Introduction

In evaluating catastrophic burn victims it is important to objectively assess the extent of scarring, outline a treatment protocol, and predict future disfigurement to determine a prognosis and long-term expenses and medical costs.

Incidence of Burn Injuries

The American Burn Association reports 450,000 burn related hospital admissions and emergency department visits annually. [1] Minor burns treated at community health centers, hospital clinics, and private offices are not included in these numbers. 40,000 burn patients required hospitalization, 30,000 of whom were admitted to 127 specialized burn centers across the U.S. [2] 69% of burn admissions are male: 31% female. [3] Etiology of admissions are as follows: 43% fire/flame; 34 % scald; 9 % contact with a hot source; 4 % electrical; 3% chemical; 7 % other.  Seventy two percent of burns occurred in the home; 9% occupational; 5 % street/highway; 5% recreational/ sport and 9% other. [4]

Children
Annually, 250,000 children less than 17 y.o. require medical treatment. [5] The most common etiology in children less than 4 y.o. is scalding from food, drink or hot steam.  The remainder are from direct contact from flames or hot appliances such as stove, irons, hair curlers, fireworks or space heaters.

Fatalities
Burn related injuries account for 3400 fatalities annually.[6]  2550 of these deaths occurred in residential fires, 300 from vehicle crashes and 550 from other sources such as contact with electricity, scalding liquids, or hot objects. [7]

Economic Impact

Burn related costs total approximately $11.7 billion each year.  Dollar loss for fires in residential buildings amount to $7.1 billion dollars. [8] Economic loss in non-residential buildings total $2.4 billion dollars. [9]  Fatal burn and fire injuries total $3 billion/ year or two percent of the total cost of fatal injuries. Burn related hospitalizations cost $1 billion annually or one percent of hospitalized injury costs. [10] Non hospitalized burn and fire injuries accounted for $3 billion or two percent of outpatient costs. [11] Moreover, these figures do not factor in the intangible losses due to pain and suffering of the burn injury victims.

Psychological Trauma

Eighteen to thirty three percent of patients who have experienced catastrophic burns will experience Posttraumatic Stress Disorder (PTSD) within 3-6 months. [12] Symptoms are characterized by excessive anxiety, sleep disorders, withdrawal, impaired school performance, diminished creativity, and startle responses. Research using the PTSD Checklist confirm the PTSD behavior in patients 16-65 y.o.  following these adverse life threatening events. [13] Shame and guilt on the parents’ or spouses’ part are often woven into the family dynamics, particularly if the negligence contributed to the burn incident.

Re-Mirroring Process
Following reconstructive surgery, a “re-mirroring” process occurs in the facially disfigured patient. Linda Gunsberg PhD and I have written a chapter entitled “Psychological Effects of Facial Disfigurement” in my plastic surgery textbook Aesthetic Facial Restoration (Lipincott-Raven, 1998). [14]This chapter is based on detailed interviews with eight facial restorative patients.  In summary, patients need to re-establish the positive feedback (“mirroring”) that ordinarily occurs from maternal and family interaction during infancy. This mirroring process culminates in a positive “self-image” by the age of 24-36 months. That positive self-image is virtually destroyed by a devastating, disfiguring facial injury. Affirmative self-esteem can only be restored by the re-mirroring process that arises from the reassurance of the surgeon, family, and peers following reconstructive surgery.  Re-mirroring reestablishes the continuity with the old psychological self as the physical traits of the repaired face are integrated with his or her self-identity and body image. This process often requires extensive psychotherapy over a sustained period of time.

Comprehensive Medical/ Surgical Evaluation

Select burn victims may have medical claims against their homeowner’s policy or liability claims against other parties (i.e. landlord, driver of another vehicle, employer, manufacturer of a product, etc).  Causal and temporal relationships, treatment parameters and medical expenses can be defined to both parties to assist resolution of the claim.  Most burn injuries exceed the $1000-$5,000 medical limit on standard homeowner’s or auto policies. Therefore, most victims are reliant on their own health insurance (often limited to in-network surgeons) or settlements from third party carriers to pay for the treatment.  From a human empathy standpoint, quick resolution of the legal issues will grant the victim the funds to speedily proceed with necessary reconstructive surgery.

