A 2-year-old girl was rushed to the University of California, San Diego (UC San Diego) Medical Center on her birthday with 60% of her body covered by scald burns caused by hot water. The burns were intentional, inflicted on her by a family member. Standing ready to help on that terrible day was UC San Diego’s Dmitri Lerner, PharmD, a burn surgery and critical care pharmacist, along with a team of surgeons, physicians, and nurses. “It was touch and go for a long, long time,” said Lerner. “She spent a year with us, but she got better.”
It takes a special kind of provider to work in the burn unit. “Sometimes kids and adults are so badly injured that it makes it difficult to do your job,” said Lerner, who is responsible for the entire patient population of the burn unit and the ICU, roughly 20 patients per day.
Recovery from burns is a slow, painful process that can take months or even years. An in-depth knowledge of the pharmacokinetics of pain medications, sedatives, and antimicrobials is critical to helping patients get better. Lerner monitors the safety of every medication prescribed and administered to every patient.
“I review the medication order, make sure it’s appropriate, the right dose, and that the patient responds,” said Lerner. “I am always reassessing a patient’s response to therapy and making dose adjustments.”
The UC San Diego Medical Center is the only burn center in the area. Patients come from as far north as Camp Pendleton, as far east as El Centro, and as far south as the Mexican border. According to Lerner, the majority of burns among adults are flame burns. Around 90% of burns are accidental. Fewer than 5% are self-inflicted, and even fewer are inflicted by a third party. In children, the most common type of injuries are scald burns, which happens when a child accidentally spills something on him- or herself.
“Whether a patient stays in the ICU or is moved to the burn unit depends on the extent of the burn, the depth of the burn, size of the burn, and how much of a total body surface area is involved,” explained Lerner. The age of the patient is also a factor. “The older the people are, the higher their mortality after a burn,” he added.
Burn injuries can be classified as first, second, or third degree based on the depth of the dermal tissue affected. First-degree burns, such as a sunburn, although rather painful, will usually heal without much surgical or medical intervention and will not result in admission to the hospital, noted Lerner. Second-degree burns can be split into superficial or deep partial thickness burns.
“These are much more complicated and difficult to treat,” Lerner explained. “The affected skin, depending on the extent of the damage, can start to heal on its own with careful and skillful wound care over a period of 7 to 10 days.”
Some deep partial thickness wounds progress to full thickness and become third-degree burns. “This process cannot usually be stopped or reversed, only observed,” said Lerner. “Once deemed full thickness, the damaged or dead tissue will need to be completely surgically removed, prepared for a skin graft, and finally grafted with patients’ own skin taken from a different part of the body.”
This process may need to be performed in stages and may take weeks to months, depending on total surface area and depth of the burn. Multiple complications, such as infections and exacerbations of comorbidities, can further extend patients’ hospital stay.
Lerner begins his day by getting a report from the night pharmacist. “Because patients tend to stay so long on the unit, you already know them pretty well, but often there are new patients admitted during the night,” said Lerner. He then conducts a “preround” meeting with a pharmacy resident and a student pharmacist who are on rotation in the unit.
“I make sure we have a plan if there’s anything we want to recommend or change in therapy, in pain management, glucose management, anticoagulation, or anti-infective management,” said Lerner.
The pharmacists then round with a multidisciplinary medical team. “We discuss every single patient, so sometimes rounds can last a couple of hours,” Lerner said, who has order verification responsibilities. This means that as orders come up for patients, Lerner must electronically verify them, even during rounds. After rounds, Lerner makes sure all the medication changes are implemented and monitors patient response.
According to Lerner, it is important to have specialized pharmacists dedicated to the ICU and burn unit because “medication-related issues can jump out at you at every single turn.”
Burn patients are extremely ill, and their entire body is out of balance. “Any new medication that is ordered, any new therapy that is attempted, any procedure could throw their metabolic processes out of balance,” said Lerner. “Pharmacists are innately trained to notice these situations, to pick those clues up, and communicate them to the medical or surgical team. A pharmacist should be a staple in the ICU and burn unit.”
There are also pediatric medication considerations. “It is important that the doses we’re giving are correct and that the child is responding in the way we want them to respond to medical therapy,” said Lerner.
In addition to patients with burns, the UC San Diego Medical Center also takes care of patients with other types of skin injuries. Certain medical conditions can trigger systemic reactions that manifest as Stevens–Johnson syndrome or toxic epidermal necrolysis.
Lerner and the burn unit team recently treated a 22-year-old active college student who developed a severe bacterial infection, in which the bacteria released an exotoxin that caused severe edema of his extremities. The patient ended up losing both legs.
“It was a multidisciplinary effort to treat him,” said Lerner. “There were a lot of wound healing issues, and we had to do a lot of skin grafting and a lot of surgical procedures to save his upper extremities. He was in a lot of pain and quite depressed when he came to the realization that he had no legs.”
When it comes to treating burns and other skin conditions, it can sometimes be difficult to communicate treatment goals clearly to patients and their families. “It may sometimes appear to the family that what we’re doing may not be in the patient’s best interest,” said Lerner. For example, a family may not think the patient is receiving sufficient pain control. “There are issues with excessive use of pain medications over a long period of time,” explained Lerner. “Patients become tolerant of opiate medications, and constant dose escalations are required.”
According to Lerner, patients often reach a point at which receiving more pain medication is a greater risk than a benefit. When this happens, Lerner takes special care to communicate clearly with families about the steps needed to switch medications and develop a patient-specific pain management plan.
Lerner believes that in the burn unit and ICU, it’s especially important to have face time with the patient and the patient’s family to address questions and improve the patient’s care experience “As a pharmacist, I’m there, and I make sure I’m available to the patient,” he said.
For the college student with the skin condition, Lerner’s clear communication to the family about pain medications was an important factor in his care. “It went from a bad situation to a much better and manageable situation. The patient’s attitude toward the team and me changed for the better,” Lerner said. “The more information his parents understood about what we were trying to accomplish, the better they felt.”
Working with burn patients and helping them recover from such traumatic injuries can be heartwarming. “Because the patients have such severe injuries, they stay so long that we become part of the patient’s family,” said Lerner. “Patients often come back and visit us.”
One of Lerner’s patients had burns on 90% of his body. His ankles were the only things that weren’t burned. “He spent 2 and a half years in the hospital. There were good days and bad days, and then more good days than bad days,” said Lerner. Now, a year and a half after the patient was discharged, he still comes back for regular visits.
“The relationships that pharmacists, and especially nurses, form with the patients is unparalleled,” said Lerner. “And I know that I am making a difference every day for the patient. My decisions and my recommendations that are accepted have a lasting effect on the patient’s outcome, and that’s incredibly rewarding.”