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Management of a self-immolation victim

A nursing challenge in burn care

Candyce N. Kuehn, RN, BAN

Self-inflicted burn injuries compose a small percentage of the patients seen in burn centers and self-immolation is only a fraction of that population. Persons who commit self-immolation have many motives; suicide, impulsive behavior, various psychological illnesses, sacrificial religious rituals and political protest are a few examples. The incidence of self-inflicted burns ranges from less than 1 to 9 percent of patients admitted to burn care facilities.1,3,4 More than 50 percent of these patients have had previous psychiatric hospitalizations.3

Persons who burn themselves are among the most difficult patients to treat7 because of the combination of major medical trauma and psychiatric needs. These patients are known to have a higher-than-average incidence of mental illness, substance abuse, family problems, poor judgment and poor coping skills. Daniels et at3 report findings of pre-existing psychiatric diagnoses such as major depression, schizophrenia, organic psychosis, schizoaffective disorder and bipolar disorder. There is little consensus in the literature regarding treatment approaches for these very challenging patients because of the complexity and variability of both their injuries and motivations.

Case study

At approximately 11 p.m. early in October, TJ, a 19-year-old man, attempted to commit suicide after his girlfriend broke off their relationship. He doused himself with gasoline and lit himself on fire at the end of her driveway. He then climbed into his pickup truck and drove the quarter-mile approach to her house while engulfed in flames. As he approached the front door, he stopped and leaped from the cab of the truck and extinguished the flames by rolling on the ground. Within minutes, he was transported by ambulance to the local emergency department, where his burns were assessed to be 94 percent total burn surface area and his weight was estimated at 76.5 kg. Initial airway, breathing, circulation (ABC) assessment was completed and intravenous fluid resuscitation with lactated Ringer’s (LR) solution was begun. Arrangements for air transport to our burn center were made. Prior to transport he was intubated and a central intravenous line, a Foley catheter and a nasogastric tube were placed. About five hours after injury, TJ arrived at our burn center.

Fluid resuscitation in the early postinjury phase

In the early postinjury phase, generalized organ hypofunction develops as a consequence of decreased cardiac output from hypovolemia.6 Therefore, second only to establishment of a patient airway, fluid resuscitation is crucial to ensure patient survival. Using the Parkland formula (2–4 mL LR/kg per burn surface area percentage) for fluid resuscitation, our burn team calculated TJ’s fluid needs to be 1500 mL/h for the first 8 hours from the time of injury.

Prior to his arrival to our burn center, TJ had received 1000 mL normal saline, 4500 mL LR and 1000 mL hetastarch at the referring emergency department. In the five hours since his burn, his total urine output was 600cc.

The patient’s response to fluid resuscitation can be assessed by hemodynamic response, level of consciousness (when appropriate) and urinary output.6 During the first hour after his arrival at our burn center, TJ’s urine output was 90 mL, with a specific gravity of (1.040), and the history of administration of mL 1000 Hespan alerted us to monitor for advancing intravascular hypovolemia. Hespan is a fluid volume-expanding colloid solution which can cause circulating volume depletion because of the initially poor capillary permeability. Additional laboratory values—a hematocrit of 60.8 and hemoglobin level of 20.5—reinforced this assessment. Consequently, TJ’s calculated fluid requirements were doubled, increasing the intravenous LR to 3000 mL per hour for the next four hours until the urine specific gravity dropped to 1.022. We continued to titrate his fluids to maintain a urine output of 30 to 50 mL per hour.

Twenty-four hours after injury is the general timeframe during which capillary integrity is expected to be re-established and colloid-containing fluids are needed to replete intravascular volume. Thus, the team began infusion of fresh frozen plasma, at 470 mL per hour, and 5 percent dextrose in water, at 100 mL per hour, for his second 24-hour fluid maintenance and replacement requirements.

Stabilization phase

TJ had been in the burn unit for 24 hours. Our burn team, which includes the physicians, nurses, nursing assistants (burn technicians), occupational therapists, a social worker, a psychologists and a dietician, were busy developing a treatment plan. TJ’s multisystem challenges included massive metabolic requirements, potential cardiovascular and pulmonary insult, psychosocial and financial requirements and the need to understand his motivation and thought process as the cause of this overwhelming self-imposed injury. Although TJ remained intubated, he was alert and followed commands. Team members knew that TJ’s survival depended on early excision and expeditious wound closure. Early excision of eschar, placement of cadaver homograft and initiation of biopsies for fostering cultured epithelium were the key elements of his medical treatment plan.

