I was able to return to work. But never fear, I don't work on that machine anymore. We keep a distance from each other. I'm very happy to say that I've had a really good outcome. I'm very fortunate to have incredible range of motion and good strength in my hand, to the point that I don't have to think about my injury most days. Dealing with the immediate aftermath of a burn is really difficult. I dealt with nausea, fatigue, lack of appetite, pain, discomfort,
3:49 Speaker 04 fear, and a lot of isolation, especially during my long hospital stays during COVID. I had a lot of support and care from my family, especially my parents, who allowed me to stay with them and took care of a lot of really extensive wound care. My coworkers who visited and checked in on me frequently, and a really fantastic medical team that went above and beyond in caring for me. It took at least a year after my final surgery to begin to feel like I was returning to normalcy, but I also had a very small burned area, about 1% TBSA, or total body surface area. I have so much respect and empathy for those that are recovering from larger burns and
4:34 Speaker 04 the strength it takes to endure that every day. I also want to take a moment to recognize and emphasize the importance of workers' compensation. Without workers' compensation, the cost for burn treatment and wound care supplies would have been astronomical. It's so important that workers have access to medical care and financial support to help them recover from injuries sustained at work and receive long-term care for any lingering complications.
5:51 Speaker 03 Emma, thank you. Thank you so much for sharing your story with us. It is so meaningful, and you hit on such a number, a number of incredibly important points.
6:03 Speaker 01 Yeah.
6:04 Speaker 03 And we just really appreciate you being willing to relive that and
6:07 Speaker 01 I know. And go through it all and share it with us and share it with all of our listeners. Thank you.
6:12 Speaker 03 Yeah, thank you. Hi, I'm Erin Welsh.
6:15 Speaker 01 And I'm Erin Almond Updike.
6:16 Speaker 03 And this is This Podcast Will Kill You.
6:19 Speaker 01 Welcome back to Burns.
6:21 Speaker 03 Welcome back, Burns Part Two. We're here, we're here. This is the episode where if you didn't listen to the first episode, go check it out because it really does lay some important groundwork for what burns are, how we measure the severity, what's going on, and I mean, really, the treatment of burns throughout most of human history, which is
6:41 Speaker 01 Most of it.
6:42 Speaker 03 Yeah, kind of
6:43 Speaker 01 Which is grim.
6:44 Speaker 03 Grim. It really is. But this episode is where things turn around. So
6:50 Speaker 01 Yeah. Today, we're talking how we have figured out how to treat burns in modern times and how we treat them today.
6:59 Speaker 03 And how we treat them today. Yeah, it's pretty, it just, it's one of those topics that makes me go, can you believe how far, like, medicine is so cool. Science is so cool.
7:11 Speaker 01 I feel like it's one of the topics, wow, this is gonna get too niche, I just thought of this, but it's one of the topics that makes, that would make Doctor Who be like, humans, you know, how Doctor Who is always like, humans.
7:24 Speaker 03 That's adorable. Yes, yes, yes.
7:27 Speaker 01 Anyways.
7:28 Speaker 03 Anyways.
7:29 Speaker 01 Before we can do any of that, it's quarantine-y time.
7:32 Speaker 03 It is. We're drinking the same thing that we drank last week, which is a non-alcoholic Beesnees that we're calling By Degrees. And, listen, we're not, we're not equipped to create a new cocktail recipe every week. We're in the hundreds of episodes now.
7:51 Speaker 01 Listen, just drink it.
7:53 Speaker 03 And so we are, we're making, we're borrowing from established knowledge, which is Beesnees.
7:59 Speaker 01 You can find the full recipe on our website, thispodcastwillkillyou.com, and on all of our social media channels.
8:05 Speaker 03 You can. We didn't mention this, but it is honey and lemon and non-alcoholic gin, and it's great. And on our website, which is also great, you can find lots of things, like transcripts, you can find links to merch, links to our bookshop.org affiliate page, our Goodreads list, music by Bloodmobile, the firsthand account form, contact us form, and an about us page that hasn't seen an update in a number of years and doesn't have that much information anyway. So to see what information is provided, check it out.
8:40 Speaker 01 Sold that about us page there.
8:44 Speaker 03 Do we even have like the start date of the podcast? Which still blows my mind that we are in our ninth year of doing this.
8:50 Speaker 01 I know. No, we don't have that on there. It might say that we're still in grad school, which is quite out of date.
8:56 Speaker 03 No, we graduated in 2018. Yeah.
8:59 Speaker 01 Yeah, listen. Anyways.
9:01 Speaker 03 Anyways, let's get to the episode itself.
9:05 Speaker 01 Let us, right after this break. Dry hands can be uncomfortable and frustrating, especially when frequent hand washing, changing weather, and everyday wear and tear take their toll. O'Keefe's Working Hands is here to help keep dry hands feeling hydrated and comfortable. O'Keefe's Working Hands creates a soothing barrier on the skin that locks in moisture and prevents further dryness. It's concentrated and non-gracey, and you start to feel relief in one use. Go to okeefescompany.com to get yours today. That's O-K-E-E-F-F-E-S company.com for guaranteed relief. O'Keefe's Working Hands. Yeah, it works.
9:41 Speaker 05 Hey, it's Niall Rogers, host of Before the Moment, a Lincoln original series. I'm driving across the country, meeting some of today's most fascinating artists. We're exploring the stories before the moment that changed everything. This week, I'm joined by my friend, John Ledge. How does music actually enter your mind?
10:03 Speaker 06 I'm not sure why or how the music comes to me, but I think people who love music and write music, our brains are just filled with music.
10:13 Speaker 05 Right.
10:13 Speaker 06 Like, we have listened to so much music. We've been a part of so much music. I think of the story that I want to tell, the mood that I want to create with the music, start playing chords, see where they lead me.
10:24 Speaker 05 Sometimes I'm just not even thinking about music, right? And I hear this little thing, and I go, oh, that could be this.
10:34 Speaker 06 You know, you just have to be ready for when the inspiration hits.
10:37 Speaker 05 Here it comes.
10:38 Speaker 06 Yeah.
10:39 Speaker 05 Experience Before the Moment, a Lincoln original series on the iHeartRadio app, YouTube, or wherever you get your podcasts.
11:03 Speaker 03 Last week, I took us through the history of burns from before humans were humans until the late 1800s, early 1900s, which is quite, quite a lot of time to cover.
