Burn Care for Bhutan

by Clare Hagerty

Globally, burns are a serious public health problem. More than 195,000 deaths occur annually worldwide from fires alone, according to the World Health Organization, and burn fatalities are among the leading causes of death for children and young adults between the ages of 5 and 29.

Of these fire-related deaths, more than half take place in Southeast Asia, and females in this region account for the highest burn mortality rates globally. Open fires used for cooking and heating in rural areas are a major cause of burn-related injuries and deaths. In addition to those who die, millions more whose wounds go untreated face lifelong disfigurement and disability — often accompanied by stigma and rejection.

One place where this grim reality is evident is in the beautifully bucolic and mountainous Kingdom of Bhutan, secluded in the Eastern Himalayas between Tibet and India. That’s where a Harborview Medical Center team, led by renowned burn surgeon David M. Heimbach, M.D., now retired from UW Medicine’s Department of Surgery, has joined other healthcare professionals from around the world to care for burn patients, share best practices, and train Bhutanese providers in the latest burn treatment methods. Together, they are fundamentally changing burn care in Bhutan.

The Global Burn Care & Reconstructive Institute comprises a number of UW Medicine personnel; the team is seen here in the Himalayan foothills of Bhutan in May 2011. The back row includes Sam Sharar, M.D. (far left), David Heimbach, M.D. (third from left), Bhutan Secretary of Health Dr. Gado Tschering (fourth from left ), and institute founder Margrit Elliot, R.N. (fifth from left). The front row includes Fran O’Donnell, R.N. (second from left) and Debra Ford, R.N. (third from left). Other members came from Washington, California and Italy to join the team.

“If we’re going to make an impact on burn care around the world, we have to make it sustainable,” explains Heimbach, a former president of the International Society for Burn Injury, who also was honored as an “Unsung Hero of Compassion” by the Dalai Lama in 2009. “One way to do this is to teach caregivers in other countries how to care for burns.”

Since 2008, that’s exactly what staff from the UW Medicine Burn Center at Harborview have been doing. Each year, they travel to Bhutan’s capital city of Thimphu as part of the Global Burn Care & Reconstructive Institute, a nonprofit volunteer medical services group founded in 2001 by Margrit Elliot, R.N., a retired nurse from La Conner, Wash. Elliot’s volunteer work in Bhutan, Tibet and China, which began in the late 1980s, had first focused on surgeries to repair cleft palates. “But, based on the number of burn victims we encountered throughout the years, it became evident that initial burn care was very much needed,” she explains.

When Elliot heard Heimbach’s 2002 presidential address to members of the International Society for Burn Injuries — in which he addressed the huge gap in global burn care —she knew she’d found the right partner to make her mission a reality. After approaching him with her idea, Heimbach said he realized, “if I’m going to practice what I preach, I need to do this.”

During a subsequent fact-finding trip to Bhutan, Elliot and Heimbach met with the Bhutan minister of health — a meeting that resulted in an invitation to set up a reconstructive surgery program to treat burn patients.

“We set the tone by respecting the culture, being good listeners, and understanding interactive participation,” Elliot recalls. “We agreed it would be best if the team was kept small, and that continuity and training were key elements.”

Under Elliot’s leadership, this team of doctors, nurses and therapists has been instrumental in the development and design of a new hospital in Thimphu with a burn care unit, which opened in November 2010 and is slowly building its staff of trained providers. Funded through the generous support of charities, foundations, rotaries and private donors, the Global Burn Care & Reconstructive Institute has purchased equipment for the hospital and paid travel expenses for the patients who travel long distances to reach its doors.

“Dr. Sam” Sharar administers anesthesia to a three-year-old boy prior to surgery. The child sustained multiple burns after saving his puppy from a fire.

Since its formation, the institute has organized an annual trip to Bhutan to treat burn patients and to train local providers from across the sparsely populated country. Several visits have featured educational workshops led by Harborview Burn Center staff, including one in 2008 that was videotaped for the Bhutan national television network. In turn, Bhutanese providers have travelled to Seattle for a month-long observational training at Harborview — learning the latest procedures, and how to adapt and translate these techniques into better care and outcomes for burn patients in Bhutan.

Each trip to Bhutan lasts about two weeks — to ensure patients heal as fully as possible before the team departs — and involves evaluating anywhere from 60 to 100 potential burn surgery patients. Of the 62 patients evaluated during the most recent trip in May, 32 underwent surgery.

Sam R. Sharar, M.D. ’83, Res. ’85, ’86, ’90, Fel.’91, a UW professor of anesthesiology based at Harborview, has been traveling to Bhutan as part of the Harborview Burn Center team since 2009.

“The patients we see fall into three categories,” Sharar says. “Acute burns, meaning patients show up with very recent burns, kids with post-burn scars due to open-flame accidents that were never treated, and adults who’ve sustained burns as children and then suffered contractures, sometimes for decades, and have learned to function with those disabilities.”

Disabling post-burn contractures form when burns go untreated, resulting in a shrinking — or contracting — of the scar tissue. This shrinking can cause lifelong deformities and severely restricted movement.

That was the case with 5-year-old Dema, who traveled with her family from rural Trashiyangtse in the northeastern corner of Bhutan, a three-day journey from Thimphu.

Like so many of the burn patients seen by the institute’s team, Dema traveled to Thimphu’s new hospital at the request of Bhutan’s 31-year-old ruler, King Jigme Khesar Namgyel Wangchuck. A steadfast supporter of the institute’s work, the king made sure word got out to local villages that burn-care screenings would be taking place. For many, that meant a three-day walk just to get transportation to carry them along Bhutan’s single road to the capital city.

The burns on Dema’s right palm and fingers were the result of an accident caused by a cooking fire when she was nine months old. With time, the burn healed, but the contracture scars that held her third, fourth and fifth fingers flexed tightly against her palm made her right hand essentially non-functional.

Five-year-old Dema recovers from surgery on her hand, burned in a cooking fire accident when she was nine months old.

Enter Heimbach, who, together with local Bhutanese general surgeon Dr. Tashi Dendup, Sharar, and Harborview Burn Center nurses Fran O’Donnell, R.N., and Debra Ford, R.N., worked to restore functionality to the child’s right hand. The surgeons were able to release her third and fourth fingers, apply skin grafts, and amputate her deformed fifth finger. Five days later, her dressings were removed to reveal healthy skin grafts to her palm, and she began physical therapy to regain use of her fingers.

Dema’s is just one of hundreds of burn treatment success stories that have resulted from this reciprocal partnership. From a three-year-old boy who saved his puppy from a fire, to a young woman burned on her face and arms by a propane stove that flared unexpectedly, each case is a new opportunity to help patients heal and to teach local providers the finer points of surgical and post-operative burn care.

“A burn is forever and, if not cared for properly, it becomes a huge problem,” Heimbach says. “We are very encouraged by the work we’ve been able to do in Bhutan, as well as at Harborview, with this dedicated team. And we hope we can continue this partnership — and our wonderful friendship with the Bhutanese people — for a very long time.”

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