The nursing staff decided to assign TJ two primary nurses because of the meticulous and extensive wound care that he would require. His nursing plan of care had both short- and long-term goals: monitoring and stabilizing hemodynamic equilibrium and preventing complications of multiple organ system insult.

The occupational therapists began by developing a regimen of splinting, position and exercise to maintain joint function. The psychologist and social worker met with TJ and his family to assess their present state of coping and developing a plan of support (both psychological and financial) and intervention.

Nutrition is a major concern for patients with burn injuries. These patients are routinely hypermetabolic and require an increased calorie intake. Therefore, precise energy requirements were calculated with the Harris-Benedict equation to determine TJ's needs; The equation is calories = basal energy expenditure x 2. The nutrition team recommended that TJ start to receive internal feedings of 3800 per day. Table 1 shows TJ’s nutritional course.

Regions Hospital - Regions Direct – Burn Center - Table

Airway management

TJ remained intubated for the first 25 days of his hospitalization. Clinical signs and symptoms associated with inhalation injury include facial burns, singed nasal hair carbonaceous sputum, tachypnea, stridor, wheezing, dyspnea and cough.2

TJ had inhaled flames and smoke as his clothing burned and while he was enclosed in the cab of the truck. On admission, the team members observed deep partial-thickness facial burns, singed nares and carbonaceous secretions, thus putting TJ at high risk for inhalation-injury complications.

Pulmonary dysfunction after inhalation injury is directly related to the mechanism of injury, length of exposure to smoke and heat and previous health. The scope of this insult can include impairment of bronchociliary mechanisms, a decrease in surfactant production and the disruption of the alveolar capillary membrane, resulting in ineffective clearance of particles and secretions, bronchospasms and atelectasis.

Remarkably, TJ maintained adequate pulmonary function with ventilator settings of assist-control of 18 at fraction of inspired oxygen (Fio2) of 35 percent, tidal volume of 800 and a positive end-expiratory pressure of five. His arterial blood gases were monitored every six hours and as necessary during the first three days after admission with a goal of maintaining an oxygen saturation above 94 percent, partial pressure of carbon dioxide below 45 and a normal acid-base status. Ventilator adjustments were made accordingly.

Once correlation of oxygen saturation by oximetry and pO2 had been established, we observed oxygen saturation levels and decreased the amount of arterial blood gases drawn, a strategy which proved both accurate and cost effective. Arterial blood gases were measured at least every 24 hours to document correlation with pulse oximetry and as needed if additional pulmonary problems were suspected.

Additionally, the immunosuppression resulting from his loss of skin, combined with his pulmonary insult, put TJ at significant risk for infectious pulmonary complications. Use of prophylactic antibiotics and steroids was not initiated because they have not been proven effective in preventing these complications; however, nursing care standards for meticulous pulmonary toilet and protocols for surveillance cultures of endobronchial secretions were initiated.

TJ’s respiratory status warranted hourly assessments, including auscultation, turning every two hours and suctioning to maintain adequate airway patency. Keeping the head of TJ’s bed elevated helped facilitate his lung expansion and reduce airway edema. Close monitoring of hydration helped promote evacuation of thinned secretions.

A unique challenge in nursing assessments involved chest auscultation because even placement of the stethoscope diaphragm on his chest was painful. TJ and the nurses negotiated some additional interventions such as warming the diaphragm with the hands before placing it gently on his chest, making sure not to put much finger pressure on the diaphragm and to inform him before pulmonary assessments. Pulse oximeter probes worked best when placed on his earlobes because his toes and fingers were burned and had poor perfusion. At times, turning him caused intolerable pain. He was placed on a low-pressure, high-air-loss therapy bed, which was used mechanically to adjust the bed position enough to stimulate him or he would adjust himself in the bed using an overload trapeze. Additionally, his dressing changes and linen changes accounted for most of his frequent position changes.

Wound management

Because nonviable necrotic burn tissue experiences significant surface colonization within a few days, wound management through surgical intervention is used to minimize the episodes of infection and to promote primary healing or closure.

