ASSESSMENT OF FAMILY PHYSICIANS' KNOWLEDGE AS AN INDICATOR OF BURN MANAGEMENT KNOWLEDGE AMONG NON-BURN PRACTITIONERS IN ISMIALIA, EGYPT

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1 ASSESSMENT OF FAMILY PHYSICIANS' KNOWLEDGE AS AN INDICATOR OF BURN MANAGEMENT KNOWLEDGE AMONG NON-BURN PRACTITIONERS IN ISMIALIA, EGYPT Moghazy A.M.,* Kamel M.H., Farghaly R.M. Faculty of Medicine, Suez Canal University, Ismalia, Egypt SUMMARY. The management of burns within the first hours of injury has a significant impact on mortality and morbidity. In case of burns disasters, most patients are managed by non-burn practitioners. The knowledge held by our local family physicians is thought to be representative of that of non-burn practitioners, as they had not partaken in any courses or training on burn management beyond graduation. With regard to emergency burn management, the knowledge required is: assessment of burn extent and depth, associated injuries, indications of escharotomy, fluid therapy and airway management, as well as safe transportation. The aim of this study therefore was to assess the knowledge of family physicians - as an indicator of that of non-burn practitioners - on emergency burn management, and design accordingly an appropriate burn educational program. An interview questionnaire was distributed to all physicians working in Family Medicine Centers in Ismailia, Egypt, who did not possess a post-graduate degree. A total of twenty-four family physicians (100%) participated in this study. The questionnaire findings showed that, out of a possible score of 25 correct answers, the highest result was 12; achieved by 6 physicians (25%). The highest frequency score was 8 correct responses; obtained by 10 physicians (29.2%). This demonstrated a knowledge deficit among Ismailia s family physicians, and subsequently non-burn practitioners, with regard to burns management, due to gaps in undergraduate teaching. Keywords: family physicians, non-burn practitioners, burn education, emergency burn management, knowledge assessment Introduction Burn is a specific type of trauma; its emergency management has some particularities that should be considered by the first respondents. As our region s family medicine physicians had not participated in any post-graduate training on this subject, they represented first respondent nonburn practitioners. The assessment of knowledge of nonburn practitioners is extremely important in establishing preparedness for burn disasters. In general, all burns cases are transported directly to the health facilities where there is a burn unit or center; either by ambulance or private unequipped vehicles. As there are few specialized burn care facilities, most burn patients involved in major accidents or disasters are attended to by non-burn specialists who might never have treated a burns patient before. It is therefore of prime importance that these physicians receive the most appropriate education and training for safe and effective emergency burn management. As the first hours management in burns has a significant impact on mortality and morbidity, 1 all non-burn practitioners should be aware of their role in this crucial period of the victim s life. Moreover, they should have sufficient knowledge, and preferably the appropriate skills, to implement emergency burns treatment even with the limited resources available. Life and limb saving procedures, as in all cases of trauma, are the first that should be taught to all health professionals. They should master the indications and preferably the techniques necessary to perform these procedures. Moreover, the conditions that might endanger the life of the victim should be properly and rapidly diagnosed by the first respondents. 2 In burns, the main procedure that might be life and limb saving is the escharotomy. It is a relatively simple and safe procedure, conducted without anesthesia and with minimal instrumentations; it could therefore be carried out safely at any health care facility. The other limb saving procedure is the fasciotomy; a much more complicated procedure that requires experience, skills and various equipment. Fortunately enough, it is very rarely practiced, being applied principally for cases of high voltage electric burns. * Corresponding author: Dr. A.M. Moghazy, Associate Professor of Plastic Surgery, Department of Surgery, Faculty of Medicine, Suez Canal University, Ismalia Ring Road, Ismailia, Egypt. Tel.: +20 (0) ; moghazy@med.suez.edu.eg; moghazy@yahoo.com 1

