Dr. Crombie:
We have Dr. Brett Hartman from Indiana here to discuss some topics on burn surgery and debridement. Tell the audience just a little bit about yourself, your background and how you got interested in burn surgery.
Dr. Hartman:
I'm Brett Hartman. I'm the medical director of both the adult and pediatric burn units in Indianapolis. I did general surgery training at Penn State. And then after that, I actually just wanted to be a plastic surgeon, had no intentions of doing what I do now. And then, then went to Indianapolis to do my burn surgery fellowship, and that did it for me. That's where I kind of fell in love with burns. So, and then after that, I did a year of critical care in Chicago at Loyola. And then I came back to Indiana and finished plastic surgery fellowship, and ended up staying in Indiana for my job.
We take care of obviously adult and pediatric populations. And so, we do all the acute burn care as well as all the reconstruction. So it's kind of nice to see that patient the whole way through.
Dr. Crombie:
So go back to when you were a new surgeon or when you were first learning about burns. What do you think are the important parts of how to debride? What are the techniques for debridement that you think are important?
Dr. Hartman:
I tell the fellows this now, that the end of their fellowship, I want them to to be able to see what I see. And I think that’s hard. When you're in the operating room, somebody can't just walk in there and see one debridement and say, ‘Okay, I know how to do that.’ Everybody thinks debridement is easy. I don't think that it's easy actually. Maybe the technical part of it may be easy, but actually getting down to a healthy wound bed and knowing what that looks like, I think it's the hard part.
Dr. Crombie:
What are the things that you look for when you're trying to get down to a healthy wound bed?
Dr. Hartman:
One, I look for punctate bleeding and that has to be in my mind, people that I'm training, they look at and say, oh, that's punctate bleeding, but it has to be pretty brisk punctate bleeding for me. And I want to see those, I can't see them, but the end capillaries. You want to kind of cut the tips off of those capillaries and see all of them. Then I leave that alone for maybe a minute or so, and then I come back to it and look.
In my mind, I think you can define what hasn't been debrided by looking at those more pale or white-ish areas that haven't really bled as much as you thought they originally did. I always go back and look at a wound after I've debrided it, and maybe it's a minute or maybe I move to a different part of the body debride it, and then always come back to it. And if there's certain areas that to me don't look good, I'll go back and re-excise it.
Dr. Crombie:
Is this something you're doing on the first time to the operating room or second time or?
Dr. Hartman:
The initial debridement is the most important and I found that some people, if they think they've done a good debridement initially, they'll put allograft on, well, if that debridement’s not good and now you’ve covered it. Then it’s opened up a whole other can of worms, or infection, and so on and so forth. The first debridement is the most important, but what I just described, I do that every single debridement I do. I try to teach my fellows that too. I hope in the end that they are able to see what I see. And I think that's hard. I think that just comes with experience.
Dr. Crombie:
When you and I think about our early failures that may have built us in a way to fully understand what's a better way to debride, a better way to look at the wound. What failures do you remember? Is there a case or a turning point?
Dr. Hartman:
I think everybody has under excised a wound for sure. That's how you learn. I've certainly done that. Obviously you learn a lot from your failures. Everybody can get up there and present all the successes, but I think it's the failures that you learn the most from.
It's those early, first maybe year two, that you really have those failures and hopefully you don't have as many. So, you're going to have some. We're pretty good about taking photographs and pictures. So I think it's important to go back retrospectively or, and look at those pictures and photographs in the operating room and say, this is why it failed.
Even though you thought it looked good going back and you'll say, that doesn't look good. At all. And again, I think it's time and experience. But how do you prevent that? That’s the goal is to have everybody come out and have as little failures as possible. That’s the goal of the burn fellowship. But then how do you teach everybody the same way?
Dr. Crombie:
Moving forward as we've become more connected since you and I were younger surgeons, I think just sharing ideas and failures and talking about cases that can be incredibly helpful for that.
Dr. Hartman:
Yeah.
Dr. Crombie:
When you think about just the concept of excision, what specific technique do you think has stayed with you all these years that you would tell your burn fellows?
Dr. Hartman:
It's the bigger burns where we get into trouble. There's so much to do and so much going on that I think you lose sight of that wound. We go and debride a leg real quick and we go and debride another leg or an arm. That's when you always have to go back and take a second look.
Technically, we've all used a Weck blade, or a Watson blade, or the Malveton, whatever it may be. I thinking it’s getting down to that healthy tissue layer. That's the most important, and going back after you're done debriding, taking a look, making sure everything's okay, even after all the chaos. That's when I go back, get hemostasis, get adequate hemostasis, and really take a look at the wound.
