Dr. James Jeng on Why He Almost Always Does Multi-staged Burn Excision

In this episode, Dr. Roselle Crombie, a general and burn surgeon from CT Burn Center, Yale New Haven Health System, speaks with special guest Dr. James C. Jeng, general, burn and trauma surgeon at the University of California-Irvine Medical Center.  Dr. Jeng shares why he almost always does multi-staged burn excision and grafting surgery, and what he thinks surgeons have to look for beyond robust bleeding.

The opinions expressed, and techniques described, herein are general in nature and based on the clinical experience of the presenting physician. Physicians should use their own professional judgment and consider patient-specific factors in treating their own patients. 

Dr. Crombie is a paid consultant of Integra LifeSciences. Neither Dr. Crombie nor Dr. Jeng has been compensated for their participation on this podcast.

Visit the Tissue Technologies blog to learn more.

Transcript

Dr. Crombie:

I think you could just introduce… I can’t even say everything that you’ve done. Your contributions to medicine and burn care… just thank you. And you’re still going. 

Dr. Jeng:

Well, thank you. Predominantly, I'm an academic burn surgeon, but I'm also a full-fledged trauma, EGS, critical care and wound surgeon. Surgical critical care. This is about 30 years into my career now. I was trained by one of the great people in burn care, Marion Jordan, and with every passing year, the little nuances that I have to share with the youngsters, I trace directly back to my lineage to Marion Jordan. So there really is a coaching tree here. I'm currently at the University of California at Irvine. I'm the gray hair in the burn shop, meaning that I'm not the director. I work for Victor Joe. But I'm the one who has all the stories over 30 years of taking care of burns. And I'm also responsible for wounds on the University of California Irvine campus.

Dr. Crombie:

Fabulous. So, you've had a long illustrious career. One of the things that I always ask surgeons is, because we were never born knowing exactly how to look at a wound, how to debride. Go back to the beginning, when Dr. Jordan was teaching you. What are the things that you looked at then that may have changed over your career that you can share with the youngsters in terms of debridement?

Dr. Jeng:

Training was a lot more harsh back then. And the premise of training back in the eighties was see one, do one, teach one. And then after you got to the see one, do one, there'd be a long period of time where you're still an apprentice and a journeyman with the master still criticizing you on every case that you do.

That's how I learned to do burn excisions. I would sit at the foot of his table at the end of work every day. And we would go over the cases of the day and he would go over why my skin grafts failed. And he said to me once Jimmy, “You think the skin grafting stuff is real easy, don't you”? And I said, “uh-huh.” And then he took me behind the wood shed and just read me the riot act. That's how come your skin grafts are failing. And so it was by this rigorousness and daily education at the feet of a master that I learned what an adequate excisional preparation for skin grafting is. And all sorts of tricks about how to handle tissue and what can, and can't take a skin graft. And what are the special considerations when you're applying skin grafts on different surfaces.

Dr. Crombie:

So let's dig a little deeper into those four things you just mentioned. Looking at the wound bed. What do you look for? You've got a resident, a fellow medical student that's asking you, how do I know I'm deep enough? How do I know I've gotten all the burns? What are you looking at in the wound bed specifically?

Dr. Jeng:

That's an impossibly difficult question and it's an impossibly difficult thing to teach because the real art of excisional preparation for grafting is in that very question that you're posing. You can take a tangential knife and you can cut down to robust bleeding, but there's a lot of things that you have to look for beyond the robust bleeding to tell you whether the tissue is going to allow skin graft engraft or not. There's a lot of micro-trauma to the tissue, and there are a lot of nooks and crannies, so that even if you have really robust bleeding in the excised surface, that doesn't mean that you have a totally complete wall to wall planar viable surface. And it takes a lot of experience to really get there. Jeff Saffle who is now the past president and good friend of Marion Jordan's used to say to Amalia Cochran, Amalia, if only you would take one more pass with that Humby knife. So it's really, really nuanced to try to figure that out.

Dr. Crombie:

Got it. And then just in terms of when you mentioned autograft versus ADM, let's just talk about the wound being ready to take a graft. What are the things that you look for?

Dr. Jeng:

I'm inherently lazy and I've developed tricks over the years that allow me to be lazy with no detriment to the patient's arc of care or the patient's outcome. And my major trick is to almost never one stage things anymore. The older I get, the more I go to multi staged burn excision and grafting surgery. The penalty for losing cadaver skin or in the old days when we had pig skin to a graft take failure is somewhat trivial. The penalty from losing an autograft is unconscionable. And so I take great advantage of the fact that I can lay down cadaver skin on something that I think might be adequate, but I don't want to take away more native tissue than I have to and then come back in a handful of days and to assess whether that cadaver skin was able to engraft or not.

And the really nice thing about that is if it doesn't really stick robustly and you pull it off, the areas that need more attention are color coded. So it's paint by numbers. And at that point in time, it's color coded and you just go back and take away the stuff that's screaming by virtue its color, I need to be removed. And Dr. Jordan also taught me, there's no shame in going back even two or three times with re-excision and cadaver skin, temporary grafting to get it right, because the penalty for losing autograft is that you don't close the hole and you've created a new hole. And in big burns, you're flirting with the undertaker.

Dr. Crombie:

So say you have an area, the wound bed is ready. How do you personally in your practice decide do you want to use a dermal substitute here or do you want to just autograft it? What are some of the tenets that you look for?

