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. 2018 Jun 30;31(2):138–143.

Knowledge on emergency management for burn and mass burn injuries amongst physicians working in emergency and trauma departments

NN Lam 1,∗, HTX Huong 1, CA Tuan 1
PMCID: PMC6199015  PMID: 30374267

Summary

A survey was conducted on 397 physicians working in Emergency and Trauma Departments of district and provincial hospitals in Vietnam. The contents of the survey were emergency care for burn and mass burn injuries. Results showed that only 39.8% of participants gave more than 50% correct answers. In the case of mass burn injuries, only 10.3% of participants gave correct answers for triage, and 71.8% of participants considered oral fluid resuscitation to be an appropriate method. In addition, intubation for suspected inhalational injury was indicated by 51.9% of doctors. Bivariate analysis showed that working experience did not remarkably affect knowledge level. A significantly higher knowledge level was recorded among doctors working at provincial hospitals compared to those working at district hospitals (47.9 ± 13.5% correct answers vs. 42.2 ± 14.8% respectively, p = .0001). Moreover, physicians who had attended training courses in the past had a significantly higher knowledge level compared to the others (53.1 ± 13.6% vs. 44.5 ± 14.2% respectively; p = .0003). Multivariate logistic analysis indicated that both these variables were independent factors that affect the knowledge of healthcare providers with p < .01. Further continuing medical education on burn management and mass burn injury response needs to be conducted for physicians, especially doctors working at primary hospitals.

Keywords: emergency burn management, mass burn injuries, physician knowledge

Introduction

Burn injuries are common and can occur at any time. First aid and initial management for burns are important stages in the progress of burn care, including mass burn injuries.1,2,3Around the world, not all burn victims are specially treated at burn units from the early stage of hospitalization. Most burn patients are admitted to emergency departments for initial management before being transferred to burn units, or trauma departments if a burn unit is not available. Moreover, in the case of mass burn injuries, emergency departments will receive and perform triage, giving emergency treatment to the burn victims. Physicians working in this department often join the burn assistance team, which is deployed to the disaster location.4,5 Therefore, the knowledge and practical skills of health caregivers in these departments are very important to qualify burn care progress.

It is stated that more than 90% of burn-related deaths occur in developing or low- and middle-income countries.6 Like in other developing countries, limitations have been reported regarding the first aid provided and initial management of burn patients before they were transferred to the National Institute of Burns in Hanoi, Vietnam, especially as far as mass burn injuries are concerned.2,7As a consequence, these patients faced many difficulties throughout their recovery, leading to more complications, higher mortality rate and longer hospitalization.

This study evaluated knowledge of emergency burn management, including specific case and mass burn injuries, among physicians working in emergency and trauma departments.

Materials and methods

From March to July 2016, a survey was conducted on 397 physicians working in the Emergency or Trauma Department of district or provincial hospitals from 12 provinces around Vietnam. An anonymous questionnaire was directly delivered in person, and the participant had 30 minutes to answer. The contents of the survey included basic knowledge of diagnosis for burn extent, burn shock pathology, first aid measures for thermal burn and eye injury, fluid resuscitation using the Parkland formula, manifestation of inhalation injury and intubation indications, triage and appropriate methods of fluid resuscitation for mass burn injuries. Some questions required time for calculation, and most of the others were multiple choice (see appendix). Overall knowledge level was defined as percentage of correct answers.

Data was collected and calculated as percentage of correct answers, tabulated and analyzed using T-test and Chi square to compare mean and distribution of values between groups. Multiple logistic analysis was used to find the independent factors affecting the knowledge level of participants. Stata 11.0 software was used with confidence intervals at 95%, and p value ≤ .05 was considered to be significant.

Results

Characteristics of the participants are shown in Table I. Out of 397 doctors, 223, accounting for 56.2%, were working at provincial hospitals. Most participants (87.4%) had less than 5 years working experience since graduating from medical school. In addition, only 10.1% of participants had taken part in training courses for emergency burn management.

Table I. Characteristics of survey participants (n = 397).

Table I

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Table II indicates that only 10.3% of participants exactly calculated adult burn extent and the same situation was seen for pediatric burns (10.8%). Regarding first aid for burn injury, 89.9% of participants knew to use fresh cool water, and 82.6% of them gave the right answer not to use other remedies (fish sauce, butter, toothpaste…) to cover burn wounds. Correct first aid measures for eye burn injury were given by 73.3% of total physicians. In addition, 58.4% of participants gave the right answer for inhalation injury manifestation.