Comprehensive medical evaluation includes a thorough review of the past medical records and reconstruction of the events leading up to the catastrophic burn injury including detailed descriptions from the victim and witnesses of the specifics of the accident or vehicular crash—i.e. smoke inhalation,  deployment of the airbag, the functionality of sprinkler systems or smoke alarms, occupational exposure to electrical arc current or noxious gases, safeguards and servicing of the equipment or appliances, etc.   Specifics of the encounter are critical to the resolution of liability claims or third party compensation.

Case example: A 24 y.o. female sustained 23.5 % total body surface area flame burns during a house fire in a rented apartment. The patient was “asleep on the couch” while the fire was initiated in the kitchen, eventually consuming the entire apartment. Plaintiff’s attorney alleged that the “fail safe” mechanism on the stove was dysfunctional and the sprinkler system in the apartment was inoperative. My testimony at deposition detailing the incident and  confirming the causal relationship of the flame injuries to the burn deformities and disfigurement was used by plaintiff’s counsel in their action against the management company and stove manufacturer.

Review of Emergency Department Records

Review of the emergency department record is critical in evaluating lag time to treatment, extent of burn (as a ratio of total body surface area), depth of injuries (first, second, third, or fourth degree), loss of tissue, injury to deeper structures, and immediate resuscitative treatment. Hospital or burn center medical records are meticulously reviewed to determine course of treatment, operative intervention (debridement, grafting, bioengineered skin substitutes, escarotomy, etc) and unanticipated complications (sepsis, wound infection, respiratory distress, anemia, organ failure, etc)  Rehabilitation records document fabrication of custom compression garments, face masks, assistive devices/splints, and responses to joint mobilization and strengthening exercises administrated by the physical therapist. Debilitating hand injuries often require extensive occupational therapy or vocational retraining. Adaptation to activities of daily living are an important part of the rehabilitation process.

Subjective Findings Reflected in Records

During the medical evaluation, subjective findings related to impairment of physiologic activities of daily living are documented (chewing, fluid management, speech patterns, airway patency, smile symmetry, visual impairment,  lifting, grasping, fine dexterity, etc).  Burns of the head, neck and trunk are often extra sensitive to tight clothing, scarves, neckwear or environmental exposure.   Expressions of anxiety, fear of animals, recurrence of event nightmares, school performance, peer interaction, etc are elicited from patients and their families.  Referral to a psychiatrist or mental health care professional is often recommended to assess responses to injury and coping mechanisms. Family therapy may be necessary to assuage feelings of guilt, shame or rejection.

Clinical Examination and Objective Findings

On clinical exam, a quantitative analysis of each burn scar is documented including length, width, orientation.  The Vancouver Scar Scale (VSS) is used to assess scar vascularity, height/thickness, pliability and pigmentation.[15] Differentiations are noted between normal scar maturation and pathological hypertrophic/ keloid scars. Pain and pruritis (itching) are recorded.  Distortion of key facial structures (lips, eyelids, nose, and ears) are documented. With 3rd degree burns to the scalp or face, significant loss of hair (alopecia) may be evident. Limitation of joint mobility, scar contractures of the neck/shoulder/elbow/ knee/wrist, and digital webbing are measured and quantified.  High resolution studio photographs memorialize each of the scars.  Video monitoring using Mirror Imaging software (Canfield Imaging Systems Inc, Fairfield NJ) is utilized in documenting aberrations in dynamic facial or hand movements and to give the patient a “virtual preview” of surgical outcomes. In head and neck burns, a Frenchay Dysarthric Assessment (Pro Ed Publishers, 2008) of facial expressions is performed by a PhD speech pathologist if physiological function deficits are reported (see above paragraph).  Peri-ocular injuries are assessed by a board certified ophthalmologist.   All of these studies objectively quantify the extent of injury to the litigants and eschew subjective parameters of assessment.