Wound management and the prevention of wound infections are major issues for any burn team. The acute-care phase of burn wound management has been defined as “that time until the burn wounds are closed.”10 In TJ’s case, the acute phase lasted for more than 5.5 months. Care focused on daily wound monitoring, hydrotherapy, mechanical and surgical debridement, nutrition, pain control and continued rehabilitation needs. Because of the large surface area of TJ’s burn and limited donor sites, the burn team decided to enlist this patient as a candidate for cultured epithelium, in addition to the use of autografting. The use and application of cultured epithelium are relatively recent advances in burn wound management.

TJ was taken to the operating room 33 hours after his initial injury and excision to the fascia under tourniquet and application of cadaver homograft to bilateral lower extremities were performed. At this time, small biopsies from his scrotum and left hip were harvested to grow cultured epithelial autografts. This was the first of 17 operations during his 5-month and 18-day stay in the burn center.

Under ideal circumstances, it takes about 28 days to grow enough epithelial cells from 1 x 2 cm biopsy specimen to cover the entire body–surface area.8 The surgical excision and cavader placement continued and by day 23, enough cultured epithelium autograft had grown to be placed on both upper extremities and the lower anterior abdomen.

Because of the extremely fragile, delicate nature of cultured epithelial autografts, they are at high risk for dislodgement and destruction from the slightest amount of pressure or shearing. Our surgical team decided to place radial and calcaneal skeletal traction pins to accommodate four-point extremely positioning, which facilitated daily dressing changes and helped minimize possible loss of cultured epithelium from shearing or pressure.

Surgical excisions of TJ’s burn wound and placement of cadaver homograft continued for several operations. The first split-thickness meshed autograft was placed on his right hand 11 days after injury; his scalp was used as the donor site. The process of sequential excision, placement of cadaver grafts, culture of epithelium and split- thickness meshed autografting continued until January, four months after injury.

Our nursing team believe that during the early postoperative period, minimizing the care givers’ and maximizing verbal and written communication would optimize the chances for graft survival and promote continuity of care. Therefore, two primary nurses were assigned to TJ, one who predominantly worked days and another who predominantly worked evenings, because much of the care of wound and graft site was being performed on these shifts.

Dressing for TJ’s cultured epithelium were individualized. Our nursing goals were to cause the least amount of loss cultured epithelium due to shear, pressure, dislodgement or infection. Inservicing for the staff was provided frequently and detailed wound-care instructions were developed. TJ’s dressings were kept moist but not saturated and were changed at least daily. The dressing covering the remaining eschar was changed twice daily. These elaborate dressing changes could consume four to five hours in an eight-hour shift, requiring assistance by at least two staff members for some of the time.

Initially, TJ’s dressing changes included application of mafenide acetate in the morning and silver sulfadiazine in the evening. These creams were applied directly on the wound surface, which was then covered with Kerlix dressing (The Kendall Co., Monsfield, MA) or large, torso-sized Exu-dry pads (Frastec Wound Care Products, Bronx, NY) depending on the anatomic area involved. TJ’s toes and fingers were bandaged individually, supported to promote function and elevated to reduce edema. As the excision and placement of cadaver skin began, the dressings were changed to include moist bulky wraps on the lower extremities, which also were changed daily.

Four days after injury, the burned tissue on the upper extremities was excised and covered with cadaver homograft. Moist bulky wraps and Robert Jones extension dressings were then applied and changed daily. This sequence continued with excision, cadaver homograft placement on the lower back eight days after injury and daily moist-dressing changes.

On the 12th hospital day, excision and split-thickness autografting were performed on the right hand, as was cross-pinning of the proximal interphalangeal joint. A moist Kling fluff wrap (Johnson & Johnson Medical, Arlington, TX) was applied and remained intact for three days while the arm was kept elevated. On the fourth postoperative day, daily changes of the dressing on the hand were resumed. On the 24th day after injury, the cadaver homograft was removed and cultured epithelium was placed on both of TJ’s arms and on his lower anterior abdomen. Bilateral radial traction pins were also placed to suspend his arms. The arm dressings were changed daily, with Xeroflo dressing (Sherwood Medical, St. Louis, MO) used over the cultured epithelium. The cultured epithelium on the arms gradually became pink, indicating viable circulation; it continued to survive and adhere well.

Thirty days after injury, cultured epithelium autograft was placed on both of TJ’s legs and on his anterior thighs; at this time, tibia and calcaneal traction pins also were placed to provide suspension. For three days, the Xeroflo dressing over the cultured epithelium was left untouched until it was removed under general anesthesia in the operating room late on the third day.