Table II. Knowledge of burn pathology and first aid (n = 397).

Table II

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Regarding knowledge of burn shock pathology, only 34% of total participants had sufficient knowledge of haemo-concentration in burn shock, 47.1% gave the right answer on electrolyte disorder, and only 18.9% understood the concept of colloid fluid. The Parkland formula was fully understood by 60.5% of participants. Moreover, only one third of participants gave the correct answer regarding sufficient urine output when performing fluid resuscitation for both adult and pediatric burn patients (Table III).

Table III. Knowledge of fluid resuscitation, inhalation injury and mass burn injuries.

Table III

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In the case of mass burn injury management, 71.8% of doctors answered that oral fluid resuscitation is the appropriate method. Meanwhile, only 10.3% of participants gave the correct answer regarding triage before transferring victims from the scene to hospitals. Pre-transportation intubation for suspected inhalation injury was indicated by 51.9% of doctors (Table III). Table IVreveals the overall survey results. A total of 158 doctors, accounting for 39.8% of the participants, gave more than 50% correct answers. The average percentage of correct answers was 45.4%, ranging from 5.9 to 82.3% of total questions, meaning nobody had all the correct answers.

Table IV. Overall survey results (n = 397).

Table IV

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The relationship between overall result and proposed criteria is shown in Table V. Doctors working in province-based hospitals had a significantly higher knowledge level than doctors working in district-based hospitals (47.9 ± 13.5% correct answers vs. 42.2 ± 14.8% respectively, p = .0001). In addition, physicians who had undertaken training courses had a significantly higher knowledge level than those who had not participated in any training course (53.1 ± 13.6 vs. 44.5 ± 14.2 respectively; p = .0003). It is interesting to note that working experience did not closely relate to the knowledge level of the doctors surveyed (p > .05).

Table V. Relationship between overall result and proposed criteria.

Table V

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Table VI shows the results of multivariate logistic analysis for two variables - working place and experienced training course. As can be seen, both variables were independent factors affecting the knowledge of the health care providers with p < .01.

Table VI. Logistic analysis for overall result and variables.

Table VI

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Discussion

It has been widely proven that suitable initial first aid measures and initial management can significantly improve burn outcome. In addition, the knowledge and practical skills of healthcare providers play an important role in the success of diagnosis, prognosis and treatment of a specific patient situation. However, it is noted that current worldwide reports indicate different knowledge levels about first aid and initial management for burns amongst healthcare providers.8,9

Common insufficient knowledge of emergency burn management has been reported in developing countries. In 2005, a survey by Kut and colleagues on knowledge among 510 occupational physicians in Turkey showed that only 21.8% of total participants knew appropriate burn classification, and only 4% had sufficient knowledge of burn first aid and initial management.10 In Saudi Arabia in 2016, Alomar et al. surveyed 408 healthcare providers in pediatric departments about burn first aid and initial management. This indicated that only 15% of participants had taken part in first aid training. Forty-one percent of participants knew to use fresh cool water for first aid. Ninety-seven percent had insufficient knowledge of application duration. Moreover, a high rate of participants answered that remedies including toothpaste, fish sauce, ice or oils could be used to cover the burn wound surface. This study did not show any significant correlation between age, language or training and knowledge level.11

Our results indicate that there is still a limit to doctors’ knowledge in terms of calculation of burn surface area for both children and adults, and misunderstanding about the Parkland formula and required urine output for burn shock fluid resuscitation. In addition, our study also indicated that doctors had a fairly low knowledge of mass burn injury management, particularly triage (only 10.3% correct answers) and indication for intubation, although 71.8% doctors knew a suitable method for fluid resuscitation. This status agrees with our previous report about limitations in initial management and immediate care for mass burn injury patients in Vietnam.7

In Taiwan, a report by Kuo et al. in 2018 indicated that preliminary local hospitals had enough capacity and capability to provide acute care for mass burn injury patients, apart from those with suspected limb ischemia, who should be rapidly transferred to a burn center for optimal care. The authors also suggested setting up telemedicine and personnel collaboration to maximize the function of preliminary hospitals in the burn care system.12 In Vietnam, the district hospital is considered the first level with the responsibility to care for patients in the health care system, even in the case of mass casualty incidents. Meanwhile, most specialized healthcare providers are working in provincial hospitals and at higher levels. So it is easy to understand why the knowledge level of doctors working in province-based hospitals was significantly higher than that of doctors working in district-based hospitals.