11:13 Speaker 01 Just a few millennia?
11:15 Speaker 03 I think, I think the earliest thing I mentioned was like 400 million years ago, fire was possible on this planet. So, but for that entire time that we covered, burns remained pretty much beyond the reach of medicine.
11:29 Speaker 01 Right.
11:30 Speaker 03 In 1900, those who were under 61 years of age, who had burns covering more than 25% of the body's surface, of those, 100% died.
11:44 Speaker 01 Wow.
11:46 Speaker 03 100% in 1900, 25% total body's surface area.
11:51 Speaker 01 Wow.
11:53 Speaker 03 And adults under 50, under 61.
11:56 Speaker 01 But it's actually interesting that it's not also in adults over age 61, but I wonder if there just weren't that many of them?
12:02 Speaker 03 I mean, I'm sure that there were. I don't know why. I think because mortality even increases further at that point.
12:08 Speaker 01 Oh, okay.
12:09 Speaker 03 But it doesn't, how can it increase beyond 100%? I'm not sure why that cut off.
12:13 Speaker 01 It might be a lower body's surface area even, or something like that.
12:16 Speaker 03 Yeah.
12:16 Speaker 01 Cause, yeah, cause age is a big part of it. Oh my God, though, that's horrific.
12:20 Speaker 03 Yep, yep.
12:20 Speaker 01 That's very different than today, just so everyone's aware.
12:24 Speaker 03 Well, and that's sort of what I wanted to, to kind of establish where, where things stood in 1900.
12:31 Speaker 01 Yeah.
12:31 Speaker 03 50 years later, 1950, nearly 70% survived.
12:37 Speaker 01 Wow.
12:38 Speaker 03 So the mortality had gone down to 30%, from 100% to 30%. That's huge.
12:44 Speaker 01 That's huge. It's unfathomable.
12:47 Speaker 03 Yeah, yeah. In those 50 years, burn care had undergone a profound revolution. And we've continued to make tremendous strides up through the present day. And I'm going to leave those present day strides to you, Erin. And what I want to focus on instead is those 50 or so years. Okay. What changed in medicine to drive such a transformation? There was no single moment or breakthrough, but there were many. There was skin grafting, antiseptic technique, fluid balance and nutritional support, antibiotics and airway management. Really, it was through integrating all of these medical advancements through the
13:28 Speaker 03 formation of burn care as a specialized approach that the scales finally tipped. The survival rates that this integrated management could now achieve were beyond the imagination of any physician in past centuries. Like, I imagine someone trying to treat someone with a burn in like 1500 and then coming today to a burn center and just, just like chills. That it's amazing to think about how much- Like the opposite of Outlander. Yes, yeah. Here's some moldy bread. We'll try that out. Right. Yeah. Yeah. But so what I want to do today is take us through how that happened, piece by piece. Skin grafts and burn excision.
14:13 Speaker 03 Okay. So, these approaches date back to ancient times. For instance, in the 5th century CE, Sushrada, the famous surgeon from ancient India, described how he treated amputated noses by taking a flap of skin from the forehead and then later the butt, and then grafting it over the nose wound. Fascinating. Yeah, so skin grafting in that way has very, very deep roots. Wow. And from this point until the 1800s, a few physicians had tried their hand at grafting over the centuries with varying rates of success. Allegedly, the first rhinoplasty, I think, was performed in the 1600s or 16th century. I can't remember. Okay. Like a while ago. Yeah, a while ago. Yeah.
14:55 Speaker 03 But still, it was very much touch and go, not very. It was definitely more of an art than a science. And things turned around in the 1800s. The early part of the century saw a few surgeons experimenting with skin grafting in animals, which showed some promise. But more importantly, those experiments helped to clarify some crucial concepts about, you know, tissue death, circulation, and immune rejection. What's actually going on in the wound healing process? And what's necessary for the skin graft to actually take?
15:27 Speaker 01 Right. What is it? What is it that determines whether or not this one is going to work versus that one?
15:32 Speaker 03 Yep.
15:33 Speaker 01 Yeah.
15:33 Speaker 03 Okay. In 1869, inspired by these animal experiments, Swiss surgeon Jacques Louis Reverden, who was still a medical intern at the time, transplanted a tiny slice of skin into the middle of a wound. Free skin grafting, no skin flaps required. So finding success with this, he varied his approach to see what was possible. Your own skin, skin from another human related to you, skin from a human not related to you, skin from another species. Just let's run the full gamut here. This free skin grafting technique was first applied to burns in 1870, when a surgeon named G. D. Pollack treated his eight-year-old patient's thigh burn by transplanting skin from her abdomen to the wound.
16:17 Speaker 01 Okay.
16:18 Speaker 03 And after six weeks, the grafts looked pretty excellent. Which is kind of incredible.
16:23 Speaker 01 Yeah.
16:24 Speaker 03 Skin grafting became really popular. And other surgeons refined various techniques, like the split thickness skin graft, where you take bits of the dermis along with the epidermis. And this technique promoted faster healing and less scar formation, which reduced scar contractures, which also you'll talk about, I know. And skin grafting proved to be a major advancement in burn care. And physicians also noticed that wounds healed much more quickly and completely when that burned tissue was removed beforehand. So that was where sort of the excision comes in, which people had experimented with in the past. But it kind of became more of like, no, this needs to be a routine part of things.
17:06 Speaker 01 Right. This is actually helping to take this off.
17:10 Speaker 03 It was debated. Yeah. So by the early 1900s, grafting and burn excision was or wound excision was they were pretty well established techniques.
17:21 Speaker 01 Okay.
17:21 Speaker 03 But no matter how skillfully you grafted or debrided, if your instruments weren't clean, if the wound wasn't clean, infection often led to death.
17:31 Speaker 01 Mm hmm.
17:33 Speaker 03 Antiseptic technique. This is like a mini history of many different things.
17:37 Speaker 01 Of all of medicine. Yeah. Like the things that revolutionized all of medicine also revolutionized burn care.
17:43 Speaker 03 Pretty much.
17:44 Speaker 01 Surprise, surprise.
17:45 Speaker 03 Yeah. Okay, so antiseptic technique. For centuries, surgery of any kind remained a last resort, an act of desperation. Before science and medicine had connected the dots between dirty instruments and deadly infections, anyone bold enough to go into surgery believed that the best surgeons wore the bloodiest, filthiest coats.
