27 Sep, 11 | by BMJ Group
A story has just emerged in the local press about a 30 year old woman from Guangdong province (just across the border from Hong Kong) who sustained 85% deep burns in an agricultural accident. The reason this unfortunate burns patient became the focus of publicity is that she is HIV positive and that has led to her being refused treatment in three different hospitals. Details are scanty regarding the original route of infection although there are a significant number of HIV positive patients in China related to blood transfusion contamination. Whatever the case the hospitals concerned raised the issue of risk to health care workers from dealing with an extensive burns patient with a socially stigmatised infectious disease.
Reading this story took me back to my days in the UK where, as director of the burns service at Frenchay Hospital, Bristol, I was invited to take part in teaching ethics to the first year medical students at the University of Bristol.
For those who are not aware of the association, one of the key clinical cases which has helped to define modern day medical ethics relates to a young man who sustained extensive burns. The “Dax” case really brings into focus the concepts of patient autonomy, (the patient wanted to be allowed to die), beneficence, and non-malficence (the doctors didn’t want to let him die). “Dax” did not die and survived to become a lawyer and a powerful and eloquent supporter of the “right to die” movement in America. Professor Alistair Campbell (now in Singapore) was the inspired teacher of medical ethics at Bristol and used the “Dax” case to open the eyes of the new medical students to the ethical dilemmas inherent in professional practice. I was there to share the reality of burns with students. Like all burns surgeons I have my portfolio of distressing pictures. I shared some successful outcomes, some poor outcomes, and indeed some fatalities to emphasise the labour intensive, physically arduous, and emotionally draining reality of dealing with complex major burns.
But one year I did even better. I brought a patient along to the lecture; quite an extraordinary patient who was an ex-public school educated young man who had fallen into bad times and had contracted HIV. He was a passionate and eloquent speaker and spoke openly, honestly, and factually about his life and experiences, particularly as a burn patient.
Let’s give this patient a name, but not his real one of course. “Art” had HIV and was on triple antiretroviral therapy. From time to time he would go “on a bender” and he was known to the police in his home town. After one fracas he was arrested, hands cuffed behind his back, and put in the back of a police van. ”Art” had a cigarette lighter in the back pocket of his jeans and managed to get it out and whether by accident or design set himself alight. His shouts and screams were initially ignored by the police as that was “Art” acting up. But the smoke was different and it was two very subdued policemen who diverted their van from the police station to the local hospital. ”Art” was eventually admitted to my unit with over 30% body surface area (BSA) full thickness burns of both arms and his back.
My policy of dealing with extensive full thickness burns has always been an early total burn wound excision at fascial level using coagulating diathermy. Although it takes time this is a very safe and effective technique to convert a burns patient into a surgical wound patient with far less morbidity and mortality. The question then was how to close the wound? Typically for a 30% BSA wound, I would use meshed autograft covered with sheet cadaver skin. I was concerned about the risk to my surgical team of the grafting aspect of the burn management and sought to eliminate/minimise the risk by closing the wound with a tissue engineered dermal regeneration template, Integra, which had recently become available in the UK. The problem was expense and the chief executive of the hospital together with the nursing and medical directors regarded the expense of Integra outweighed the risk to my staff. In the end we operated with a team of volunteer’s i.e. I did not allow our young and single junior surgical and nursing staff to assist and asked the senior staff to discuss the potential risks with spouses and or an infection disease counsellor before volunteering. The operation progressed smoothly and lasted for over six hours and then in the last few minutes; my first surgical assistant had a needle stick injury. It was a closed “needle” but she drew blood and everyone witnessed it. Dilemma indeed and that is another story but “Art” survived and shared his story with the students. I do wonder what those first year students made of this. The sex, drugs, and recklessness of a very well educated young man; HIV, burns, personal, and professional ethics and distributive justice. I am happy to say that my surgical assistant survived but not without considerable hardship as she was a freelance worker.
We were lucky, though, to have the mechanisms for dealing with the HIV positive burns patient. This should not be such a big deal and in some parts of the world e.g. in South Africa the combination of burns and HIV is not uncommon.
The ethical basis of medicine in mainland China is still evolving and refusal to treat individual patients is an option for hospitals. The counterpoint to this is another very distressing recent story about a leading ENT surgeon in Beijing who was viciously attacked by an ex-patient with head and neck cancer. Chinese medicine, of the Western variety, still has great room for improvement both in fundamental ethical principles related to duty of care manifest by the providers, but also in terms of honesty, trust, and respect for health care workers manifest by patients and relatives.
Andrew Burd is professor of plastic, reconstructive, and aesthetic surgery at the Chinese University of Hong Kong. His major clinical interests involve paediatric burns care and the role of plastic surgery in the palliation of advanced malignancy. Academic interests include pragmatic ethics related to the practice of medicine including research and publication.