Starting on the fourth postoperative day, daily changes of the Xeroflo dressing were done by the nursing staff. Accomplishing the bed linen change to coordinate with TJ’s dressing change required seven or eight staff members. Six staff members slowly placed their hands on posterior burn areas covered by the cultured epithelium or on areas that were thought to be durable, in addition to supporting his radial traction pins. The seventh person removed the soiled linen and replaced it while another person held his suspension weights. These complex procedures and multiple dressing choices continued for months. Almost four months after injury, TJ’s complex wound dressings were reduced to three different choices because his skin could now endure turning and positioning by only two caregivers. Our limited experience and evolving knowledge of cultured epithelium prompted us to landmarks where epithelium had been placed and to document strategies that were successful in achieving minimal shearing and epithelial disruption. Nursing interventions in skin care evolved throughout TJ’s hospital course and were fine-tuned on a daily basis.

Daily and prn assessments of the wound and graft sites are essential to detect purulence, odor, increased tenderness, sloughing or shearing. Dressing-change times were negotiated, specified time units with TJ to allow him some control. The dressing changes were also coordinated with the physicians to facilitate their assessment and visualization of TJ’s wounds. Wound exposure time was minimized and done in stages to conserve body heat and minimize pain.

Nursing staff members also heated the irrigation solution used during different dressing applications to conserve body heat and to keep TJ more comfortable. All dressings over the cultured epithelium were moistened if they were at all adherent during attempts at removal and they were removed tangentially (slowly and at a 45-degree angle) to minimize the risk of disruption. Surface cultures were done frequently to monitor closely the need for appropriated antibiotic therapy.

Ineffective coping

As might be expected, these long, frightening and delicate procedures elicited enormous pain and anxiety for TJ. After burn injury, the goals of psychosocial nursing care for the burn patient and family are to promote functional adaptation and to facilitate psychological recovery.9 As with most self-immolation victims, TJ had a history of ineffective coping. His mother and father shared their impressions with the burn team that TJ was immature, impulsive, manipulative, violent and depressed prior to the initial injury. His usually maladaptive coping skills were to bully, manipulate, confront and act out aggressively, which were compounded by an increased use of alcohol within the year before the injury. These factors further impaired TJ’s ability to participate successfully in his care or to cope effectively.

During the initial resuscitative phase after burn injury, physiologic survival is of prime importance and most of the hospital staff’s efforts are directed toward survival. Given TJ’s history and the extent of his burn injury, there was much initial discussion with his parents regarding survival chances and the ethical dilemma of whether to resuscitate TJ at all. His parents’ shock and disbelief compelled them to deny that the self-immolation was a suicide attempt. Therefore, their shock and disbelief caused them to insist on full resuscitation measures. Consequently, during the first few days, reassurance coupled with honesty helped establish a working rapport with TJ and his family.

When TJ was admitted, his family was given a family information book that described some of the experiences that their son would encounter and helped them prepare for the changes in lifestyle that would occur. The staff physicians met with the family on admission, then daily and also after each surgical procedure. Once TJ’s condition was stable, the attending staff physicians met with the family twice weekly and as necessary; however, the residents continued to meet daily with the family. The nursing staff worked closely with the family, trying to continue to provide reassurance, condition updates, accurate information and to build rapport and trust.

Multiple services were needed to help design, direct and implement a plan of psychological recovery. Social Services worked closely with TJ’s family, who needed housing, food, transportation and financial help because they lived in a different state. The social worker established and built a therapeutic relationship with the family to help deal with their anxiety about TJ’s survival, the threat to the family unit, their frustration at their lack of control and their minimization of the depth of the problem. The social worker also spoke with TJ’s former girlfriend and her family to help her deal with guilt and continued friendship issues. TJ’s parents wanted his ex-girlfriend to come to visit TJ but neither she nor her parents desired such contact; however she did speak with the social worker to help her decide how much or how little she wanted to be involved with TJ.

The nursing staff provided TJ’s family with unit policies and visitation information within 24 hours of admission. Visitation hours for TJ’s mother were individualized because she chose to stay with TJ for the duration of his hospital stay; however, his family had no idea that he would not be discharged until more that five months later. His mother was allowed to visit TJ’s room only after nursing care had been performed. TJ’s grandmother occasionally convinced his mother to take breaks and to go home for several days while she stayed with TJ. The nursing staff met with the family and agreed to keep them apprised of TJ’s condition and the family agreed that there would be one spokesperson with whom the team could communicate. The psychologist also met with the family to establish rapport and to try to gather some insight into this patient’s needs.

