Discussion

Abstract

Perhaps with some justi®cation, we who work in Burn Centres tend to concentrate on the acute care of the patient with thermal injury. Without the work we do, few badly burned patients would stand any chance of making it back into their community. On the other hand, if survival is our primary end-point, if reduction in mortality is our measure of improved care, if cost reduction resulting from reduced length of stay is an indicator of success [1], are we not sometimes in danger, inadvertently, of pushing our patients o€ the edge of the hospital nest and expecting them to y? Because of what we provide by in-hospital rehabilitation most of them do y, physically at least, but some hit the ground hard. As we rescue ever more severe burns by early surgery and better skin substitutes, to what sort of future can they look forward? What are we doing to promote better support for them when they return home? Do we, the acute care professionals, have a role in long term, community rehabilitation? Can we do more to prevent them being injured in the ®rst place? If so, how should our e€orts be directed? Our answers to these questions will depend to some extent on who we are, which country we live in and which region or state of that country; some burn care services are undeniably further advanced than others in these issues. It will depend on resources, both expertise and ®nance [2, 3]. There is nevertheless increasing evidence that reintegration into the community to live a ful®lled life is an achievable objective, even for severely burned patients [4]. It is therefore our job as acute care professionals to establish the goals for injury prevention and the objectives for community reintegration, even if we delegate achievement of those standards to others. Our ultimate goal is full, holistic healing of the person Ð if you will forgive the overworked word `holistic', and accept my deliberate use of the word `person' instead of `patient' Ð or as near to that as can be achieved. The ISBI's good friend Dr M. Keswani often quotes the Chinese philosopher Kuan Tzu, ``If you plan for one year, sow rice. If you plan for ten years, plant trees. If you plan for a hundred years, educate people [5]''. In burn care, education should be used to reduce the identi®ed problem signi®cantly, for both the immediate and the foreseeable future Ð aiding the rice being sown by ®rst class health care in specialised burns centres and the trees cultivated by those researching and providing rehabilitation following thermal injury. Public education is important for prevention and, as school reintegration programmes testify, for rehabilitation. Prevention needs the involvement of nonmedicals, engineers, industrialists, economists, the police, charities and rescue organisations [6], but their perspective and agenda may di€er from ours. The UK Fire Brigade has a duty towards property as well as people, for instance, and has little to say about prevention of scalds. In 1992 the UK Department of Health white paper, `The health of the nation', included a target to reduce death by accidents among children under 15 years of age by 33% before the year 2005. Mortality ®gures are readily available, but the objective must also include reduction of morbidity. In the UK, mortality from burns and scalds has declined from 2000 per year to around 700 per year. Legislation and social change account for much of this decrease in respect of buildings, coal mining, ®reguards, sleepwear, foam furniture ®llings, improved ame-proo®ng of materials and publicity on smoke detectors, ®reworks and bon®re safety. But UK ®gures suggest in excess of 13,000 thermal injuries annually requiring hospitalisation, of which 45±50% are children, most of whom su€er scalds [7], and this is true also for most countries [8]. EEC data estimate 0±4-year-old European children at just 6% [9] of the population, so the number of child Burns 24 (1998) 594±598