18:07 Speaker 01 Yeah, it's so gross to think about.
18:08 Speaker 03 It was like, wow, you've got some experience. How many people have you operated on today? Fifteen? And you haven't rinsed your hands once? That's what I want in a surgeon. No.
18:19 Speaker 01 No, thank you. Please.
18:22 Speaker 03 No, no, no. Thankfully, Joseph Lister, see our sepsis episode, revolutionized surgery in the 1850s with his recognition that if you operated with clean surgical tools and you cleaned the wound, your patients were less likely to die. His solution of choice, his antiseptic solution of choice was carbolic acid, often mixed with vaseline for use in burn patients to reduce the pain of having acid rubbed into your wound.
18:49 Speaker 01 Yeah, okay.
18:50 Speaker 03 Later during World War I, other antiseptic solutions were developed, like boric acid, acetic acid, and a 25% solution of sodium hypochlorite, also called Daken solution.
19:01 Speaker 01 Still use that today.
19:03 Speaker 03 Still use that today. Antiseptic technique was a major step forward in reducing infections and deaths following surgery, such as removing burn tissue or performing skin grafts. And the same principles were used for wound management in burn patients, even if they didn't have surgery. Because your skin, as you've talked about, is a barrier to infection, when that barrier is disrupted, it leaves it super vulnerable to infection. And so if you can find a way to decrease that vulnerability through antiseptic ointments, antimicrobial ointments, bandages that are infused with antiseptic components. Stuff. Stuff.
19:44 Speaker 03 These things are integral in improving outcomes for those who have burns, both minor and major. By reducing infection through antiseptic technique, and these specialized ointments, physicians could chip away at one major, major source of mortality for burns. But other threats remained. Fluid balance and nutritional support. Yeah. Yeah, this is a big one. More than I realized, I think, despite having rewatched all of ER, I don't think it really hit home to me how important this part of it was. As though ER is a super. Super accurate. Great. It's like I was saying, despite med school, despite ER.
20:29 Speaker 03 Same, same. Over the centuries, a handful of physicians had noticed that providing a burn patient with lots of replenishing fluids and food seemed to help. But this was very much against the beliefs of the day. Things like bloodletting and purging were still the standard for centuries. And it wasn't really until the late 1800s, the late 1800s, that doctors began to crack the code on fluid balance and nutritional support. Wow. And it started when a few doctors observed that the renal failure in burn patients looked very similar to that that they observed in cholera patients. Oh. Yeah. Where their bodies were extremely dehydrated and they just, their fluid balance was not
21:14 Speaker 03 even, it was in super imbalance, I guess. Right. They're losing tons of fluid and.
21:17 Speaker 01 And they're losing tons of electrolytes because they're pooping pure water liters at a time in cholera. And that totally makes sense because the same thing is happening. It's just going out through the surface area that you have lost from your skin.
21:30 Speaker 03 Yep.
21:31 Speaker 01 Fascinating.
21:32 Speaker 03 Yeah, that was sort of like the first little light bulb of moment.
21:36 Speaker 01 Yeah.
21:37 Speaker 03 And then one doctor went further and discovered in 1893 that blisters and burned tissues were filled with plasma, meaning that fluid, that fluid was not where it should be. And so it was like, oh, this is the same thing. It's just not.
21:52 Speaker 01 This belongs in our blood vessels.
21:54 Speaker 03 This belongs somewhere else, not where in the blister.
21:56 Speaker 01 Yeah.
21:57 Speaker 03 And some people then tinkered around with fluid replacement with saline administered orally, rectally, or intravenously. But it wasn't really until World War I that the technique was refined, and not until 1921 that it was applied systematically to burn patients.
22:13 Speaker 01 Okay.
22:14 Speaker 03 So that year, a fire broke out at the Rialto Theater in New Haven, Connecticut, and a professor at Yale, Frank Underhill, saw that the composition of fluid in blisters was the same as plasma, and a loss of those compounds, he suspected, is what led to shock in burn patients. And so he was like, I think that this is actually causing, that fluid loss is causing mortality in burn patients. It's not toxins. So previously, it was believed that toxins were the thing that killed people, which it can still be if you think of toxins as like bacterial infection or whatever, fungal infection.
22:53 Speaker 01 But that would be more usually later rather than like immediately following.
22:58 Speaker 03 Yeah. So he's like, this is an emergency, like, this is what's happening right now, fluid loss. Can we, can we treat fluid loss? I mean, this was a huge step forward.
23:07 Speaker 01 Wow.
23:07 Speaker 03 Because fluid loss could be reversed by providing saline solution with protein intravenously. And later work in this area led to formulas to quantify how much fluid was needed, depending on the age and the size of the person and the surface area and the depth of their burn.
23:23 Speaker 01 Yeah.
23:24 Speaker 03 About a decade after the Rialto Theater fire, which happened in 1921, physicians began to notice that burn patients also needed an increased caloric intake. And that extreme loss of lean body mass put them at high risk for poor outcomes. So death, decreased wound healing, impaired immunity, and so on. So the nitty gritty of how to best provide adequate nutrition and calories, that took decades to figure out.
23:49 Speaker 01 Oh, yeah.
23:49 Speaker 03 Or get consensus on. But the recognition of this issue was absolutely critical.
23:55 Speaker 01 Yeah.
23:57 Speaker 03 Next up is antibiotics.
23:59 Speaker 01 Mm hmm.
24:00 Speaker 03 Antisepsis and antimicrobial dressings were a huge step forward, but they didn't always entirely prevent infection. The development of penicillin in the early 1940s, I mean, it was discovered in 1928, but it wasn't widely available until the war ended in 1945. And then later, broad-spectrum antibiotics, this really helped to control infection when it did arise in burn patients. One of the very first uses of penicillin in the general public was, in fact, after the Coconut Grove nightclub fire in Boston on November 28, 1942.
24:35 Speaker 01 Huh.
24:36 Speaker 03 Yeah.
24:37 Speaker 01 I didn't know that.
24:38 Speaker 03 Yeah. I think, I feel like I remember talking about it in our antibiotics episode in
24:45 Speaker 01 You probably did. Right, that was season three, so I don't remember it.
24:51 Speaker 03 No, no. But
24:53 Speaker 01 Coconut Grove sounds vaguely familiar, though, doesn't it?
