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Resident Orientation Manual

Produced by Galveston Shriners Burn Hospital and
The University of Texas Medical Branch Blocker Burn Unit.
Contributors:  Sally Abston MD, Patricia Blakeney PhD, Manubhai Desai MD,
Patricia Edgar RN, CIC,John P Heggers PhD, David N Herndon MD,
Marsha Hildreth RD, Ray J Nichols Jr. MD



   Every child who is admitted to Shriners Hospital can be expected to experience psychological distress and to demonstrate symptoms of that distress.  The psychological, as well as the physical condition must be addressed from the time of admission of the patient in order to promote recovery.  The acutely burned child's distress is both physical and psychological.  Common reactions of children in this situation are fear, anxiety, acute stress disorder and, of course, expressions of pain.  Issues of body image, social relations and self-concept will arise as the child progresses toward discharge from the acute care setting.  It is not uncommon for the acutely burned child to have experienced great losses in addition to their injury; for example, children may have lost a parent, a sibling, their home or a beloved pet in the catastrophe that caused their own injuries.  They must be told of such losses and assisted in grieving even while continuing to struggle with the discomfort of recovery and rehabilitation.

   The family of the burned child is also greatly impacted by the injury to the child.  They are traumatized and grieving and feeling extreme guilt, usually irrational.  They, too, can be expected to exhibit symptoms of trauma.  They, too, are our 'patients', for we need them to be healthy assets to the recovery of the child.

   Shriners Burns Hospital has a staff of mental health experts who follow every child and family from the time of admission to eventual discharge from the Shriners system - i.e. through the acute admission, as outpatients during clinic visits, and through subsequent admissions until the child is 21 years old or no longer needs our services.  They also do clinical research.  There is no need to write a consult for these services for they are provided routinely for every patient.  However, there is a need for the psychology-psychiatry team to hear of any observations made by other staff on an on-going basis.

Clinical Services

Staff:  Clinical Psychologist
    1 full-time Child Psychiatrist
    2 Psychologists   

   We also have 1 or more psychology residents or interns at any given time.

  Intake Assessment:  Upon arrival, the family is assessed for risk factors or problems that must be addressed during and following hospitalization.  All families have strengths and weaknesses, and their difficulties are exacerbated by trauma.  At this time, risk for abuse is also assessed.  If the child is 2 years of age or younger OR if any risk factors are present, e.g. injury does not match parent's story, Department of Protective and Regulatory Services (DPRS) have been contacted prior to arrival at Shriners; inconsistencies in repeated versions of the story, appearance of burn (e.g., dip lines, bottom of feet not burned while all surrounding skin is), we will contact DPRS.

        Resident's Role:  If you observe indicators of abuse, tell us.  You, and we, must report suspicious injuries and protect the child.  You must order a long bone series x-ray and be sure that signs of abuse are documented in your notes and by photographs.  If we contact DPRS, we ask you to complete the Physician's Report of Suspicious Injury form.  If we report a suspicious injury, we must not discharge the child until DPRS gives the 'okay'.

  Psychotherapy (both individual and family):  Each family is assigned a primary mental health professional.  The family can choose the extent of service they receive.  At minimum, the mental health professional will routinely assess for current or anticipated adjustment difficulties and intervene accordingly.  If appropriate, the professional will offer more extensive psychotherapy.  Issues commonly brought to counseling by the child include:  symptoms of acute stress, management of acute pain (through hypnosis or relaxation), anxiety or depression, grief due to death of another or loss of objects or partial loss of self, body image, and self-esteem.  Families are commonly dealing with fear, guilt, anxiety, and post-trauma stress.

        Resident's Role:  For both the patient and the patient's family, you are likely to see signs of emotional distress and behaviors that have the potential to escalate into a crisis situation.  Symptoms of depression and anxiety (notably Acute Stress Disorder) are most common.  Common signs of distress include, but are not limited to:  tears, withdrawal, sleep disturbance, agitation, refusing treatment plan, yelling, grinding teeth, verbalization of hopelessness, denial of disfigurement, expressed fears, short temper, anger, hypervigilance (in general and in seeking information about child's care), nightmares, flashbacks.  You should hunt for emotional distress in the same manner you would hunt for any anomaly in physical function.  Note your observation to the patient or parent.  Express your interest/concern through queries.  If distress is present and you wonder if further intervention may help, call the assigned mental health professional or call x6718 and state the name of the child for whom you are concerned.

 Bereavement Counseling:  If a child's condition is taking a life threatening direction or if a child is dying, call the psychologist or psychiatrist involved with that child or ask the unit clerk to page that clinician.  The psychologist or psychiatrist will assist in discussions with the family and in attending to family concerns while you attend to the child.

Clinical Research

  Longitudinal Assessment:  A multi-disciplinary research project that assesses post-burn adaptation for a minimum of 3 years.  Areas assessed include:  1) physical adaptation - bone age, bone density, muscle strength, pulmonary functioning, magnitude of disfigurement, sexual maturation, growth (height and weight);  2) emotional adjustment - family environment, child's behavior as measured by parent, child and teacher, parenting stress, post-trauma symptoms, child's developmental competency level, level of emotional distress for parent and child.  {Part of the National Institute on Disability and Rehabilitation Research (NIDRR) Burn Model Systems project}

        Resident's Role:  Parents will likely ask you about the NIDRR studies, so be aware of the study, know that research protocols are available to you on the unit, and call for any questions or assistance in responding to parent or child queries/concerns.

  Pain, itch, anxiety and post-trauma symptoms - Assessment:  In addition to the pain medication protocol, the staff in the Department of Family Services work at assessing the patient's discomfort, as well as guiding all staff to assess the patient's pain in the most effective manner.  Symptom management can be addressed at any time, but is specifically addressed in the Discharge Planning Meeting and in Rehab. Rounds.

        Resident's Role:  As you spend a great amount of time with the patients and their families and are involved with the most painful of interventions, you can be most effective in assessing and treating the patient's pain.  With the infant and children up to the age of 3, the patient's pain is assessed by the Observer Pain Scale with the primary caregiver being the reporter.  Ask the parent to assess pain in each of these 4 environments:  1) when your child is lying or sitting and his/her wounds are fully dressed, how much pain do you imagine he/she is in?;  2) during the bath, how much pain do you believe your child is in?;  3) during dressing changes in the hospital room,........  4) during the rehab. exercises, .........

Elicit from the parent what behaviors of the child contribute to his/her assessment, e.g. flailing of limbs, rigid extension of limbs, lack of cooing, developmentally regressed behavior, type of cry or whimper, lack of interest in toys, changes in indicators of symptomatic function (blood pressure, pulse, temperature), repetitive or stereotypic behavior.  For the children 4-8 years of age or greater, the Faces of Pain Scale is utilized, and the patient is the reporter.  Assess pain for the same 4 environments.

Also, when addressing pain, a good habit is to inquire about quality and amount of sleep, especially nightmares, and level of itching.

  Sleep Disturbance and other symptoms of acute post-trauma anxiety:  We have studied the efficacy of imipramine in low doses to treat these symptoms and have now begun a study comparing imipramine to prozac.  Both studies are blinded.  If a child is experiencing nightmares, flashbacks, intrusive memories, please refer that child for the 'sleep study'.  We will assess and communicate our findings/recommendations to you.

And finally, we are always on call and serve a liaison service to you.  If you have any hint of a concern or any question, please ask the unit clerk to page us.



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