BY MAORE ITHULA
Two weeks before an explosion on Nakuru-Eldoret highway burned five people to death and left eight others with burns when they recklessly scrambled to scoop fuel spilt by an overturned tanker, The Nairobi Law Monthly had held an interview with Dr Loise Kahoro, the head of Plastic Surgery and Burns Unit at Kenyatta National Hospital KNH.
She talked about the odds in treating patients with more than 50 percent burns in public hospitals. It helps only so much if they seek treatment at Kenya’s only referral Burns Unit at KNH.
This publication has established that the problem of congestion at the burns unit that even if a victim had less than 50 percent burns of their body surface area, chances of recovering fully are at most 50 percent.
Several factors contribute to this situation. Firstly, facilities are stretched to the very edge at the unit. Secondly, a plan by a donor to finance the construction of a bigger and independent burns centre has failed to take off. Thirdly, burns are mainly a ‘disease’ for the poor because fire accidents are more likely to afflict the needy. Therefore, private hospitals are not keen to invest in a facility designed specifically for burns.
TNLM has independently established that the construction of a Burns Centre next to KNH has stalled because of corruption and meddling in the project, both within the institution and by senior officials at the Ministry of Health.
Kahoro says all serious burns from across the country end up being referred to KNH’s unit because it is the largest facility in the country.
This is how large Kenya’s only referral burns unit is. When the larger KNH was constructed some 40 years ago, the burns unit was part of the package. At that time, grown-ups were not playing with fire as carelessly as they do today. Therefore, use for critical care facilities like an intensive care unit (ICU) and high dependence care unit (HDU) for burns patients was not envisaged.
Today, burns patients are literally dying for critical care!
After insightful thoughts, those good planners of the burns unit at KNH also found that eleven beds for seriously burnt inpatients were sufficient. As you read this article, 21 beds are squeezed into the unit and they are almost permanently occupied as more and more Kenyans claim their space in the unit by living dangerously along the major highways where fuel to burn in does not lack.
But healthcare providers are a benevolent lot, or they are bound by the Hippocratic Oath to be, even when their clients almost willing plunge into their misery. Therefore these good people found it necessary to set aside a 30-bed ward (among the general wards of the main KNH) for burns patients. With 90 occupied beds now stacked into this ward, there is just enough room to breathe. Finally there is only a single three-capacity theatre dedicated for burns patients. For technical reasons of tissue grafting for each patient, the theatre can only operate three times a week.
Therefore, a patient who could have been treated in say, three months takes up to one year in the ward. Many of them succumb to bedsores and infections because of the long stay. If the Burns Centre were operational with three such theatres, operations would be conducted seven days a week and treatment success would be at least 70 percent for those with serious burns, Dr Kahoro revealed.
Independently, TNLM can now reveal that for the last 10 years, there is sufficient money to construct such a facility but the funds are idling in an account for years. Why?
In 2001, we have found out, a survey was carried out at the KNH’s burns unit to establish how many patients sought treatment there. The research was commissioned and conducted by plastic surgeons at the hospital.
The medical experts found that the demand for this crucial service was almost a dozen times higher than its actual capacity. The small plastic surgery fraternity in Kenya was then astonished.
Dr Ismail Aref, who was among this group of experts says, “We embarked on a campaign to expand the unit. For some time we toyed with as many options as there were issues regarding congestion in various departments at the referral hospital. We eventually concurred that time was then ripe for the country to start developing units that constitute KNH into fully-fledged independent centres.”
Dr Aref who is a plastic surgeon and a former head of the burns unit has since resigned from KNH and moved on.
He says his colleagues agreed to start with helping to build an independent burns treatment and management centre at KNH’s precincts but away from the main hospital. The centre was to be constructed opposite KNH’s Accident and Emergency ward. Work was to begin in January 2007 and the facility was to be completed in about two years at a cost of $20million (Sh 2 billion) with funds provided by the Organisation of Petroleum Exporting Countries Fund for International Development (OFID).
But there was a catch that has stalled the project. Naturally, the OFID-funded project is not attractive to wheeler dealers in and outside both KNH and the Ministry of Health because there is no room for sleaze.
Dr Aref shies away from commenting on how the project’s potential for corruption may have stalled the scheme. Instead, he refers us to KNH for such a comment.
He says, “I am no longer at KNH or part of that project. Perhaps I would have had something to say when I was still the head of the burns unit many years ago. But many things must have changed since I left. Please talk to KNH. They have all the answers to your questions.”
When contacted, Mr. Simon Ithai, the head of communications at KNH referred us to Dr Bernard Githae, KNH’s Deputy Director, Clinical Services and Head of Department, Surgical Services and Plastic Surgeon.
But no comment was forthcoming from Githae for a long time. For two months, he did not answer our phone calls or respond to our e-mail questionnaire. Regular text messages remained unanswered.
However, our sources at the Ministry of Health and KNH reveal in confidence that OFID has tightened bribery loopholes around the contract so firmly that there is no room for fraud.