24:56 Speaker 03 Yeah.
24:56 Speaker 01 Okay.
24:57 Speaker 03 But yeah, so that was the first time that penicillin was used to see if it improved. And I don't think, I think that the data were not strong enough to see, did this actually help anything?
25:07 Speaker 01 Right.
25:08 Speaker 03 Yeah, there was a lot, still a lot of other things that needed to be figured out. But, but this tragedy also led to the refinement of fluid replacement calculations and the recognition of airway injuries after a fire.
25:20 Speaker 01 Yeah.
25:21 Speaker 03 And so, but since, since then, since this nightclub fire, antibiotics have often been employed in treating systemic infections that arise after a burn or used prophylactically to prevent infection in the first place. But their use in burn patients can be tricky. So first antibiotic resistance is a major problem, especially for certain types of bacteria found after burns, like pseudomonas.
25:45 Speaker 01 Yeah.
25:46 Speaker 03 And antibiotic use can also lead to other opportunistic pathogens taking over. So for example, certain fungal species such as Candida albicans. So it's, it's not, it's not, it's a little bit of a mixed bag. Or it's like, it's not, it's not the way that antiseptic technique or fluid replacement is
26:06 Speaker 01 Right.
26:07 Speaker 03 The role that it plays in the history.
26:09 Speaker 01 Especially because you're talking about like systemic antibiotics.
26:12 Speaker 03 Yes.
26:12 Speaker 01 Right, like IV antibiotics or oral antibiotics, like the kind that you would use to treat an infection.
26:17 Speaker 03 Mm hmm.
26:18 Speaker 01 And yes, and that, and that makes sense because we don't really use them that much in burns today.
26:23 Speaker 03 Yeah.
26:24 Speaker 01 Unless we need to.
26:26 Speaker 03 Unless, exactly.
26:27 Speaker 01 Right. So like having it there when needed. Exactly.
26:30 Speaker 03 Exactly. But yeah, like you said, I mean, the systemic part of it. And so having this knowledge of antimicrobial properties to then infuse bandages, I kind of lumped that in with the antiseptic technique, but like that was a huge part of it.
26:44 Speaker 01 Yes.
26:45 Speaker 03 Just like, how do we topically treat this and prevent infection?
26:48 Speaker 01 Right.
26:48 Speaker 03 Yeah.
26:49 Speaker 01 Right.
26:50 Speaker 03 And then last on the list is airway management. So this includes both the recognition of airway injury as well as ways to treat it. Now, if we're still considering just that 50 year window between 1900 and 1950, airway management was mostly restricted to recognizing the damage that smoke inhalation could do to lungs that could lead to poor outcomes.
27:12 Speaker 01 Okay.
27:13 Speaker 03 So doctors treating victims of the Coconut Grove nightclub fire in Boston in 1942 made, made note of this, quote, "It was obvious almost at once that we were dealing with something more than the problem of burned skin. A severe impairment of respiration also existed," end quote. And this was due to, yeah.
27:33 Speaker 01 Inhalation. That's so interesting that that's so late.
27:37 Speaker 03 I think that people recognized it, but it like, what could you do about it?
27:43 Speaker 01 Right.
27:43 Speaker 03 I mean, I think that, I don't know. I don't know. I don't know.
27:47 Speaker 01 Yeah, I know. It's a lot. There's a lot of components there.
27:50 Speaker 03 There's a lot of components. This is like the one where I was like, I don't even know where to begin covering the history of this because respiratory issues following burns, it could be due to direct burns, carbon monoxide poisoning can happen, inhalation of the toxic substances that are being burned.
28:08 Speaker 01 Burned.
28:09 Speaker 03 Later on, it could be bacterial pneumonia due to impaired immune response.
28:14 Speaker 01 Or ventilation assistance, like we see today, if someone is intubated because of swelling.
28:18 Speaker 03 Yep. Yep. Yep. Right. So there's, there's a lot of, there's a lot of factors to this. And, and doctors, though, I think that the recognition that those who had smoke inhalation injury and pneumonia tended to experience worse outcomes. And that led to increased focus on how to better manage lung injury alongside wound management, fluid balance, nutritional support, and so on. And then later, of course, supplemental oxygen and the invention of mechanical ventilators led to some relief. But really, like, what, what you can kind of see is the pieces of all of this. Like, okay, well, we're relieving the threat due to fluid imbalance. We're relieving the threat due to infection in
29:03 Speaker 03 the wound directly. We're relieving the threat of all of these different things and kind of saying, okay, what's left that we can improve upon? And that's how the history of burn treatment kind of goes. And it's a lot, right? Like,
29:17 Speaker 01 It's a lot.
29:17 Speaker 03 Even though I haven't been talking for all that long compared to somehow, sometimes how I go on and on, there's, I'm sure that you've already forgotten the details of how fluid replacement was discovered or the earliest skin graft performed. And if, if you have forgotten, don't sweat it. Like, that's, you don't need to remember the details. The important thing that I want everyone to take away from all of this is kind of what I already said at the top. It's not one thing that changed the landscape of burn care. It's many things.
29:48 Speaker 01 Right.
29:48 Speaker 03 Not working in isolation, but coordinated care. At the end of the 1940s, researchers had made all of these incredible advancements that made survival after a severe burn more possible. But one last step remained before possible turned into probable. And that was the formation of burn units or burn centers. Coordinated, round-the-clock care that integrates expertise across many different disciplines, working as a team.
30:18 Speaker 01 Yeah.
30:18 Speaker 03 The first burn units in the United States were founded in the mid 20th century, and they have transformed burn care and offered tremendous hope. They also act as a research unit, constantly striving to improve not only survival, but quality of life. Pain management, psychological trauma, stigma, physical therapy. At these centers, people with burns are treated not in pieces, but as a whole.
30:44 Speaker 01 Yeah.
30:44 Speaker 03 And as we've gotten better at managing the immediate injury, at managing the physiological impact of burns, it has also left us more able to address and improve the injury to the parts that you can't see, right? Like the huge trauma that happens, the stigma, all of these different aspects. And I just like, especially after doing these episodes, really want to acknowledge the incredible work of the healthcare professionals at these centers because it is crucial, what they do.
