Diagnosis in the Management of Burns*

An extensive burn is an incident which starts a fastmoving progressive illness. The natural history of the disease is known. Within an hour or two a severe burn will produce oligaemia, clinical shock, and sometimes renal failure. Bacterial colonization of the burn surface follows, and sometimes invasive infection. Soon anaemia and wasting become apparent, and in a few weeks the formation of fibrous tissue may cause contractures and deformity. Against this background the need for constant re-diagnosis of the patient's changing condition is imperative to prevent or arrest the expected complications. To achieve more accurate assessment a constant endeavour is being made to introduce into the early stages of emergency treatment new diagnostic methods of proved value. Although special investigations are difficult to fit into the tempo of emergency treatmentand these call for increased staff and facilities-they are part of the price of improving treatment and saving more desperate cases. Like the fast-moving traffic on the highway, the fast-moving illness of trauma can be handled most safely in a separate lane which is unobstructed by slower-moving problems. Without doubt, the commonest mistake in the management of severe burns at present is the failure to make an adequate diagnosis. In no other branch of medicine do we so easily neglect physical signs or fail to look for them. Perhaps this is partly because so much of the skin surface is burned, and therefore untouchable by bare hands for fear of implanting infection. Again, if extensive burns are dressed, little of the patient can be examined except when they are re-dressed. Neither of these difficulties is insuperable, and I think that the chief reason for our failure to assess burned patients adequately is a genuine lack of appreciation of the importance of diagnosis. For this reason it is perhaps worth while to consider the management of severe burns in a way which will answer the question, "What should we look for, and how should we look for it ? "