The challenge of managing burn wounds in Uganda ?????????????????????????????????????


????????????????????


absence of specialist burns care and expertise, including burn surgeons and anaesthetics, highlights the gulf between this setting and those in Western hospitals. The differences are also reflected in the higher morbidity rate of burns in resource-poor settings.


THE CHALLENGES FACING UGANDAN CLINICIANS The general lack of support for surgery in Africa has been well documented[2, 4–7]


and although


Mulago’s A&E is a busy department, it is poorly funded. Surgical conditions make up 11% of the global disease burden[7]


basic surgical procedures can arguably be just as cost-effective as the treatment for infectious diseases[6, 7, 9]


, yet in Africa spending is


minor when compared with the amount spent on infectious disease treatment [6, 8]


. However, many The Disease Control Priorities Project


publishes data demonstrating that the average cost per disability adjusted life years (DALY) averted for a set of basic surgical procedures is less than the cost of HIV/AIDS treatment[9]


.


Surgical departments are often understaffed and there are only 75 specialist surgeons in Uganda to cater for a population of 30 million[5]


. In any case, specialists are mainly


based in the larger cities, leaving the district hospitals in severe need of essential medical expertise.


Lack of staffing is compounded by poor funding and training opportunities as well as the loss of doctors who leave to work overseas. Between 1998 and 2002, Ghana lost $35 million of training investment in health when doctors left to work in the UK (allowing the UK


to save $65 million in its own training costs) [10]


. To address the need for skilled workers, a number of African countries have trained non-doctors in basic surgical procedures in order to increase the numbers of competent staff through faster and cheaper channels. This has proven to be highly successful[2, 4] and the majority of procedures are carried out by general doctors and a specially trained workforce[6]


.


The human resources and surgical issues facing many African countries are being addressed by international committees such as the Bellagio Essential Surgery Group, which is gathering evidence and lobbying for improved surgical care in Sub-Saharan countries[4, 11]


. It has highlighted that burn


surgery, in particular, needs to be improved. Mulago has links with a number of western universities, including the University of California, San Francisco (UCSF) and Yale


Figure 4 – Patient presenting with an established rectal prolapse of unknown aetiology.


University in the US, allowing for intellectual exchange and the promotion of awareness of the difficulties that Uganda faces.


BURN MANAGEMENT A brief overview of the general principles of managing burns is outlined below, including methods to estimate TBSA burned, evaluating burn depth and some essential early management aspects. The ‘rule of nines’ is a useful tool for estimating


the TBSA of a burn — clinicians should allow 18% each for the chest, back and each leg, 9% each for the head and each arm, and 1% for the perineum. The patient’s palms and fingers, which represent just under 1% of the TBSA, are also a useful method for estimating the size of the burn area. The types and features of different burn depths are highlighted in Table 1.


Management of minor burns A burn should be cleaned initially with soap and water (or a diluted water-based disinfectant) to remove loose skin, including open blisters. Any blisters should be de-roofed apart from those that are isolated and under 1cm2


in area — these can be left alone. Simple


non-adhesive dressing such as a soft silicone padded by gauze is effective in most superficial and superficial dermal burns. However, biological dressings such as Biobrane™ (Smith & Nephew) and non-animal derived synthetic polymers such as Suprathel™ (PMI) may be useful in certain types of burns, although their use is limited to specialised burns units. Silver sulfadiazine can be used for deep dermal


burns and dressings should be examined after 48 hours for reassessment of depth. Further dressing changes for superficial partial thickness burns may


Page points


1. The general lack of support for surgery in Africa has been well documented


2. Surgical conditions make up 11% of the global disease burden, yet in Africa spending is minor when compared with the amount spent on infectious disease treatment


3. However, many basic surgical procedures can arguably be just as cost-effective as the treatment for infectious diseases


References


7. Ozgediz D, Riviello R. The ‘other’ neglected diseases in global public health: surgical conditions in Sub- Saharan Africa. PLoS Med 2008; 5(6): 0850–1.


8. Angemi D, Oyugi J, Aziz I, et al. The money flows, the boy dies. International Herald Tribune 2007; April 25: 29.


9. Laxminarayan R, Mills AJ, Breman JG, et al. Advancement of global health: key messages from the Disease Control Priorities Project. Lancet 2006; 367: 1193–1208


10. Editorial. Finding solutions to the human resources for health crisis. Lancet 2008; 371(9613): 623.


11. Bellagio Essential Surgery Group. Bellagio Essential Surgery Group 2008; Available from: http:// globalhealthsciences.ucsf.edu/ bellagio/index.html (accessed 25 November 2010)


www.woundsinternational.com


20


Practice Development


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