One source put it with the requisite caution, “This money from OFID is already available and the donor has put enough precautions to ensure that none of it goes to waste. Even at the architectural design and construction levels, OFID has contracted its own architects, engineers and many other technical experts needed to build the centre to ensure there is no pilferage.” Declining to be named, he inevitably referred us to KNH for more details.
Undeterred we dug deeper into the issue. We established that, a cabal of greedy officials in the health sector has blocked this project demanding that the donor allows the Government to handle the procurement process of the construction and equipping the facility. But since the policy in OFID projects across the globe is to ensure that its donations are properly accounted for, our sources reveal, every year the donor sets aside $20 million (Sh1.8 billion) for a Burns Centre at KNH and every year the money goes back to the donor; unspent! This has been the trend for more than the 15 years gone by.
OFID funds education and healthcare projects in Kenya. Another source reveals that the bar for the management of OFID-funded projects in Kenya was set that high after money for several projects were embezzled in the past.
The Burns Centre prototype designs, that TNLM has seen, were ready and approved by OFID experts seven years ago. The centre is designed with a bed capacity of 78, an Intensive Care Unit, High Dependent Unit and three operation theatres.
Another source told us that a foundation stone of the centre was laid sometimes in 2009. We could not independently locate it. Contacted, Mr. Ithai denied there was such a thing.
The centre is also designed to have its own casualty and outpatient service departments complete with a skin bank.
Noting that cadaver tissue harvesting is illegal in the country, yet another source says, the centre would be equipped with facilities that would enable the skin bank to have its raw materials developed from patients themselves through tissue culture technology.
To reduce the clumsy paper medical recording that is the hallmark of confusion and fertile ground for corruption in most of Kenya’s public institutions, the centre is designed to be purely on digital operations.
But constructing a modern burns facility is one thing and sustaining it is yet another, bearing in mind that most burns patients are the poorest of the poor.
Concerned about this reality, the small fraternity of plastic surgeons had a plan to tackle the setback. One of them who took part in basic intricacies of the project confided in us that if the centre is built, plastic surgeons intend to lobby for a nominal taxation of one cent per litre of petrol per day, which translates to more than Sh50, 000 a day, to keep the hospital running. This is based on the 2010 estimate that motorists in Kenya use in excess of 5 million litres of petrol per day.
On her part Kahoro has a different set of brief and impression of the proposed Burns Centre. The three-storey Burns Centre she knows of will house two centres; a burns patients section and the other wing as a paediatric emergency centre. Although she is not sure when construction will start or end, Kahoro says the project will be funded by Arab Bank for Economic Development in Africa (BADEA) in collaboration with the Government of Kenya at a cost of Sh2 billion. But Kahoro does not know whether the funds available or when they will be availed by the State or the donor. Interestingly, an internet search of OFID and BADEA shows the latter runs the former’s projects in Kenya. BADEA has its offices in Saudi Arabia and so is OFID.
Efforts to get a comment from either were futile as our emails remained unanswered.
“The plans for the proposed Burns Centre were done by SKair and Associates and were ready two years ago,” Kahoro says adding that construction will commence when public tendering for a contractor is completed.
All the same, Kahoro says, this second set of Burns Centre will have a capacity of 100 beds, a critical care unit (ICU and HDU) with 10 beds, six-bed emergency ward and an 84-bed general ward.
But how different is a burns unit from a burns centre? We found that the two are indeed different.
Kahoro says, to establish an internationally recognized burns centre, at least 100 patients should be dealt with every year. KNH meets the criteria a dozen times over. Kahoro estimates that at least 1,200 in patients are treated at the unit every year, out of which 400 are attended for severe burns and are therefore admitted at the unit while the rest are admitted at the burns general ward.
Predictably, it is the already assailable segment of the society that is most vulnerable to burns in Kenya and for that matter can hardly pay for their treatments. Many die or recover a semblance of health, leaving the congested burns unit and the entire KNH to contend with huge bills that are often waived to the peril of other equally poor patients.
Kahoro says, “Between 70 and 80 percent of all burns patients come from the lower income bracket of the society both in the rural and urban areas. And very few of them can afford the bills they incur when undergoing treatment.”
She continues, “The lower income segment of the society is more vulnerable to burns because of poor housing which comes with congested spaces and use of energy sources that can easily catch or set off fires. For example, in these areas, use of charcoal and kerosene for cooking and lighting is the norm. These sources of energy are prone to accidents and when they occur, casualties are high because of congestion,” she said.
In the urban centres fires are common in informal settlements where rescue efforts are also difficult because roads do not exist.
For this reason, she says, burns patients in urban areas mainly come from the informal settlements.
But even the poor, who do not live in informal settlements but instead reside near highways, are exposed when fuel tankers take dangerous turns thus spilling their inflammable cargoes. Inevitably people rush to these scenes to scoop the spilt fuels with calamitous consequences.