In the current study, only 39.8% of doctors gave more than 50% correct answers, and no participant answered all the questions correctly, which is poorer than expected. In addition, our results revealed that working experience is not a factor that affects knowledge level among participants. This suggests that senior doctors are not updating themselves on the acute management of burns and mass burn injury management, as guided.

In developed countries, the situation is better but still with limitations. For example, in England, Allison et al. surveyed the knowledge of medical staff working in the ambulance service and found that 55% of ambulance team members did not know standard protocol for burn management; 97% used pain killers, 87% applied cool fresh water, 74% would give oxygen and 90% canulated regardless of fluid administration.13 Rea et al. show that in Western Australia only 18.8% of healthcare providers gave the right answers to questions on the burn scenario.14 In the UK, in 2013, Tay et al. conducted a survey to assess burns first aid knowledge among healthcare workers. This showed that 59% of participants had attended a first aid course. However, only 16% achieved correct answers in all questions.15

Previous studies demonstrated that knowledge of first aid correlated with first aid training courses. A study by Rea et al. indicated a statistically significant difference between participants who had taken part in a first aid course and those who had not.14 Our study results were in agreement with that statement: physicians who undertook training courses had a significantly higher knowledge level (53.1%) compared to those who had not participated in any training course (44.5%). Our study and others also proved that participating in training courses is an independent factor affecting knowledge level. These results emphasize the importance of conducting frequent training courses for healthcare providers.

Limitations in medical education in medical school is one of the reasons for the gap. In 2013, Egro and Estera surveyed 29 medical schools in England and found that only 13% of medical schools had a burn curriculum, with a total time of around 4 hours, on simple contents including calculating burn extent, determining burn depth and initial management. In 2015, only 50% of programs mentioned fluid resuscitation and criteria for burn patient referral.16 Lemon et al. conducted a survey on the last year of English medical students and found that 35% of participants had received no training on burns, only 32% felt confident giving burn treatment, 17% thought chemical agents do not cause burn injury, 9% used ethanol and 7% used butter for first aid, and only 3% gave the right answer for the whole scenario.17 In 2016, another survey by Zinchenko et al. on 348 finalyear medical students in the UK indicated the same situation. Seventy percent of students did not receive any specific teaching on burn management. In addition, 66% have never observed a case of burns treatment during their training. Over 90% did not feel confident about initial burn management and 57% of participants did not know the criteria for referring a burns patient for specialist treatment.18 In Vietnam, most medical universities do not have a separate burn training curriculum. Some medical schools have only 2 hours of basic burn training. In addition, after graduation, doctors have fewer opportunities to attend training courses that focus on burn education.

Besides supplementing burn teaching programs for undergraduate students in medical school, conducting continuing medical education that focuses on burn emergency management is one of the best ways to improve the knowledge of healthcare providers. In 2016, a cohort study by Kua Phec Hui et al. at the children’s emergency department in Singapore showed a statistically significant increase in knowledge immediately after a short training course (22.9% vs. 78.3%).19 Currently, continuing medical education is compulsory for healthcare providers in Vietnam. However, not many training courses focus on burn care and mass burn incidents, especially those for doctors working at primary level (only 10.8%). This limitation should be noted to initiate a training program to improve the situation.

Conclusion

Our study indicates limitations and insufficiencies in physicians’ knowledge of emergency burn management and mass burn injury response, especially among those working in primary healthcare facilities. Training courses significantly contribute to improving their knowledge. It is necessary to conduct continuing medical education for all grades of doctors, regardless of their working experience.