Dr. Crombie:
So theoretical big burn. How do you guide your team and your fellows in terms of timing to go to the OR? How much to do in the OR? And how long?
Dr. Hartman:
I have some really good help. A little bit of that depends on how good my fellow is too. I have a couple PAs, and me, and one fellow usually, and, or resident in the operating room. So, the first thing I always tell them to have a plan in mind going into that case, you can't just go in and say, we're just going to debride.
You have to have a plan from day one, from the time that patient hits the door. We like to get to that patient really within 72 hours. Usually after they've finished their resuscitation, I'll give them a day or two, and then we'll take them to the operating room. I plan on excising as much as I can in one trip.
The other important thing is to be systematic. Don't be all over the place. We'll start distal to proximal. We'll start on the hands, depending on how big the burn is. If it's big, I'll leave the hands alone initially, but we'll work distal to proximal legs first, and then arms, and then probably chest, back. If I can get the majority of a big burn done, in one trip, I will.
If not, I'll stabilize them for a day, and then probably take them back either the following day or the next day. If we have a 50, 60, 70% burn, we're pretty much excising it all in one trip.
Dr. Crombie:
That's amazing. How long are you in the operating room for those bigger burns? If you're trying to make a decision about, ‘can I keep going with an operation?’ Or do you have a standard subset of hours? How do you think through that?
Dr. Hartman:
Once we get to the five, six hour mark, I think that's about our limit. Usually we can get a big burn done in that timeframe. The other important aspect is that we have two dedicated operating rooms that we use at all times with dedicated staff. And so, there's never a time where I have to wait for an OR or change plans based on availability.
Dr. Crombie:
Say you have a patient, you're planning on being there for five hours, you have your strategic plan to go from distal to proximal, but what are the decisions that would make you say stop?
Dr. Hartman:
What I don't want is to somebody to get unstable, but if I, so we, I look at hemodynamics. If somebody is receiving their total blood volume in one trip to the operating room, that's probably not good.
We're in constant communication with our anesthesiologist, how much blood are we getting? How much FFP, what kind of products are we giving and where are we? That's another thing I teach my fellows, you got to make sure that the patient's doing okay.
I'm constantly looking at that monitor and looking at blood pressure and heart rate. That's a big factor in, are we going to keep going or are we going to stop?
Dr. Hartman:
And like I said, we have lots of help. So, I think we can get a big burn done relatively quickly.
Dr. Crombie:
Fabulous. So, you've gone through your first initial excision, going back for your second time, maybe doing a little bit here and there. When you are debriding say the second time around, and you're looking at any of, there's some areas that have scant dermis, there's some areas that have you're down to the fat. What do you saw to your fellows about, you know, this is good fat, we’re going to leave it. We should take this. What are you specifically looking at?
Dr. Hartman:
That’s a good question. Because before I talked about punctate bleeding. And that doesn’t always happen because now you’re into deep dermis, and you don’t have that punctate bleeding, that you would be more superficial dermis. So, now I’m down to deep dermis and I see these little fat globules poking through, well, how do you know that’s okay?
You need to see that shiny, bright, yellow fat. If it looks dull, or dry, or it’s just not that bright, shiny fat, then you got to go deeper. That’s time and experience and learning what that looks like. I constantly make it a habit of when I’m in the operating room, this is not good fat. Look at this, it’s not good fat.
Take another swipe. You can’t just look at it once and then leave it. I think you got to come back and take a look at it.
Dr. Crombie:
Say you’re overlying the anterior tibialis, and you’re down beyond the fat, because there’s not that much fat in that anatomical location. How do you decide what’s healthy there? How do you decide for the bone, what's healthy there?
Dr. Hartman:
We do a fair amount of fascial excisions if needed. I look at the kind of the dull nature, or if it's dull, it's got to go in my mind. It's got to go. I don't really tell my fellows this, but now that I think about it, if you look close enough, you can kind of see little veins and arteries, little vessels in that fascia. That's important if those are desiccated or thrombosed vessels, obviously. I think that's another thing I, for sure, teach fellows thrombosed vessels obviously are dead.
That tells me that burn has gone pretty deep. So we'll excise that. And then, okay. Next, what does dead bone look like?
I'll debride, I'll take a bone burr and debride. And, the bone, it will bleed pretty briskly if it's alive. So, we'll take a quick swipe through the bone to be whatever it may be. And, if bleeds, then I leave it alone.
If it doesn't, then I'll drill holes into the bone, into the, through the cortex and hopefully get some of that bleeding from inside to come out.