Psychologic support

The nursing team faced many dilemmas during TJ’s stay because establishment of a therapeutic psychosocial relationship with him was very challenging. Some staff members felt angry and raised ethical questions about all the energy that the team would expend on a person who “tried to kill himself.” These conflicting feelings led to discomfort and discontent among the staff. Staff members were edgy and irritable, highlighting the need for psychological and emotional support for the burn team as well as the patient. Staff support was provided by co-worker groups, the social worker and the psychologist.

Individual staff members used various communication styles with TJ. Both his communication and behavior were manipulative; he could push staff to their limits of patience and was masterful at staff-splitting. He often told one staff member that he or she was the best care giver and that another was mean and then later described the person to whom he was talking at the time his “hero”. After staff members became aware of what he was doing, TJ was instructed to voice all of his concerns and praises to the nurse manager so that she could deal with them appropriately.

During TJ’s critical acute phase, when his dressing changes were elaborate and his pain was exquisite, he focused his verbal aggression on the two primary nurses who were present when he experienced the most pain. Because of his pain, immaturity and poor coping skills, he had difficulty concentrating or cooperating in his care. Having all four extremities in traction added to his feeling of powerlessness, further compounding his poor compliance and cooperation.

When TJ felt particularly powerless and was experiencing pain, he would often verbally fly out of control, becoming aggressive, threatening, loud and vulgar. He continued to try to pit certain staff members against others, resorting once again to his previous maladaptive behaviors. About two months into his hospital course, he became increasingly agitated and abusive, refused care and started making inappropriate sexual comments. Nursing staff members were in conflict about his plan of care and some nurses requested that they not be assigned to TJ.

TJ continued to refuse treatment, saying he wanted to die. For example, he wanted his bed left untouched, he did not want his teeth brushed, he wanted all the lights in his room turned off, he wanted a tent made with sheets around his traction to give him a sense of isolation and protection and he wanted to be left alone. The psychologist working with TJ met with the nurse manager and they collaborated on some interventions for both the staff and the patient.

TJ described having nightmares about his two primary nurses and believed that they did not like him because he could not handle the pain of his dressing changes. The nurse manager and psychologist concluded that his focus on the primary nurses had become a staff-splitting behavior that put the nurses at unnecessary risk with their peers and that they in fact found it impossible to be effective or objective with TJ. These two nurses were reassigned to other patients because of the breakdown in his trust and his pain, anxiety and focus on them as the ’bad guy”.

The psychologist and nurse manager agreed that the nurses needed a break from TJ, as did he from them. Additionally, the decision gave TJ some means of control over his situation. A modified case/team management approach for TJ’s care was begun and primary nursing was discontinued. Nurses were assigned in blocks of their schedule (i.e., the same nurse was assigned to TJ for a 1-week to 2-week period). He responded favorably for three days after the reassignment. After these three days, his same behavior of tearfulness, excessive demands, verbal aggression and inappropriate comments such as asking people to shoot him resumed and he continually demanded more narcotics and sedation.

Pain management

Nearly three months after the injury, TJ’s pain control was unmanageable, especially during wound care. He was receiving scheduled doses of 27.5 mg of methadone orally every six hours. In addition to 25 mg oxycodone, 10 mg midazolam, 45 mg oxazempam and 20 mg morphine sulfate total over a 2.5 hours to 4-hour period during his care. Still, TJ complained bitterly and thought that the staff was insensitive to his needs. The physicians, nurses, psychologist, social worker and family discussed this problem and decided to increase his narcotics doses with institution of a continuous morphine drip. As the days progressed, his methadone dosage was increased 7.5 mg every four hours. The psychologist also tried to be available to TJ during his care to help with distraction, relaxation and additional coping skills.

Despite continued attempts to meet TJ’s personal pain-control goal, he became more insistent on pain-free care. The nursed discussed with him his physiologic responses to the narcotics and sedatives, such as hallucinations, hypotension and apneic periods during which his oxygen saturation rate would fall into the 80 percent range. Despite these worrisome symptoms, TJ and his family were adamant that these excessive amounts of narcotics be administered. On December 31, almost three months after TJ’s injury, he required reintubation due to an inability to recover adequately from effects of medication on his respiratory drive. It took five days to accomplish extubation and re-establish adequate respiratory exchange. After that experience, the burn team recontracted with TJ and his family regarding allowable clinical parameters for his pain management. He reluctantly agreed that he needed to be able to cough, breathe deeply and respond to stimulation, and to achieve and maintain an oxygen saturation level above 90. Through the course of his hospitalization, TJ’s pain management had extended limits that we have rarely seen. The burn team reviewed his analgesia and sedation weekly at care rounds and the nursing team assessed them daily during dressing changes. The patient’s goal, which is not uncommon, was to be totally pain-free. The burn team’s goal was for TJ to be comfortable, to cooperate in his care, to maintain emotional control and not to compromise his respiratory status.