2 Fluid therapy is the corner stone of emergency care in moderate to major burn treatment. It can be initiated anywhere without sophisticated equipment or maneuvers. Although emergency airway management is not usually necessary, a cricothyroidotomy is enough to save a patient s life in most cases. This technique is ideal as it is simple, safe and can be carried out easily by general practitioners. Still, if the more sophisticated technique of endotracheal intubation could be done, or at least its indications are well known, the management would be more effective. In rare instances, airway and respiration management in burn patients is complicated; this is only when the burn is associated with inhalation injury or other trauma. 3 The transportation period is also an important phase in burn management. When this period is well managed, the outcome of the burn patient is significantly enhanced. 4 Therefore, knowledge assessment of non-burn practitioners, represented by family physicians, is important in evaluating preparedness for major burn accidents and disasters in Ismailia. Furthermore, this assessment will determine the knowledge gaps and defects which will be the main content of their burn education module. Candidates and methods The study population was the physicians working in the Family Medicine Centers within the Ismailia Governorate who did not have any post-graduate qualifications. The sample size was comprehensive including all working physicians. There was no exclusion criterion for this study. Data collection was carried out via a questionnaire (Annex) that was approved by the Faculty of Medicine, Suez Canal University Ethical Committee on February Reliability and validity of the tool The questionnaire was based upon two already validated tools: the questionnaire and the Burn courses to General Practitioners implemented during the activities of the burn project. 5 There was no need to test the reliability of the questionnaire as it was based on the same two tools that were already assessed for reliability. In addition, the second author was always present with the candidates to explain its items and reply to any inquiries. The questionnaire was designed as short modified essay questions. The open-ended question format was chosen over multiple choice questions because it allows for better simulation of actual practice: when the physician sees a patient, there is not a limited set of options to choose from; physicians must rely on their retained knowledge to deal with the situation. To avoid subjectivity, candidates were asked to give short precise answers referring only to the core data requested. For grading purposes, each item was considered as a separate question so that, for example, a question comprising four items, would count as four questions. The grading for such a question therefore would be calculated out of four according to the number of correct responses; for example, two correct answers were calculated as two out of four and so on. The responses were considered either correct or incorrect based on knowledge provided in the undergraduate study course. Nevertheless, any appropriate alternative responses were also considered correct. An example is the resuscitation formula: the recommended formula of our center is Parkland s formula, but any other formula, mentioned in its correct form, e.g. Brooke s, Modified Brooke s, Evan s, and so on, was considered correct. During their work in the Centers, the candidates were informed about the study and its objectives. After accepting to participate, the candidates signed the consent and had a brief explanation about the questionnaire s content before answering it. Results The total number of physicians working in Family Medicine centers in the Ismailia governorate was 24; all of them accepted to participate in this study. The data collection period was from March to May The results revealed that 22 of the participating physicians were graduates of Suez Canal University Medical School. The year of graduation is shown in Table I. Table I - Frequency of physicians per graduation year Graduation year Frequency (total = 24) Percent Before About two thirds of the graduates mentioned that undergraduate burn courses were partially sufficient to deal with burn patients (Table II). This was roughly the same Table II - Physicians opinion about sufficiency of undergraduate burn course Degree of sufficiency Frequency (total = 24) Percent Insufficient Partially sufficient Sufficient