Treatment Recommendations

Comprehensive treatment recommendations are included in the medical evaluation. Short term scar management may include a regimen of topical steroid creams, scar massage, intra-lesional steroid injection and application of silicone sheeting.  Long term solutions encompass innovative advances in burn scar revision surgery—laser technology, tissue re-arrangement, intra-operative and staged tissue expansion, microsurgical free flap reconstruction and post-operative scar management and camouflage that can improve the appearance and function of disfiguring burn scars.  Range of surgical options can be viewed on my website at http://www.facemakernyc.com/restorative-facial-surgery/burn-reconstruction/

Assessment of Disfigurement/Disability

A detailed medical report should answer the questions of causality, short/long term disfigurement, and permanency of scarring with a “reasonable degree of medical certainty”. Was there a causal and temporal relationship between the burn incident and the subsequent scarring?   Has the maturation of the scars reached a “plateau”? If not, when? What are the surgical and non-surgical options? Which option will offer the patient the most optimal opportunity for improved appearance and function? What will be the extent of the permanent visible scarring with or without surgery? Can the scars be “erased” in their entirety? Is there a need for life-time cosmetic camouflage make-up?  Are there associated systemic issues related to the catastrophic burn injury such as respiratory compromise, diabetes, heart disease, nutritional imbalance, bleeding disorders, kidney or liver dysfunction, or suppression of the immune system.?  Is there evidence of permanent functional deficits?  What is the effect of functional impairment on activities of daily living?  Is vocational retraining necessary? Will long term physical, respiratory, or speech therapy be necessary? What is the long term emotional impact of the burn injury on the patient and the family?  Is there evidence of PTSD?  Will the disfigured child or adult be subject to a lifetime of peer abuse, discomfort in social settings, and permanent loss of self-esteem?  Is there a need for a pain management specialist?  Will long term psychological counseling be necessary for “re-mirroring” of the body image? These are all issues that should be addressed in the medical report.

Estimate of Future Medical Expenses

The comprehensive report should include a detailed cost analysis of the anticipated medical/surgical costs. Each stage of the surgical reconstruction should be defined by procedure, location, and recovery time. Cost factors should include surgeon’s fee for each CPT code, anesthesia costs, hospital or outpatient surgery center fees.  Allowances should be made for pre-surgical testing, medical clearance, lab work, splints, face masks, post-surgical rehabilitation, and other vendors. Estimates should be included for para-medical costs such as lifetime camouflage make-up, aesthetician services, medical tattooing, or microfollicular hair transplantation (for eyebrow, scalp, or beard loss). Allocations for long term counseling should be deferred to the mental health provider. In the event that the patient does not elect to have surgical correction, allowances should be made for long term camouflage make-up and noninvasive scar reduction treatments.  Estimates of these costs will give the litigants a matrix to remove the “mystery” of fair compensation and more clearly define long term medical/surgical expenses in realistic terms.

Case example.   In the previously mentioned case of the 32 y.o. female, I meticulously described in video deposition the extensive burn scars of the face, neck, chest, breasts, upper and lower extremities, pointing to detailed photos of each. I opined that the scars had reached a “plateau” and would not improve without further reconstructive surgery. I outlined a multistage burn protocol including estimates of surgeon’s fees, anesthesia, hospitalization, facility fees, and recovery times. Allowances were made for future rehabilitation, life time cosmetic camouflage make up and psychological counselling.

Conclusion

The above is a broad overview of some of the complexities in evaluating catastrophic burn injuries and assessing long-term disfigurement and medical costs.  I am hopeful that better understanding of the nuances of scar evaluation and scope of surgical intervention will assist attorneys and others involved in evaluating and litigating these cases.