31:19 Speaker 01 I think too, Erin, it shows how much, like, all of the changes that you had mentioned just kind of show how much people have started to recognize or pay attention to the fact that a burn is not just skin damage. It's not the same thing as a cut or a scrape. It is a system-wide, is a whole-body, system-wide, like, event that we have to treat as such.
31:42 Speaker 03 Right.
31:43 Speaker 01 Yeah.
31:45 Speaker 03 Yeah, it is such a, to me, it is such an interesting way of approaching medicine because it's, you have to have expertise in all of these different areas, all at once, and apply them differently. And each case is different. And At the same time, as amazing, as incredible as these centers are, they can only help someone if someone has access to them, which is a pervasive issue across the globe that I know you'll talk about. And as transformative as burn treatment has been over the past century, continued improvement can only be achieved through funding for research. And I know everyone who's listening has heard this all before, but I just, it bears repeating. Like, it bears repeating until we all internalize it forever.
32:30 Speaker 01 Until something changes.
32:32 Speaker 03 But with that, Erin, I'll turn it over to you now to fill us in on some of the incredible treatments out there for burn injuries that happened after those 50 years were up.
32:41 Speaker 01 Oh, I can't wait to do that, Erin.
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33:18 Speaker 05 Hey, it's Niall Rogers, host of Before the Moment, a Lincoln original series. I'm driving across the country, meeting some of today's most fascinating artists. We're exploring the stories before the moment that changed everything. This week, I'm joined by breakout singer-songwriter Alex Warren. I'm like a kid when I play music and I make music, and I'm constantly asking questions. You know, whether it's an instrument I haven't played or it's a melody that seems foreign. You know this, every night you play a show, and it's the same set, but it's not the same show. At a certain point, your brain kind of goes on autopilot. When I'm in the studio or if I'm making music, that's where that curiosity kind of comes back. You know, I haven't lost it yet, but I'm also on my sophomore album.
34:01 Speaker 05 So, and you, you obviously are an expert here. Experience before the moment. The Lincoln original series on the iHeart Radio app, YouTube, or wherever you get your podcasts.
34:25 Speaker 01 The basic principles of burn care today, Erin, kind of fall along a lot of the same lines that you just walked us through and how we figured out to do a better job at treating burns. So what I want to walk through is less of the like acute phase of fluid resuscitation and nutrition management and airway control, which is integral and so important in those first, especially those first like 24, 48, 72 hours. All of that is imperative, so I'm not, you know, knocking the importance of that. But what I want to really focus on is the long term on how we treat these burn wounds
35:09 Speaker 01 to heal them over time. Because the technology that we have now to improve upon these outcomes is really, truly phenomenal, and it builds on everything that you talked about already, Erin. So the first part is the surgery. And this idea of surgical excision is a mainstay of burn care for anything that is a deep, partial thickness. So a to be a second degree, like a deep second degree burn, or worse, a third degree or down into the muscle or bone tissue. Surgical excision early is a mainstay. Exactly when and exactly how early depends on the burn center, depends on the situation.
35:53 Speaker 01 But usually within the first day or two or three, to remove all of the dead or necrotic tissue. What this does is it helps to ensure that the surrounding tissue has less damage. Because remember, we talked in last episode about how there's kind of a zone around the worst Part of the burn that is really at risk of further damage. So by removing the necrotic tissue, we can help to kind of keep that tissue viable. And this can go in a lot of different ways. So sometimes it means like actual surgery with like sharp instruments where things are kind of scraped away down to healthy bleeding viable tissue.
36:38 Speaker 01 Sometimes it might mean newer technology like water, like high pressured water we now have.
36:44 Speaker 03 Okay.
36:45 Speaker 01 Which is fascinating. And that's to basically like go through the planes of tissue. But in a way that causes hopefully less damage to healthy tissue because it can sometimes be really hard to tell apart healthy tissue from dead tissue.
36:57 Speaker 03 How does it help?
36:58 Speaker 01 Sorry?
36:59 Speaker 03 No, yeah, I mean, it's, yeah. How does it help preserve healthy tissue? Like, how is, yeah?
37:07 Speaker 01 Essentially because it's not going to cause as much damage. So it's not something that's sharp where you're going to accidentally cut where you didn't mean to, but it's just really high pressured water that can kind of go through the layers and it will like take off the dead tissue because that is dead. So it kind of just falls away.
37:24 Speaker 03 Okay. So it does a better job with distinguishing healthy and not healthy tissue?
37:30 Speaker 01 Potentially in some scenarios.
37:32 Speaker 03 Okay.
37:33 Speaker 01 Sometimes we might also use enzymatic debridement, which you mentioned, Erin. Some of the solutions that they used way back when might still be solutions that we use today to kind of in a much more gentle manner, debrided away all of that dead tissue. In some cases, we might even use maggot larval therapy.
37:51 Speaker 03 I was wondering about that. Okay.
37:52 Speaker 01 Yes. And so that might not be, you know, not in those first 24, 48 hours, but especially if areas become necrotic later or places that you didn't get to in surgery. There's a lot of reasons why you might end up using those kinds of therapies later. But removing the dead tissue is the first incredibly important step.
38:12 Speaker 01 Next is preventing infection. And this is both next and at the same time. So that means washing wounds, right? To remove any dirt, remove any debris, and then covering wounds, whether they needed surgical excision or not, with antibiotic-infused dressings or ointments or what have you. And we've had huge improvements. Like, there are way too many to count in terms of the types of dressings and antimicrobial dressings. A lot of the ones that we use in burns tend to be silver-infused dressings. And that's because silver is a good antimicrobial that is really only topical. So it's not penetrating deep. It's not going systemic, et cetera. But honey-based dressings,
38:56 Speaker 01 aloe vera-based dressings. With all of these, the goal is to inhibit the growth of bacteria to reduce the chance of infection. IV antibiotics, like I mentioned, we don't tend to use unless there is an infection that leads to something like sepsis. Because not only is it overboard to use IV antibiotics that might increase the risk of antibiotic resistance and other things, but also, these wounds don't really have any blood flow. So IV antibiotics don't really work that effectively.
39:29 Speaker 03 That was sort of the conclusion of the coconut grove. They were like, we don't know if this did anything or not.
39:35 Speaker 01 Exactly, yeah. And it might not have.
39:38 Speaker 03 It might not have, maybe for some people it did.