Dr. Crombie:
How do you then go about deciding two things: Whether your wound bed is ready to receive either dermal substitute or autografts? And then the, probably the second, probably more complex part of that question is how do you decide which one of those two options to use and where do you use them?
Dr. Hartman:
I use dermal substitutes over joint services. Next, stuff that is going to be a problem down the road. I think about contractures right away. I don't just look at a wound and debride and autografted and leave them alone.
I'm thinking about down the road, what's this patient going to look like when they're all done and healed?
I don't want them to have a big neck contracture or axillary contracture, whatever it may be. If I'm into fat, I'll usually put a dermal substitute on those areas. The problem I have with that is that takes time for that stuff to incorporate, and then, you got to come back and autograft. A lot of times if I'm on fat, I'll put allograft on, and make sure that wound bed, that's kind of my test. Make sure that if that stuff sticks and everything looks good, then I'll bring it back, take the allograft off, and usually autograft.
Dr. Crombie:
How do you decide between places that you would put just autograft versus a location where you might put a dermal substitute down?
Dr. Hartman:
Depth for sure. If I'm into fat or down to bone, I'll almost always put a dermal sub on, and then wait, and I like to bring the patient back probably at least once a week, if not, I think we're maybe a little aggressive, if not sooner. Clean, remove, and replace allograft, make sure that wound bed is okay, then go from there.
Then if it looks okay, I’m ready to autograft obviously. That's a million dollar question. It’s knowing if that wound bed is okay.
I've certainly put on some autograft, and the wound bed wasn't okay. In my early years.
Dr. Crombie:
We all have.
Dr. Hartman:
And you go back and again, you go back and assess and learn from that. I don't think I'd do that very much anymore. Hopefully nowadays. Yeah, that got a little better.
Dr. Crombie:
Just talking about bacteria on biofilm, what are you looking for on the wound bed to be kind of have your kind of antenna up or your hair follicles up saying what am I seeing here? Maybe it's not a good time to start grafting.
Dr. Hartman:
Going into a patient's room and looking at a wound bed there. Sometimes it's tough with allograft on, I think it's sometimes it's hard to see that wound bed, but if there's any sort of, I don't love, obviously desiccation, if there's any sort of desiccation there, I'll likely take that patient back to the operating room. Because that tells me it’s dead.
We’ve got to go back. If there's any drainage on the bandages itself, so, we actually really look at those and we smell them, too.
if there's any odor to those dressings or if the color doesn't look right, obviously green drainage, pseudomonas, things like that.
I'll likely take that patient back to the operating room. We'll switch up the topicals obviously, but then I'll take that patient back to operating room, take off that allograft, clean up the wound, and replace fresh allograft.
Dr. Crombie:
Is that an active discussion that you're having with your fellows as you're kind of going through all of this?
Dr. Hartman:
We try and see wounds together every day. Everyone Monday, Wednesday, Friday, we for sure do multidisciplinary rounds with the fellows and the other days I try to get them to look at wounds every day because you and I both know wound can change in 24 hours.
Dr. Crombie:
Yeah. 12 hours.
Dr. Hartman:
That's how you learn. You have to look, and look, and look and look and look.
Dr. Crombie:
Now we've had a pandemic, there's a lot of, the burn rotation is now not a formal part of general surgery residency as it was for you and I.
Dr. Hartman:
Right. Nor is it for plastic surgery.
Dr. Crombie:
Nor is it for plastics, right. How can we move forward to train the next generation of burn surgeons that are coming behind you and I to learn these techniques?
Dr. Hartman:
We all have to be on the same page and we're all surgeons, we probably have all have somewhat of an ego. Right? And think what we do it better than anybody else.
Doing something like this, which now that we're doing it, I'm surprised that we haven't done it before. Because I think it's about getting everybody on the same page and we all have the same common goal in mind is to make sure that patient is taken care of appropriately.
Getting everyone together and collaborating. Doing things like this. But, I also think it's, again, I go back to that same thing is coming to a burn center that knows how to debride a wound. So how do you define those centers?
We're able to acquire second burn fellow in our place. I would love to produce burn surgeons like me and you. That's the goal.
Dr. Crombie:
I think you brought up key points. Pointing out the things you and I do in the operating room to them. And also sharing the tinctures of time – lessons that we’ve learned as well.
Dr. Hartman:
Some people just get in there, and they debride and debride. To me, it's erratic. And so, I'm always like, hey time out, slow down. Let's be systematic about this. I think that's an important concept.
Dr. Crombie:
Well, thank you so much for your time and your expertise.