About the Author
Dr. Elliott Rose, a board certified plastic and reconstructive surgeon is currently Associate Clinical Professor in the Division of Plastic and Reconstructive Surgery at The Mount Sinai Medical School and an attending surgeon at The Mount Sinai Medical Center. Dr Rose’s international reputation in burn reconstruction, dog bite injuries and re-animation of the paralyzed face attracts patient from all over the world. He was voted by his peers as the Best Plastic Surgeon in New York City for “Corrective Facial Surgery” and is listed in the “New York Magazine Best Doctors” and “Castle Connolly America’s Top Doctors.”. Dr. Rose has also appeared on ABC’s “20/20” and “Good Morning America”, NBC’s “Today Show”, “Entertainment Tonight”, Fox News Network, as well as numerous local news segments in NYC. Dr Rose is a member of numerous professional societies including the Aesthetic Society, the American Burn Association, and both the American and World Reconstructive Microsurgery Societies. He was on the international editorial board of the Journal of Reconstructive Microsurgery and is a frequent reviewer for the Journal of Plastic & Reconstructive Surgery. Dr Rose is an invited Fellow of the prestigious American Association of Plastic Surgeons. In addition to his 40+ peer reviewed papers and over two dozen book chapters, Dr Rose is author of a textbook entitled “Aesthetic Facial Restoration” that is considered the “landmark text on enhancing appearance and correcting functional impairment…..” (Lipincott-Raven Publishers, 1998). Dr Rose uses his extensive clinical skills in objectively evaluating victims of burns, dog bites, facial trauma and providing expert testimony in future medical treatment/ prognosis/ medical costs.

Elliott H. Rose, MD acts as an expert witness in catastrophic burn injuries and other cases invlolved with cosmetic and plastic surgery. He can be reached at 212/639-1346 or  erose@facemakernyc.com.

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[1] “Burn Incidence and Treatment in the United States: 2013 Fact Sheet.” American Burn Association http://americanburn.org/resources_factsheet.php

[2] Sources: National Inpatient Sample (HCUP-NIS: 2010 data); National Hospital Discharge Survey (2010 data); recent 100 % hospitalization data from several states.

3-5 Source: American Burn Association National Burn Repository (2013 report)

6“Burn Incidence and Treatment in the United States 2012 Fact Sheet” American Burn Association.  http://www.americanburn.org/resources_factsheet.php

7,8 “Burn Incidence and Treatment in the United States: 2013 Fact Sheet.” American Burn Association http://americanburn.org/resources_factsheet.php

 [8] “Residential Building Fire Trends 2012.” U.S. Fire Administration National Fire Incident Reporting System. http://www.usfa.fema.gov/downloads/pdf/statistics/res_bldg_estimates.pdf

[9] “Non Residential Building Fire Trends 2012.” U.S.  Fire Administration National Fire Incident Reporting System. http://www.usfa.gov/downloads/pdf/statistics/nonres_bldg_fire_estimates.pdf

10,11 “Fire Deaths and Injuries: Fact Sheet.” Centers for Disease Control and Prevention. U.S.Department of Health and Human Services. http://www.cdc.gov/homeandrecreationalsafety/fire-prevention/fires-factsheet.html

 12,13 Sadeghi-Bazargani H, Maghsoudi H, Soudmand-Niri M, Ranjbar F, Mashadi-Abdollahi H. Stress disorder and PTSD after burn injuries: a prospective study of predictors of PTSD at Sina Burn Center, Iran. Neuropsychiatr Dis Treat 2011; 7:424-429.

 [14] Gunsberg L, Rose EH. Psychological effects of facial disfigurement. In Rose EH (ed). Aesthetic Facial Restoration. Philadelphia: Lippincott-Raven Publishers, 1998.

[15] Nedelec B, Shankowsky A, Tredgett EE. Rating the resolving hypertrophic scar: comparison of the Vancouver Scar Scale and scar volume. J Burn Care Rehabil. 2000;21:205–12.