39:40 Speaker 01 Yeah. But for any burn that needed a surgical excision, any burn that extended into the deep part of the dermis, into that subcutaneous tissue, is not going to be able to heal completely on its own. And it is going to need some kind of help from something like a skin graft or a skin substitute. So the gold standard for treatment of any burn that had to have a surgical excision is still a skin graft. Even though they're apparently as old as dirt.
40:15 Speaker 03 So old, so old.
40:17 Speaker 01 I had no idea.
40:18 Speaker 03 Yeah.
40:19 Speaker 01 The way that we do skin grafting today is mostly by what's called a split thickness skin graft. So that means a skin graft that has both epidermis and a small amount, the very top of the dermis. For more sensitive areas or more cosmetically important areas, like say the face, or maybe even the hands, you might use a full thickness skin graft. So that would be epidermis and the whole entirety of the dermis.
40:44 Speaker 01 And skin grafts are really fascinating. You could probably talk in way more detail about them, but I will just give us all the basics of how these work. Essentially, you take a healthy, non-burned piece of skin and use that to cover the burned wound. You adhere it with staples or sutures or something. Ideally, the skin comes from you.
41:06 Speaker 03 Yeah.
41:07 Speaker 01 Because then your body recognizes it and there's no, there's much less risk of rejection or anything like that. There's two ways that we can do this, depending on how important the cosmetic outcome is and how large the burn wound is. In some areas, you might take a piece of skin and just use it as is to cover, sort of just like a flap graft, essentially.
41:29 Speaker 03 Okay.
41:30 Speaker 01 In other cases, you might do what's called meshing, which means you take the skin that you're going to use as the graft and you run it through a machine that basically turns it into a mesh so that you can stretch it over a much larger area. Your face doesn't look like it appreciates that.
41:50 Speaker 03 Um, I appreciate the technology, just not.
41:55 Speaker 01 It is, it is so fascinating. My dad had one of these skin grafts, not for a burn. He had a fasciotomy for compartment syndrome, but he, so he has two scars, one that's barely visible. It's just like a little bit of discoloration on his upper thigh. That's a perfect rectangle from where they took a section of his skin. And then on his lower leg, he has a wound that is, it's a little bit deformed because his wound was all the way down to the muscle, basically.
42:24 Speaker 03 Okay.
42:25 Speaker 01 Um, but it also is a bit stippled looking, like it's, you can tell that it wasn't like completely covered. And that's because that was meshed. And so he had this mesh covering of his own skin that covered. That wound while it was healing.
42:39 Speaker 03 Okay, so this is the meshing. I mean, it's very cool. I just
42:42 Speaker 01 It's fascinating.
42:43 Speaker 03 It's not my favorite thing to think about the actual
42:45 Speaker 01 Okay, fair.
42:46 Speaker 03 Process of that.
42:47 Speaker 01 Fair enough. Uh huh.
42:48 Speaker 03 But this meshing, so this is for larger areas to then reduce sort of the how much other, how much skin you're taking from other parts of your body.
42:57 Speaker 01 Exactly, exactly.
42:58 Speaker 03 Okay.
42:58 Speaker 01 Yeah, yeah. Yeah, because if a person is stable, their burn wound is clean and they have enough donatable other skin, then this is the way that ideally skin grafting would be done.
43:12 Speaker 03 Okay.
43:12 Speaker 01 But in many cases, someone might not have enough skin. Maybe their burn area was really, really high, or maybe they're just not very stable. They're super sick at the time. And so we don't want to risk a prolonged surgery where we also have to take skin from other areas to try and make it into a graft to cover. And so in those cases, we might use what's called an aloe graft, which means skin from someone else. Usually it's a cadaveric skin graft. Or sometimes even xenografting, which is with another animal's skin. So something like porcine skin or something. These are usually temporary because usually our body is going to reject them in one way or another. And so they act as a covering, but often have
43:56 Speaker 01 to be removed after a couple of weeks or so, or if there's any signs of infection.
44:01 Speaker 03 So they act as a covering and they are a better covering than surgical dressings, ointments, et cetera?
44:11 Speaker 01 Well, that's a great question, Erin.
44:13 Speaker 03 Okay.
44:14 Speaker 01 It all is going to depend. And this is really where we can get into some of the life-changing technologies that exist in the world of burn healing. Because there are now a huge variety of things that
44:30 Speaker 01 Are there to act as essentially skin substitutes. Okay. Whether a skin graft is impossible, or whether, you know, maybe something wasn't quite deep enough to warrant a skin graft, but you're worried that the healing process is still going to take a really long time. And dressing changes are incredibly painful and can be really distressing. And so a lot of these other skin substitutes, even if they're not taking the place of a graft, maybe they're used while we're awaiting for a graft. Maybe they're used in a place to reduce the need for frequent dressing changes, even in a, even if we don't need a skin graft later on. There's some really incredible things.
45:10 Speaker 01 Some of them are still in the realm, not of science fiction, but of more research. And some of them are already accessed, like commercially available. And if you have access to a great burn center that actually can get them, then you can get them. So let's talk about what some of these might look like. Some of these dressings might be made from natural polymers like chitin, which is fascinating, like from an insect exoskeleton. Yeah. And things like that, right? Okay. Some of them might be made from cellulose from plants, or even like fibrin, or hyaluronic acid, collagen, gelatin, any kind of polymer that you can think of that might come from nature. And others are from synthetic polymers, something like silica, or maybe synthetic carbon-based
45:54 Speaker 01 compounds. And these dressings can come in a really wide variety of textures. Some of them are what are called hydrogels, which still take me, I still can only barely understand them because they basically are these things that help to soak up fluid in the wound. So they reduce how wet that wound is going to be. And then they, by hydrating themselves, they also, like their properties become more available to your skin or to. To your healing wound.
46:25 Speaker 03 So they
46:25 Speaker 01 They're really weird.
46:26 Speaker 03 Blot and moisturize?
46:28 Speaker 01 Yes, yes, yes, yes. They blot and moisturize. There's also films, patches, sponges, nano fibers. There's a lot of interest in like nano medicines for these dressings. But the goal of all of these things is to promote wound healing and reduce the amount of time that it takes for our body to actually grow new skin in and of itself. They also serve to reduce the risk of infection. And the goal is to maintain a kind of optimal wound healing environment. And wounds heal best when they are moist, but not too wet, because too much fluid can actually impair wound healing.
