Andrew Burd on elbows and burning babies

How do you test the temperature of the water before you give a young infant a bath in a basin? This is breaking news in Hong Kong. A few days ago a nurse was giving a baby a bath in a hospital ward. Before I continue I must emphasize that all that is included in this blog is in the public domain so no confidential information is being released. The baby is three months old. The nurse poured in cold water and then added hot water. She mixed the water with her hand until a comfortable temperature was reached. She then bathed the baby washing head, face and trunk whilst the baby sat in the bath. Then whilst drying the baby she noticed blisters on the buttocks and soles of the feet. Another nurse was called and then a doctor and a diagnosis of a scald injury was made. The baby was transferred to a PICU in another hospital and was reported to be suffering from ~14% BSA partial thickness burns. The media has been rife with speculation and the angry parents are demanding the nurse should be sacked and they want financial compensation. The Hospital Authority realizing the sensitivity of the issue appointed an expert panel to review the situation and they reported yesterday. This morning the headlines announce that the nurse has admitted her error in not testing the temperature of the water with her elbow before bathing the baby and is duly resigned to be disciplined.

So let us back track. An accident happens while a patient is in hospital. The patient is a young child. The accident results in a burn and the parents are quite understandably upset and distressed. Anger is a common emotion we see in parents of children admitted with burns. The carer? We do not have information in the public domain on the emotional state of the nurse but again with reference to the many thousands of burn injuries that I have treated there will be anguish, guilt, regret, remorse but also confusion. How did this happen? This was not the typical accident such as a cup of hot tea being spilt. This was a nurse who had bathed babies in a routine way for over a year but on this occasion a burn occurred. The investigation panel focussed on “the elbow test.” What is the background to this test? Well this where it gets interesting. I have been busy on the internet and also canvassing opinion from the world’ s leaders in burn prevention. What is the evidence for the “elbow test?” Frankly, none. Indeed it is potentially dangerous. The often repeated statement is that the elbow skin is more sensitive to temperature than the hand. Not true. For those who do not know what “the elbow test” is you can see the picture in the following link.

It is unfortunate that so much attention has focused on this as it is another of those dubious practices that lurches from text book to text book with no evidence to support a greater sensitivity to heat in the elbow than the wrist or hand. It is more a counter intuitive response to school day experiments when you put one hand in cold water and one hand in warm water and then put both hands in temperate water and the hands detect a different temperature of water!

We have just held a burn prevention symposium in our hospital and prepared posters to give out. We have committed ourselves to saying, “Test the temperature of the water with the hand “. The Mayo Clinic online recommends, “Test the temperature of water with the hand.” The members of the prevention committee of the International Society of Burn Injury recommend testing the temperature of water with the hand. In the Hong Kong Burn Association website that we developed we say use the hand to test the temperature of the bath water. I do not want to start a fight here but I cannot rest easy to see nonsense being peddled by the press which is essentially being pushed by professionals for political expediency. For all “elbow testers” out there, please look up “sensory homunculus” and compare hand and elbow. So let me end as I began: How do you test the temperature of the water before you give a young infant a bath in a basin? Respond, please, with evidence if possible.

Andrew Burd, Hong Kong, 30 April 2010

Conflict of interest statement. I declare I have no conflict of interest in this blog. I have not been involved in the care of this baby. My first concern is that the baby recovers with the minimum of long term sequelae; I feel deeply for the anguish of the parents and hope that they can move on from their anger and focus on their child’ s well-being; and the poor nurse? There but for the grace of God go many of us involved in hospital practice and my concern for her well being is sincere and genuine. Finally, I am proud to be part of the Hong Kong healthcare system and appreciate the humanity and compassion of the Health Authority in dealing with this very difficult issue in a prompt and sensitive way. It is just a matter of regret that perhaps too much attention has been focussed on ‘the elbow test’ which has the credibility of many urban myths. But let me see who comments on this blog, I am always prepared to be corrected.

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.