References

  • 1.Gianfaldoni R, Gianfaldoni S, Lotti J, Tchernev G. The importance of first aid to burned patients: 30 years of experience at the Burns Centre in Pisa. Open Access Maced J Med Sci. 2017;5(4):420–422. doi: 10.3889/oamjms.2017.131. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Nguyen NL, Gun RT, Sparnon AL, Ryan P. The importance of initial management: a case series of childhood burns in Vietnam. Burns. 2002;28:167–172. doi: 10.1016/s0305-4179(01)00079-1. [DOI] [PubMed] [Google Scholar]
  • 3.Haberal M. Guidelines for dealing with disaster involving large numbers of intensive burns. Burns. 2006;32:933–939. doi: 10.1016/j.burns.2006.08.026. [DOI] [PubMed] [Google Scholar]
  • 4.Leslie CL, Cushman M, McDonald GS, Joshi W, Maynard AM. Management of multiple burn casualties in a high volume ED without a verified burn unit. Am J Emerg Med. 2001;16(6):469–473. doi: 10.1053/ajem.2001.27147. [DOI] [PubMed] [Google Scholar]
  • 5.Brandt CP, Coffee T, Yurko L, Yowler CJ, Fratianne RB. Triage of minor burn wounds: avoiding the emergency department. J Burn Care Rehabil. 2000;21(1 Pt 1):26–28. doi: 10.1097/00004630-200021010-00006. [DOI] [PubMed] [Google Scholar]
  • 6.Atiyeh B, Masellis A, Conte C. Optimizing burn treatment in developing low-and middle-income countries with limited health care resources (part 1). Ann Burns Fire Disasters. 2009;22(3):121–125. [PMC free article] [PubMed] [Google Scholar]
  • 7.Lam NN, Huong HTX, Tuan CA. Mass burn injuries: an analysis of characteristics and outcome in a developing country. Ann Burns Fire Disasters. 2017;40(3):210–213. [PMC free article] [PubMed] [Google Scholar]
  • 8.Fadeyibi IO, Ibrahim NA, Mustafa IA, Ugburo AO. Practice of first aid in burn related injuries in a developing country. Burns. 2015;41(6):1322–1332. doi: 10.1016/j.burns.2015.02.018. [DOI] [PubMed] [Google Scholar]
  • 9.Atiyeh B, Masellis A, Conte C. Optimizing burn treatment in developing low-and middle-income countries with limited health care resources (part 2). Ann Burns Fire Disasters. 2009;22:189–195. [PMC free article] [PubMed] [Google Scholar]
  • 10.Kut A, Tokalak I, Başaran O, Moray G, Haberal MA. Knowledge, attitude and behavior of occupational physician related to burn cases: A cross-sectional survey in Turkey. Burns. 2005;31:850–854. doi: 10.1016/j.burns.2005.04.009. [DOI] [PubMed] [Google Scholar]
  • 11.Alomar M, Rouqi FA, Eldali A. Knowledge, attitude, and belief regarding burn first aid among caregivers attending pediatric emergency medicine departments. Burns. 2016;42(4):938–943. doi: 10.1016/j.burns.2016.03.019. [DOI] [PubMed] [Google Scholar]
  • 12.Kuo LW, Yen CII, Fu CY, Pan CH. The role of preliminary hospitals in the management of a mass burn casualty disaster. Burns. 2018;44(4):800–806. doi: 10.1016/j.burns.2017.11.014. [DOI] [PubMed] [Google Scholar]
  • 13.Allison K. The UK pre-hospital management of burn patients: current practice and the need for a standard approach. Burns. 2002;28(2):135–142. doi: 10.1016/s0305-4179(01)00083-3. [DOI] [PubMed] [Google Scholar]
  • 14.Rea S, Kuthubutheen J, Fowler B, Wood F. Burn first aid in Western Australia – Do healthcare workers have the knowledge. Burns. 2005;31:1029–1034. doi: 10.1016/j.burns.2005.05.010. [DOI] [PubMed] [Google Scholar]
  • 15.Tay PH, Pinder R, Coulson S, Rawlins J. First impressions last. A survey of knowledge of first aid in burn-related injuries amongst hospital workers. Burns. 2013;39(2):291–299. doi: 10.1016/j.burns.2012.05.013. [DOI] [PubMed] [Google Scholar]
  • 16.Egro FM, Estela CM. The need for burn teaching: a cross-sectional study to assess burn teaching in the United Kingdom. Burns. 2014;40(1):173–174. doi: 10.1016/j.burns.2013.10.001. [DOI] [PubMed] [Google Scholar]
  • 17.Lemon TL, Stapley S, Idisis A, Green B. Is the current UK undergraduate system providing junior doctors knowledge and confidence tomanage burns? A questionnaire-based cohort study. Burns & Trauma. 2015;3:6. doi: 10.1186/s41038-015-0005-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Zinchenko R, Perry FM, Dheansa BS. Burns teaching in UK medical schools: is it enough? Burns. 2016;42(1):178–183. doi: 10.1016/j.burns.2015.10.003. [DOI] [PubMed] [Google Scholar]
  • 19.Kua Phek Hui J, Allen JC, Mok WL. Attitudes on first aid for paediatric burns: pilot survey of a developed city state. Burns. 2016;42(4):926–937. doi: 10.1016/j.burns.2016.02.011. [DOI] [PubMed] [Google Scholar]

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