These goals set up the potential for conflict and presented yet another area for mutual problem-solving. Pain management is an art because success depends on a number of patient variables; the basis for successful pain relief is nurses’ belief of the patient’s account of his own pain. Nurses must "value” rather than judge the patient and, with the physician, must be aware of the pharmacologic latitude to meet the unique pain management needs of some individuals. The nurse must medicate the patient based on an understanding of the physiology of burn pain and advocate on the patient’s behalf for an appropriate dose. The nurse must accept the patient’s evaluation of his or her pain and assess his clinical response with an open mind. Caution needs to be a caregiver’s tool rather than a control. It is well documented that health care professionals, particularly nurses, tend to underestimate and undermedicate patients’ pain. Therefore, it is health caregivers’ greatest challenge to break their own paradigms and meet the patient’s need safely yet effectively.

Contracting for care

In addition to the psychologist, a psychiatrist was consulted early in TJ’s hospitalization to assess suicide risk and to make recommendations for any pharmacologic interventions. Now, more than two months later, the psychiatrist was asked to see him again regarding competency and further recommendations. The psychologist continued to see TJ throughout his hospitalization to help manage his acute reactions to the burn, to instruct and encourage relaxation and to offer pain control techniques.

The psychologist also pursued the motivation for of the suicide attempt and its impact on TJ. Both the psychologist and the social worker were instrumental in helping minimize the disruption to nursing staff cohesion by facilitating group meetings in which the nurses vented their concerns and frustrations and developed plans to adapt to the unique and challenging situation.

The nurses and psychologist also met with TJ and established written contracts for care. Nurses and TJ agreed that the nurses would proceed with his care even when he attempted to impede or divert them. His pain management regimen, including medications, music, warmth, relaxation and times for procedures, was reviewed and agreed on in writing. His family was involved in his contract and they agreed that their visitation times would be the reward earned by TJ.

After five months, TJ was transferred to the rehabilitation unit, where he spent 19 days. He was then discharged to his home. His mother was taught his wound care, dressings, nutritional needs and splinting regimen. Appointments for continued daily therapy at his community hospital were made. TJ was scheduled for a return-to-clinic appointment at our facility two weeks after his discharge. He also was given a referral to his local psychologist for continued follow-up care.

Sixteen months after his injury, TJ visited The Burn Center to let us know how he was doing. Physically, he is doing well, has good range of motion of all four extremities and is independent in all activities of daily living. Cosmetically, his face has minimal discoloration, no keloids and no distortions. His clothing covers most of his scars except for those on his hands. He is working part-time in the family lumberyard and hopes to work full-time within the next few months.

TJ continues to have trouble with body-temperature regulation. He perspires profusely from his face and head and fatigues easily. He has some limitations with his dexterity for fine or delicate work with his hands. He has stopped going to physical therapy but joined a health club to keep active and to exercise. Unfortunately, but not surprisingly, he is not keeping his appointments with the psychologist because he does not think that he needs help. Although TJ seems to be functioning and moving forward with his life, he has not addressed the issues that led to his troubled, impulsive act of self-immolation. As suggested by the literature, this young man is at high risk for continued emotional and psychosocial problems, especially if he does not address these long-standing issues.

Summary & conclusion

Our burn team learned many lessons from their experience with TJ. Contracting regarding care and pain medication proved to be both effective and helpful and we have used it successfully with other patients; however, we now use this tool earlier in a patient’s recovery. We have developed a communication forum in which staff members can identify frustrations and work them through as a group. Additionally, we were able to provide documentation to support budget money to be used for psychosocial support of the burn team. We have budgeted a psychologist for two to four hours per month to brainstorm and problem solve with staff on their issues. If another self-immolation victim is admitted in the future, we will draw upon our experiences with TJ and use our individual and collective strengths (including the patient and family) much earlier in the hospitalization to promote the well-being of all team members.


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