3 portion of physicians who felt partially confident of their ability to manage burns (Table III). Table III - Physicians confidence in their abilities of initial burns management Degree of confidence Frequency (total = 24) Percent Unconfident Partially confident Confident Only one physician (4.2%) had received training in burn management. Similarly, only one physician (4.2%) had seen a case of burns during his practice as a family physician. Three physicians were not convinced that burn management is one of their responsibilities. Most of the participants limited their role to the first aid (Table IV). Table IV - Physicians opinion about their main role in burn management Role in burn management Frequency (total = 24) Percent First aid Health education Emergency treatment First aid and Health education First aid, Health education and Emergency treatment Out of a total of 25 questions the highest number of correct responses was 12, which was scored by 6 physicians (25%). The most common number of correct responses was 8/25, which was achieved by 10 physicians (29.2%). (Table V). Table VI - Details of the answers of the family physicians Question Right answer Wrong answer (percentage) (percentage) Enlist the most important cause of death in the following periods: First few hours (< 1 day) 9 (37.9) 15 (62.5) Enlist the most important cause of death in the following periods: First few hours (< 3 day) 2 (8.3) 22 (91.7) What is the easiest way to assess the extent (percentage) of Burns 19 (79.2) 5 (20.8) Mention the most reliable method for diagnosing the Burn depth (Degree) 7 (29.2) 17 (70.8) What is the most suitable substance, available at home, to be applied on a burn until the patient reaches the Family Practice Unit? 22 (91.7) 2 (8.3) What is the main indication for fluid therapy in Burns? 0 (0.0) 24 (100.0) How could you calculate Burn fluid therapy ( 3 questions) 0 (0.0) 24 (100.0) What is the fastest way to by-pass upper respiratory airway obstruction 1 (4.2) 23 (95.8) Name the surgical procedure you should master for fluid therapy 2 (8.3) 22 (91.7) What other surgical technique(s) you should master for management? 24 (100.0) From the etiological point of view, what is the most dangerous Burn 9 (37.5) 15 (62.5) Mention the analgesic of choice in case of Burns 4 (16.7) 20 (83.3) Mention five criteria for referral of burn cases 4 (16.7) Enlist four precautions that should be done before transporting the burnt patient. 3 (12.5) Table V - Frequency of correct answers in the studied population Score (out of 25 items) Frequency (total = 24) Percent Mean ±SD 7.3±2.7 Table VI demonstrates the frequency of right answers for each question. Details of the scoring of the complex questions number 14 and 15 are shown separately in Fig. 1. Fig. 1 - Frequency of number of correct points listed (referred to as either one, two, three, four or five) in response to questions 14 ( Mention five criteria for referral of burn cases ) and 15 ( List four precautions that should be made before transporting a burn patient ). 3

4 The highest score attained according to graduation year was in the promotions of 2006 and Details of these scores are shown in Table VII. Table VII Scores according to graduation year Graduation year Mean ±SD P-value Before ± ± ± ± ± ±2.0 * P-value of 0.05 is statistically significant at 95% confidence level. Discussion Family physicians were chosen to represent non-burn practitioners as they had no courses or training in the domain of burns after their graduation. The principle of choosing a particular category to represent all non-burn practitioners is a well known and documented method to assess non-burn practitioners knowledge in High, as well as Middle and Low income countries. These studies have chosen General Practitioners (identical to family physicians) and emergency physicians. 6-9 Barillo 10 stated that non-burn practitioners usually see the burn patient for the first time in their professional life in cases of major burn accidents and disasters. This was confirmed by the results of the present study as only one physician, out of all 24, had encountered just a single burns case during his whole time of practice. Our belief is that burn management training for family physicians, as well as other non-burn practitioners, who might be the first respondent in major burn accidents and disasters, is of strategic importance. This belief was supported by Barillo, who recorded that in these circumstances, most deaths occur either at the scene, during transportation or shortly after arrival at a specialized burn care facility; 10 denoting bad initial management. We also believe that this training seems to be the most effective way to improve burn care with minimal resources and in a short time. Our belief is supported by several authors. 6,11 This is further supported by Fadaak, 7 who stated that most burns could be managed safely by a non-burns specialist. He based his statement upon the international practice reports stating that most patients are transferred due to lack of practice of the first respondent physician rather than the severity of the case. In addition, reducing the transportation would alleviate the heavy financial impact of burn care and would be more convenient to the patient. 