Practice development


immediate pain management was initiated with an intramuscular dose of diclofenac, which was the only pain relief that was available in the unit on that day. The child was placed on one of the four beds in the open area of casualty while sterile equipment was prepared. No general observations appeared to have been carried out, perhaps due to the lack of suitable paediatric equipment. The initial objective was to remove all dead


Page points


1. On the author’s first day in the A&E department, a one-year-old girl


was brought in by her mother after suffering scalds from boiling water


2. The initial objective was to remove all dead skin in preparation for topical administration of silver sulfadiazine


3. The patient was later referred to a burns surgery unit where fluid management could be carried out.


4. The case highlights the challenge of providing effective wound care in an under-resourced unit


Figure 2 – The surgical casualty area, including the cleaning area (centre back) where patients are showered to remove blood and other debris. One of the four beds can be seen — the room is partitioned so that there are two beds in each partition. The green tray (centre) is used to hold sterile equipment and the blue tubs (left) are where dirty equipment is dispensed, before being sterilised.


such as rectal prolapse [Fig 4] are also known to present to the emergency department.


BURNS Burns are commonplace in Uganda. In a study conducted over a one-year period in 2004, 6% of Mulago’s casualty cases were burns related. These cases are often very difficult to manage due to a lack of resources and were the cause of 15% of mortalities at the hospital in that year[3]


. On YZ’s first day in the A&E department, a Reference


4. Bellagio Essential Surgery Group. Conference on Increasing Access


to Surgical-Constrained Settings in Sub-Saharan Africa. Final Report. 2007; Bellagio Essential Surgery Group, Italy.


5. Ozgediz D, Kijjambu S, Galukande M, et al. Africa’s neglected surgical workforce crisis. Lancet 2008; 371: 627–8.


6. Kruk ME, Wladis A, Mbembati N, et al. Human resource and funding constraints for essential surgery in district hospitals in Africa: A


retrospective cross sectional survey. PLoS Med 2010; 9;7(3): e1000242.


one-year-old girl was brought in by her mother after suffering scalds from boiling water. No formal assessment of the burn area was carried out, but about 40% of her total body surface area (TBSA) was scalded. The skin was blistered and erythematous and the child was in a lot of pain. The majority of damaged skin appeared to be a superficial partial thickness burn with some areas reaching the deeper layers. The extent of the injury was difficult to assess and no formal assessment of capillary refill, sensation or blanching of the skin was carried out. Also, rather than using any established burn/scald area assessment methods, the staff had simply approximated the scalded area to be 20%. The water appeared to have been dropped from a height (similar to a ‘pull-over’ scald) and, therefore, most of the injury was confined to the head, upper torso and upper limbs. The patient’s airway did not appear to be compromised and


19 Wounds International Vol 2 | Issue 1 | ©Wounds International 2011


skin in preparation for topical administration of silver sulfadiazine. This was very difficult as the pain relief was ineffective and the child had to be managed in the busy and cramped casualty room. There was also no attempt at fluid resuscitation, either due to lack of appreciation of the seriousness of the injury, or lack of resources, or both. On a positive note, sterile gloves were easily accessible and equipment was sterilised in a steamer [Fig 2]. Once all the dead skin had been removed, the doctor and elective medical student administered silver sulfadiazine by hand wearing sterile gloves. Finally the area was covered with sterile gauze and the patient was admitted to the burns unit. The case described above highlights the challenge of providing effective wound care in an under-resourced unit. Although this encounter was brief, it nevertheless reflects a normal working day and highlights many of the problems the department regularly faces. The lack of trained emergency physicians and suitable paediatric equipment, and the


Figure 3 – The resuscitation room, showing the defibrillation machine and container containing fluids and other resuscitation equipment (left). To the right is a mattress lying over the medication cupboard. Hanging on the windows are a number of oxygen masks. After allowing enough space for staff to work in, the room can accommodate two patients.


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