47:12 Speaker 01 You need to be able to have oxygen flow in and out. So you need something that's semi-permeable, like our skin is, and prevents infection, right? So something that's going to block other, either have antibiotics in it or can just block other microbes from getting in. And ideally, these dressings can also help to reduce pain, either because they have something in them that's analgesic or just because they're reducing the number of dressing changes and the friction or anything that you might have from other dressings.
47:45 Speaker 01 So, like I said, there's two, there's literally too many of these kinds that can go into these. One that I think is quite interesting is an acellular fish skin.
47:54 Speaker 03 Excuse me?
47:56 Speaker 01 Right. So you know how I said sometimes we can use like xenographs from like porcine skin? So pigs or something like that? There is a acellular fish skin that can be used now for wound healing, including burns. But it can kind of act again as like a temporary skin. So you put it on, leave it on until your skin starts to re-epithelialize itself.
48:20 Speaker 03 My mind is blown by that.
48:22 Speaker 01 I know.
48:23 Speaker 03 Fish skin.
48:24 Speaker 01 It's really fish skin. That was, that was, I think, one of the newest ones for me. But then there's also a lot of interest in things that are even more. They honestly sound like science fictiony. So there are things that are available commercially that are kind of like scaffolds that we actually can take some of our own cells, send them off to these companies who engineer them and then spray them or otherwise infuse them into these like films, these scaffolds that we then can use as a dressing.
49:00 Speaker 03 I feel like I read about this in "Replaceable You" by Mary Roach. It's possible. It is. That totally blew my mind. Like basically kind of 3D printing your own cells in a way.
49:14 Speaker 01 And that's even, I would say, a separate thing because 3D printed cells is a huge area of research and it's been done on animal models. I think there is actually some like clinical in human data from it, but it's all in the realm of research as far as I can tell right now. But that's even like a step beyond what already does exist, which are these like these dressings that you can impregnate even with your own cells.
49:41 Speaker 03 So cool.
49:42 Speaker 01 I'm sorry. It's just like, what?
49:44 Speaker 03 I don't know. And it's, to me, it's a really interesting trajectory of burn care because for millennia, it was, the focus was on the wound itself, very topical, very isolated, the local treatments. And then, once more awareness was gained about the systemic effects that burns can have, then it was like, well, we need to provide supportive care for fluids, for food, for anis, you know, antiseptic technique, all of these different things, airway management. And then now, we have a lot of those things more under control. We can go back to the burn and say, I mean, I know it's all been done simultaneously,
50:28 Speaker 03 but like, we're now kind of, some of the most exciting research is in this area of how do we promote healing again, fixated on that burn itself, on the topical, local area.
50:39 Speaker 01 Right. And I think what's so interesting too is it's kind of like, like what you were saying, it's for a long time, it was just how can we, how can people survive this?
50:49 Speaker 03 Yes.
50:49 Speaker 01 Right? Like, early on, it was probably just treating the people who did survive. So that's why it was just treating the, the burns of people who did survive. And then it was, can we help people to survive even if they had a big burn? And now we absolutely can. How can we make sure that they thrive going forward?
51:07 Speaker 03 Yes, quality of life. Yeah.
51:09 Speaker 01 Quality of life. And so for that reason, a lot of the research that is going on right now in burns and wound healing is into improving these, especially bioengineered types of skin grafts and this idea of 3D printing and using our own cells or other cells, like just things that will help to promote healing. And the reason why this is so important is to reduce the risk of scarring. Because especially in cases when we cannot do an autologous skin graft, so if you cannot take skin from yourself to be able to do a skin graft, then one of the most common complications of burn wounds is what's called hypertrophic scarring.
51:53 Speaker 01 And hypertrophic scarring is as high as 70% in people with burn injuries. And basically what happens is that as the scar forms, it is laying down collagen in this like linear way that ends up lacking the flexibility of uninjured skin.
52:13 Speaker 03 And is that because it's like just trying to get this done as quickly as possible?
52:17 Speaker 01 Kind of. That's kind of the way that I think of it. I don't know if that's like a perfect, but that's kind of the way that I think of it. When you have a large area, your body's just like, get it down, get something down. We need to cover this up, right?
52:27 Speaker 03 Okay.
52:28 Speaker 01 And when that happens, there ends up being too much of this collagen deposited and like not the right types of collagen, basically. And it results in a very thick, inflexible scar that's really painful and really itchy.
52:43 Speaker 01 This is different, by the way, than a keloid scar, which can also be a complication of burn injury. But keloid scars grow beyond the edge of the initial wound. And that's because of them being stuck in that proliferative phase of wound healing and not moving on to this remodeling phase of typical scar formation. So certain types of skin might be more prone to keloids than others. But overall, all burned skin is very prone to hypertrophic scarring. And both keloid scars and hypertrophic scars can be painful. They can be hugely impactful on quality of life. And they're really hard to treat after the fact.
53:24 Speaker 01 Additionally, what happens as this dysregulated collagen is being laid down is that you also have what are called myofibroblasts that are being laid down. And these are cells that our body uses specifically to close up the wound bed itself. So like you said, are they just trying to get it done? Yes. And so our body uses these cells that try and decrease the area of the wound by contracting it. And that can result in what are called contractures. And you've mentioned these a few times, Erin. But these are basically scars that can form that are very tight and painful. And especially in an area where you need to have movement, like your hand or your face. I mean, almost anywhere on your body, your skin needs to be able to move.
54:10 Speaker 01 That can really impact quality of life and like the ability to do the things that you need to be able to do. In general, the deeper the wound, so the deeper the burn, the worse likelihood there is for scar formation or like the more likely you are to have bad scars. Okay. That's a weird way to say that, apologies. But what we know and what I think is really interesting is that this is more related to the time that it takes to heal. So any dressings or any treatments that we have that can reduce healing time to less than 21 days or so significantly reduces the risk of especially hypertrophic scarring.
54:51 Speaker 03 Maybe this is like a question for another episode. Maybe we should do an episode on like just wound healing scars in general.
54:58 Speaker 01 Yeah.
54:59 Speaker 03 But I, I feel like what is, the skin is different.
55:03 Speaker 01 Yes.
55:04 Speaker 03 Whether there's a graft, whether there's not a graft, like hair, does the hair grow? Does it not grow?