10 As most minor and moderate burns could be managed safely by non-burn practitioners, 12 popularizing this practice would help much in reducing the overcrowding in the specialized burn centers. These impacts are of utmost importance in enhancing burn care strategy particularly within developing countries. 13,14 Our main objective was to assess whether nonburn practitioners could safely and effectively manage burns patients throughout the first 24 hours and until they reach their final destination. This explains the similarity between the knowledge requested in our study and that of Alharbi et al.; 9 with some modifications to account for differences in the circumstances. Our questionnaire contained the main core knowledge proposed by Bezuhly et al., 8 aimed at assuring safe care of burns patients by emergency workers during the critical period. Finally, our questionnaire was very similar to that proposed by Kut et al., 15 who carried out a similar work in Turkey to assess the knowledge, attitude and skills of occupational physicians concerning burn management. Most of our candidates were young; 79.2% (19 physicians) graduated after The explanation of this is the fact that specialized and experienced family physicians are in high demand and well paid in the Gulf area. Therefore, the present physicians (candidates) were for the most part newly employed graduates. The low scores achieved by the family physicians concords with similar studies carried out in High as well as Middle and Low income countries assessing the knowledge of General Practitioners (identical to family physicians) and emergency physicians. 6-9 These low scores achieved in our studies were matched and confirmed by the opinion of the candidates themselves who stated that they were partially satisfied from their undergraduate burn education and training. In our study, the highest number of correct responses concerned burn wound first aid (91.7%) and the assessment of the extent of burns (79.2%). The lowest score concerned fluid therapy (0%). The reason for this might be the simplicity of first aid knowledge making it easy to retain (running water for first aid and patient hand size for percentage). On the contrary, fluid therapy includes more details that are more easily forgotten over time. The encouraging result is that those who graduated in 2006 and 2007 showed higher scores; these were the students who had attended the burn workshops held during the burn project. 5 This denotes that interactive methods seem to be more effective in improving burn management knowledge and awareness. Conclusion and recommendations Family physicians, and subsequently non-burn practitioners, are deficient in their knowledge of burn management. This is in concordance with results all over the world concerning non-burn practitioners both in Low and High Income Countries. It would appear that insufficient un- 4

5 dergraduate teaching results in knowledge gaps regarding practical burn care. Interactive Burn workshops seem to be an effective method in enhancing the knowledge of burn management. In Ismailia, family physicians and all other non-burn practitioners should have a Burn module in their post-graduate educational curriculum or at least a practical professional Burn training session. Undergraduate teaching needs to be re-evaluated and should concentrate more on the practical aspects. Burn workshops and interactive teaching should be encouraged and propagated as they seem to be an effective method for undergraduates. RÉSUMÉ. La prise en charge des brûlures pendant les premières heures après le traumatisme a un impact significatif sur la mortalité et la morbidité du patient. Les médecins de famille peuvent représenter les médecins non-spécialistes en brulurologie car ils n ont pas pris ni des cours ni des formations sur la gestion des brûlures au-delà du diplôme de Médecine. Ces médecins de famille peuvent donc nous donner un indicateur de connaissance de tous les praticiens non-spécialistes en brulurologie en ce qui concerne la prise en charge d urgence des brûlures. L essentiel de connaissance que les médecins non-spécialistes en brulurologie doivent maitriser est l évaluation de l étendue et de la profondeur de la brûlure et des traumatismes associées, les indications des incisions de décharge, la thérapie liquidienne et les soins de voies respiratoires ainsi que l assurance de la sureté du transport. L objectif de cette étude était donc d évaluer la connaissance des médecins de famille comme un indicateur de celles des praticiens généralistes en ce qui concerne la prise en charge d urgence des brûlures et de concevoir un programme éducatif approprié. Pour évaluer la connaissance, une questionnaire d entrevue a été approvisionné aux médecins qui travaillent aux