And almost needless to say, even the not-so-poor Kenyans also roast in road traffic accidents where vehicles explode and burn those driving or travelling in the vessels. Terrorists’ attacks in Kenya leave behind nothing funny with regard to burns.
However, not all burns are life-threatening and this is how Kahoro outlays burns injuries.
Medical experts have classified burns into three categories; first, second and third and fourth-degree injuries, depending on the depth of the burn. A burns injury first affects the skin which is the body’s largest organ which performs a number of vital functions. First, our skin separates the interior of our bodies from the harshness of the environment.
Our skins are composed of two layers; an outer layer called the epidermis and its inner part is referred to as the dermis. The epidermis consists of dead cells and prevents harmful microorganisms and other injurious environmental agents from gaining entrance into the body. The dermis is a fibrous tissue that prevents evaporation of body fluids. Embedded within the dermis and opening to the skin surface are the sweat glands. These secrete perspiration, the evaporation of which helps regulate body temperature and the composition of body fluids. The dermis also contains all of the skin’s blood vessels and sensory nerve tips that respond to touch, pressure, heat, cold, and pain. This part of the skin also synthesizes vitamin D which is essential for the growth and maintenance of the body, particularly of bones.
Damage of the skin by deep or extensive burns can disrupt all of these functions, subjecting the victim to serious complications.
Thus based on the extent of destruction of the skin when one gets burnt, the injuries are either in the first, second, third or fourth-degree level.
In a first-degree burn, only the epidermis is affected. These injuries are characterized by redness and pain; there are no blisters, and swelling due to the accumulation of fluids in the wounded tissue is minimal.
But damage in a second-degree burn extends through the entire epidermis and part of the dermis. These injuries are characterized by redness and blisters. The deeper the burn, the more prevalent are the blisters. Like first-degree burns, second-degree injuries may be extremely painful. The development of complications and the course of healing in a second-degree burn depend on the extent of damage to the dermis. Unless they become infected, most superficial second-degree burns heal without complications and with little scarring in 10 to 14 days.
Third-degree burns are also referred to as full-thickness injuries. These burns destroy the entire thickness of the skin. The surface of the wound becomes leathery and may appear brown, tan, black, white, or red.
Victims feel no pain because all pain receptors in the dermis have been obliterated along with the rest of this part of the skin.
Blood vessels, various glands, and hair follicles are all destroyed in skin in this kind of accident. Fluid losses and metabolic disturbances associated with these injuries are grave.
Occasionally burns deeper than a full thickness of the skin are incurred, as when part of the body is entrapped in a flame and not immediately extricated. Electrical burns are usually deep burns. These deep burns frequently go beyond the dermis into the muscle and the bone. Such burns are of the fourth degree, also called black or char burns.
Black burns are of grave prognosis, particularly if they involve more than a small portion of the body. Effects of char burns may release toxic materials into the bloodstream.
Experts advise that if a char burn involves only a small part of the body, it should be cut out down to healthy tissue. If an extremity is involved, amputation may be necessary.
Surgeons measure the area of a burn as a percentage of the body’s total skin area. The skin area on each arm is roughly nine percent of the body total, as is the skin covering the head and neck. The percentage on each leg is 18, and the percentage on the trunk is 18 on the front and 18 on the back. The percentage of damaged skin affects the chances of survival. Most people can survive a second-degree burn affecting 70 percent of their body area, but few can survive a third-degree burn affecting 50 percent. If the area is down to 20 percent, most people can be saved, though elderly people and infants may fail to survive a 15 percent skin loss.
Kahoro says severe burns cause immediate nervous shock. The victim grows pale and is confused, anxious, and frightened by the pain and may faint. Much more dangerous is the secondary shock that comes a few hours later. Its chief features are a dramatic fall in blood pressure that leads to paleness, cold extremities, and eventual collapse. This secondary shock is precipitated by loss of fluid from the circulation, not just the fluid lost in the destroyed tissue but fluid that leaks from the damaged area that has lost its protective covering of skin.
Burns kill not just by damaging tissue but by allowing this leakage of fluid and salts.
The treatment of a burn is, of course, dependent upon the severity of the injury. In general, first-degree burns can be adequately treated with proper first-aid measures. Second-degree burns that cover more than 15 percent of an adult’s body or 10 percent of a child’s, or that affect the face, hands, or feet, should receive prompt medical attention, as should all third-degree burns, regardless of size.
Following a second-degree burn, the best first aid is to quickly immerse the wound under cool tap water. This action will stop the burning process and dissipate the heat energy from the wound. Home remedies, such as butter or petroleum jelly, should never be applied to the wound because these items trap heat within the injury causing further damage. The rule of thumb is to refrain from applying any substance that one would fear to put into their eye.
Third-degree burns are true medical emergencies, and the victim should receive professional medical attention as quickly as possible. These wounds should not be immersed, as cool water can intensify the circulatory shock that accompanies third-degree burns.
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