55:09 Speaker 01 Yeah.
55:10 Speaker 03 What is different and what makes it different? And if that's beyond the scope, then we can just say, we'll get to that another time.
55:17 Speaker 01 I do think it would be interesting to do a whole episode on that, Erin, because there is a lot to it. It's all going to depend on the depth of the wound of if there was a skin graft, where did that skin come from? Whether melanocytes were completely lost. Those are our pigment producing cells. And so that's why a lot of times we see changes in pigment. And then, yes, like our body is healing by scar formation, especially if you have lost the like stem, the skin stem cells to where you're not fully regenerating the skin that was there before, but you are instead filling it with scar. It's like, it is a different tissue.
55:51 Speaker 03 Different type of tissue.
55:52 Speaker 01 Than the skin was initially, if that makes sense.
55:55 Speaker 03 Yeah, why?
55:56 Speaker 01 Yeah, we could do a whole episode on it someday, Erin.
55:59 Speaker 03 Okay.
56:00 Speaker 01 But what I think is really, I mean, there is so much work that has been done and it's such important work. But the biggest issue, there's a lot of biggest issues, but one of them is how are these new technologies going to be made available? Because right now, most of the people who really could benefit from access to these new technologies do not have access to them.
56:26 Speaker 03 Yeah.
56:27 Speaker 01 So the World Health Organization reports that globally, there's at least 11 million people who have burns bad enough that they are being reported, which likely means that they are severe. So more than 10 or 20% of your body's surface area. But we don't have great numbers on that because. We do not have like global repositories of burn data. No one's reporting all of this on a country by country scale.
56:54 Speaker 03 Yeah.
56:55 Speaker 01 And this results in at least 180,000 deaths from burns worldwide every single year. And it's estimated that 90% of burns, and I think 95% of deaths from burns, occur in low and middle income areas of the world.
57:14 Speaker 03 Yeah.
57:15 Speaker 01 And this is severe burns, not just burn burns. Mortality rates from burns have dropped substantially in high income countries, but that's to a much greater degree than the decreases in mortality in low and middle income countries. We also see a bimodal age distribution in who is most likely to have burns. Young children under age five and working age adults are the two highest groups that suffer from burns.
57:47 Speaker 01 And like I said in last week's episode, flame burns and scalded burns are the most common types of burns, with chemical and electrical burns being relatively rare. And kids under age five are more likely to get scalded burns than flame burns, so from hot water and things like that. In the US, where we have a little bit more like hard data, it's estimated that more than half a million people seek medical treatment for their burns each year.
58:12 Speaker 03 Wow, yeah.
58:14 Speaker 01 And that results in anywhere from 25 to 40,000 hospitalizations, depending on the year that you've looked at, and at least 4,000 deaths in the US from burns every single year, despite all of our advancements in treatment.
58:27 Speaker 03 Yeah.
58:28 Speaker 01 And like we've mentioned, burn injuries can result in really severe scarring, which is painful and can be disfiguring, which can result in social stigma, isolation, and has a really profound effect on people's mental health.
58:42 Speaker 01 And I don't want to discount the effect on the health of caregivers.
58:46 Speaker 03 Yeah.
58:47 Speaker 01 The care of people who have had burn trauma is very prolonged. It can be very intensive and that can be really hard on caregivers, especially if you don't have access to something like a specialized burn center, which even in high income countries, over 20% of the population in this country does not live within two hours by ground or air of a burn center.
59:11 Speaker 03 Wow.
59:11 Speaker 01 Which means that they don't have access. And that's in a high income country. In low and middle income countries, they have even less access.
59:17 Speaker 03 Yes.
59:18 Speaker 01 So there's been a lot of research too on people who have suffered burns, people who have been caregivers of people with burns and people who care, like medical professionals and things on what do we need to do? What are the priorities in burn management? And the biggest ones that have been identified so far are improving the actual wound management. And so that's where I think most of the research that I have seen has really been in, which is like wound dressings and skin substitutes and all of these things. But the second most common response was improving psychosocial outcomes.
59:52 Speaker 03 Yes.
59:52 Speaker 01 Which I think that we have done maybe less of a great job of focusing on. So, and then other things like rehab and helping to treat scarring after the fact were other things that were identified as kind of high priorities. And I think it shows that when we have access to dedicated facilities, to teams who are really experts in burn care and to these incredible technological developments and advancements that we've seen, there is the potential for the treatment of burns to be phenomenal.
1:00:27 Speaker 03 Like, yeah.
1:00:27 Speaker 01 Really, really incredible.
1:00:29 Speaker 03 Right. We have so many things in our toolkit.
1:00:33 Speaker 01 Yes.
1:00:34 Speaker 03 But yeah, again, who has access to the toolkit?
1:00:37 Speaker 01 Yeah.
1:00:38 Speaker 03 Yeah.
1:00:39 Speaker 01 And that, Erin, is burns today.
1:00:44 Speaker 03 Yeah. I have no words.
1:00:48 Speaker 01 Yeah.
1:00:48 Speaker 03 So instead, I'll say sources.
1:00:50 Speaker 01 Tell you where you can learn more.
1:00:51 Speaker 03 There we go. There we go. Again, I have a bunch of papers for this. And I'm gonna shout out just a few. There's by Moore, 1999, "Then and Now: Treatment Volume, Wound Coverage, Lung Injury, and Antibiotics." It was sort of like personal reflections on how treatment of burns has changed. And then by Jackson, 1991, "The Evolution of Burn Treatment in the Last 50 Years." So from, that's an interesting paper. Then by Barrow and Herndon, I think it's a book chapter called "History of Treatments of Burns."
1:01:24 Speaker 01 Love it. I actually just, I will still shout out again the paper I shouted out last week, which was from Nature of Used Disease Primers. It has a lot in there about how we treat burns today. And it was from 2020, so relatively recent. But I have some other ones as well. There was one from 2023 from the International Journal of Molecular Sciences that was called "An Overview of Recent Developments in the Management of Burn Injuries." I found that one helpful. There was a couple from The Lancet. One that was from The Lancet Global Health that I mentioned that was called "The Top 10 Research Priorities in Global Burns Care." So that one was kind of how we need to focus on burn care going forward. Another one, just specifically on hypertrophic scarring and how much we need to focus on that. A whole nother paper on nanotechnologies. Oh, my gosh. There's so much more.
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