What's it like on a typical day in one of the busiest parts of Children's Hospital? My associate, Beth Schwinn, found out recently in the burn unit. Her report:
The burn unit is scrambling to get patients ready for rounds this Tuesday morning. Most of the kids were admitted over the weekend, three unrelated cases arriving in one hour. The unit is so full that two patients are on another floor. Some children are crying, but the parents are quiet and tense. Most don't know yet whether their children will need surgery.
Joan Holihan, the director for burn unit nursing services, is at the center of one cluster, trying to answer three questions at once. Parents, children, nurses and residents are eddying about her, but her greeting is calm. She leads the way to the first patient the burn team will see, a 6-month-old girl.
Such chaos is typical of the 12-bed, 28-nurse burn unit at Children's Hospital, where the 250 patients it sees each year arrive in clusters with the seasons. During cold weather, the ward tends to fill up with injuries caused by hot drinks and heaters, the most common causes of burn injuries.
Spilling a cup of coffee is not a catastrophe for an adult, says Joan. But it can cause extensive third degree burns in a child. "One cup of coffee can put a child in the hospital for two weeks," she says.
"Every burn center has a different treatment technique," says Joan. "Here, we used the closed technique, where the burn is kept covered. Children are more comfortable when the burn is not exposed to the air. They don't have to be in isolation; parents don't have to wear gowns and masks. We try to keep the environment as normal as possible." The drawback to the closed technique is the need to change the dressing daily.
Joan helps the baby's primary care nurse, Elaine McDaniel, change the dressings on her chest and side. Tubes run to different pieces of equipment. One collects urine, so the staff will know if the child becomes dehydrated; one feeds formula through its nose into its stomach. An IV feeds nutrition directly into the blood. "Complications are the rule rather than the exception with burn injuries," Joan says, and they try to anticipate these when possible.
The baby's mother spent the night on a cot in the room, reports Elaine, because "she is blaming herself for what happened." The burn was caused by water that suddenly changed temperature during the baby's bath when the laundry machine in the house went into a cold rinse cycle. But the mother removed the child from the water within seconds, so the burn will heal.
The baby is not disturbed by the people around her, but she begins to cry as Elaine removes the dressing and gently washes the burn area. Many children have an object that represents security for them, Joan explains, and for this baby, security is a slightly rumpled cloth diaper that she won't let go of. She pulls the diaper over her head so she won't have to look at us.
Next to the burn itself, this washing, and the air on the wound when the dressing is removed, are the most painful parts of treatment. The sound of children crying or screaming is a constant accompaniment to daily dressing changes. Children are often readmitted to the burn unit when parents cannot bring themselves to continue the daily treatments at home.
Changing dressings, and the pain it causes a child, is the toughest part of the job for burn nurses, whose turnover rate is high in most hospitals.
"You know that if you withhold treatment, they stay in longer," says clinical manager Maria Morrison. "You do see them get better, and that's what keeps us going."
Turnover among nurses on the Children's burn unit is average compared to the rest of the hospital. Nurses average two years on the unit; the longest stay to date is nine. Joan attributes this to camaraderie among the nurses, the team approach on the unit and the fact that the nurses in this and other high-stress areas have group meetings with Rosemarie Scully, a psychiatric nurse clinical specialist who also deals with parents.
The nurses say that kids will do anything to avoid treatment, from dawdling over breakfast or taking a trip to the bathroom to cursing, threatening, kicking, pinching or biting the nurse, vomiting or defecating in the whirlpool.
Often, however, such sessions are followed by apologies. "Most kids actually don't leave with bad feelings. They like to visit, and are very affectionate. Parents also like to visit," said Elaine, who used to work in another part of the hospital but feels she is having a greater impact here.
Joan has worked at Children's for eight years, ever since she finished her masters' degree at Catholic University. She had always planned to do well-child care as a pediatric nurse practitioner, visiting patients in their homes, but found herself returning to the burn unit while working on her degree.
Burn rounds on this Tuesday are a chance for doctors and specialists, including physical therapists and a plastic surgeon, to evaluate the progress of each case and the treatment the child will need. Children who may need surgery are identified here.
The staff says little in the rooms. They discuss each case in the hall before examining the patient. In two cases, where the situation that caused the injury is unclear, the possibility that the child was abused is discussed.
A 1982 study found that 13 percent of the unit's admissions were documented victims of child abuse. The actual percentage, staff says, is probably higher. "Often you can tell because the way they tell you an injury happened isn't consistent with the appearance of the injury," said Joan.
The team moves into a meeting room. They discuss the children who will go home, and those who will have to stay because the parents have not been able to change the dressings during training. Throughout the meeting, each staff member adds his or her views. Maria Morrison mentions later that this strongly cooperative team is one reason the burn unit is a positive place to work. There is little tension between doctors and nurses. "Joan is like the glue that holds this team together," she says.
The hospital has mounted an extensive effort to reduce burn injuries in children through family activity kits that show children which areas in the home to avoid, and include information for parents. The kits are available free from Giant Food (341-4502), which is cosponsoring the campaign with the Washington Bullets. More than 20,000 kits have been distributed to date.
The atmosphere in the burn unit is louder and more active than in the rest of the hospital. It resembles an elementary school playground at recess. As soon as treatment is over for the day, the children, healthy except for their burns, are free to exercise and play (subtly directed by child life specialists or physical therapists).
"Often, they come in my office and want to know who I am," reports Joan. "They don't understand how I can be a nurse, since I'm not all in uniform (she wears a lab coat over street clothes unless she is on strict patient care). In fact, since I don't look like a nurse, I think they consider my office a 'safe' area, and like to stay in here."
Dinner is approaching, and Joan is preparing to go home after a 10-hour day. Outside, dinner is being prepared. Since nutrition affects how quickly burns heal, meals are an event here. The children all gather around a large table laid with a tablecloth, family-style. Nurses are busy in each room.
"Friends always ask me how I can stand to be on a burn unit," Joan says. "I stay because there's an awful lot for nursing to do here." TO CONTRIBUTE TO THE CAMPAIGN:
Make a check or money order payable to Children's Hospital and mail it to Bob Levey, The Washington Post, Washington, D.C., 20071.