centres de médecine familiale à Ismaïlia, Égypte, qui ne possédaient aucun diplôme d études supérieures. Un total de vingt-quatre médecins de famille (100%) ont participé à cette étude. Les résultats du questionnaire ont montré que, d un maximum de 25 bonnes réponses, le résultat le plus élevé était de 12; réalisé par 6 médecins (25%). Le résultat le plus fréquent était de 8 bonnes réponses; obtenus par 10 médecins (29,2%). Cela démontre que chez les médecins de famille d Ismaïlia, et par la suite chez tous praticiens non-spécialistes en brulurologie, il y a une manque importante de connaissance en ce qui concerne la prise en charge d urgence des brûlures en raison de lacunes dans l enseignement de premier cycle. Mots-clés: médecins de famille, médecins non-spécialistes en brûlurologie, formation, prise en charge d'urgences des brûlures, évaluation des connaissances ANNEX Basic data: Name of the physician (optional): Year and place of graduation: , University: Previous courses/training in Burn management: No ( ) Yes ( ), specify: Was the undergraduate Burn course sufficient? Yes ( ) No ( ) Partially ( ). Are you confident of your ability to manage a burn case properly? Yes ( ) No ( ) Partially ( ). Have you seen burn cases in your practice? Yes ( ) No ( ). Burn knowledge: 1. Are you convinced that Burn management is one of your tasks? Yes ( ) No ( ) 2. Which of the following is your main role? First aid ( ) Emergency treatment ( ) Health education ( ) 3. List the most important cause of death in the following periods: First few hours (< 1 day): First few days (< 3 days): What is the easiest way to assess the extent (percentage) of Burns? 5. Mention the most reliable method for diagnosing the Burn depth (Degree): 6. What is the most suitable substance, available at home, to be applied on a burn until the patient reaches the Family Practice Unit? 7. What is the main indication for fluid therapy in Burns? >> 5

6 << 8. How could you calculate Burn fluid therapy (quantity, timing and nature)? 9. What is the fastest way to by-pass upper respiratory airway obstruction? 10. Name the surgical procedure you should master for fluid therapy. 11. What other surgical technique(s) you should master for management? 12. From the etiological point of view, what is the most dangerous Burn? 13. Mention the analgesic of choice in case of Burns? 14. Mention five criteria for referral of burn cases 15. List four precautions that should be made before transporting a burn patient: BIBLIOGRAPHY 1. Cuttle L, Kempf M, Liu PY, Kravchuk O, Kimble RM: The optimal duration and delay of first aid treatment for deep partial thickness burn injuries. Burns, 36: 673-9, Rush RM, Arrington E, Hsu J: Management of complex extremity injuries: tourniquets, compartment syndrome detection, fasciotomy, and amputation care. Surg Clin North Am, 92: , Mansfield M: Resuscitation and monitoring. Bailliere Clin Anaesthesiol, 11: , Mlcak RP, Buffalo MC, Jimenez JC: Pre-hospital management, transportation and emergency care. In: Herdon DN (ed): Total Burn Care (fourth edition), , Elsevier Inc, Moghazy A, Abdelrahman A, Fahim A: Effectiveness of environmental-based educative program for disaster preparedness and burn management. J Burn Care Res, 33: , Ahuja R, Bhattacharya S: ABC of burns: Burns in the developing world and burn disasters. BMJ, 329: 447-9, Fadaak H: The management of burns in a developing country: An experience from the Republic of Yemen. Burns, 28: 65-9, Bezuhly M, Gomez M, Fish JS: Emergency department management of minor burn injuries in Ontario, Canada. Burns, 30: 160-4, Alharbi Z, Piatkowski A, Dembinski R, Reckort S, Grieb G, Kauczok J, Pallua N: Treatment of burns in the first 24 hours: Simple and practical guide by answering 10 questions in a step-by-step form. World J Emerg Surg, 7: 13, Barillo, D: Planning for burn mass casualty incidents. J Trauma, 62: 68, Atiyeh B, Masellis A, Conte F: Optimizing burn treatment in developing low and middle income countries with limited health care resource (part 3). Ann Burns Fire Disasters, 23: 13-18, Vercruysse G, Ingram W, Feliciano D: The demographics of modern burn care: should most burns be cared for by non-burn surgeons? Am J Surg, 201: 91-6, Lam NN, Dung NT: First aid and initial management for childhood burns in Vietnam an appeal for public and continuing medical education. Burns, 34: 67-70, Al-Mousawi A, Jeschke M, Herndon D: Invited commentary on The demographics of modern burn care: Should most burns be cared for by non-burn surgeons? Am J Surg, 201: 97-9, Kut A, Tokalak I, Başaran O, Moray G, Haberal MA: Knowledge, attitudes and behavior of occupational physicians related to burn cases: A cross-sectional survey in Turkey. Burns, 31: 850-4, This paper was accepted on 13 December