Dr. Jeng:

There are so many factors that go into that. If you're in a lifesaving mode where the Baux Score is high, you're not really going to be worried about cosmesis. And in that instance, the trump card is cadaver skin. A matter of fact, with the federal government we're stock piling cadaver skin in a national strategic stockpile because it's magic. It's live human skin that you basically have as much as you care to have, and you don't open up donor sites. If it's not a hail Mary save somebody's life sort of thing, then cosmesis really comes into play for me. And at that point in time, we'll go through all sorts of shenanigans to try to have as cosmetically good an outcome as we can.

Dr. Crombie:

So just in terms of the beginning of your career when you started with Dr. Jordan and now. If you could give two basic tenants about debridement that you think are important to kind of convey to your residents and your fellows, what would be that be?

Dr. Jeng:

I think the number one take home lesson is you should almost, almost never single stage, unless you are absolutely sure that it's going to be one and done successfully. I think that you need to have enough humility to know that when the gray hairs are not single staging, it's because they've stepped in it a bunch of times, and it's really kind of unconscionable to have an autograft failure and then have a new donor site, and a recipient site that are both open. So that's the first take home.

The second take home would be, there are very different modes of care for a burn patient. And when you have a high Baux score, your approach to closing the wounds by excision and grafting has nothing to do with a situation where you're not in a life-threatening situation. And you basically have a totally different outlook.

And if I may, there's actually another evolution in my career. I did a lot of translational research when I was younger on conditionally viable tissue. And I've always seen the burn wound as conditionally viable tissue as is stung myocardium after heart attack. Or brain tissue after a stroke. And there's a lot of evidence, both from my work and others' works that early on after a burn, the components of the skin have a lot of viability, but that viability continues to devolve over time. Over the next 24, 48, 72, what have you, hours after the injury.

And I'm a huge proponent of trying to go in there and hold onto the conditionally viable tissue. Because I think that the outcomes both in terms of the large surface area, hail Mary Burns, as well as the cosmetic outcomes are much better if you can salvage conditionally viable dermis. But that means getting in there. Because what I've tumbled to is death begets death. So if you have dead tissues sitting next to conditionally viable tissue, that conditionally viable tissue will probably go on to die either, apoptosis or necrosis. And if you can, early on remove the necrotic tissue and coax the conditionally viable tissue to survive, it really is where my practice as a very senior burn surgeon is headed. It's graduate seminar stuff. So it's not for the beginners, but it's something to strive for as you become from apprentice to journeyman to a master.

Dr. Crombie:

Right, right. Agreed. And I think we had talked a lot about how that takes time.

Dr. Jeng:

You can't do it overnight. It's not shake and bake.

Dr. Crombie:

Like, decades. I'm curious to hear your thoughts on any other specific differences between how you approach a child, like a baby versus what we were talking about in terms of debridement. 

Dr. Jeng:

Well, first of all, I'm terrified of taking care of injured children. It's terrifying. And it's terrifying because this is somebody's child and there is nothing worse emotionally than losing a child. But the flip side there really is something about youth, not only in terms of the whole organism, but in terms of the tissues. And there's a resilience to the tissue. You can just do a lot more with the tissue and it's more forgiving. And also the fact that the surface area is small, it allows you to concentrate and really bring out your A-game with the micro technique in a child that you can't with an adult, because the adult is large surface area and it's backbreaking, sweltering, physically challenging work. In a child the areas are smaller and the tissues are very forgiving and very pliable. And it's a joy to operate with such young tissue, but it's terrifying operating on sick kids.

Dr. Crombie:

Along that same vein, theoretical big 80% or 90% burn. What are your thought processes in your practice about when you take them to the operating room, how long you're there, and if you're there for short or long, what makes you change the duration of it? And then what are you thinking of in terms of how you're managing your fellows and your residents?

Dr. Jeng:

I just looked after an 83 year old with a 51% burn. He was in relative good health. He was a vegetarian, he was a little bit skinny. And I'm fairly new to UCI, it was about month three then. And so there were a lot of eyeballs on me. It's like, what is the old man going to do? And we spent a great deal of effort, really nailing the resuscitation and going after my bag of tricks. Because 83 year olds with 51% burns do not resuscitate smoothly. But we went through my bag of tricks and got him ready for the OR within 48 hours. In fine fettle, not intubated. And we went to the OR, and I basically tangentially excised all the necrotic tissue with dermis everywhere left behind conditionally viable, except for the back of the thighs and the buttock, which had to be a Bovie excision.

And he had a probability of survival of about one in seven, according to the NBR. We were close. He got through a couple of rounds and the cadaver skin that I had put on the dermis all took. The only cadaver skin that failed was the one that went on the fat. So when it's a hail Mary situation, I try to resuscitate in fine fettle as quickly as possible. And I try to hold onto dermis as much as possible. I do believe that the conditionally viable dermis still has some immunological barrier function, even though you don't have an intact epidermis. And the fact that I was able to engraft cadaver skin on the vast majority of this very large burn and an 83 year old continues to excite me about this thesis, that I practiced towards the end of my career as an aggregate of all the tricks I've learned over 30 years.

Dr. Crombie:

Fabulous. So now I'm going to lead you a little bit, but why did it fail on the fat? What's your thought process? What are the things when you talk to your residents, like why things fail on fat sometimes?

Dr. Jeng:

Fat is very unforgiving. If you look at the microscopic anatomy of fat globules, they typically have one feeding arterial, and one feeding veinule, draining veinule that comes out the bottom of the fat globule. And if you torque that in any fashion, you basically kill that fat globule and then you have this puddle of dead fat, which invites bacterial overgrowth. And this was also on a dependent area, the buttocks and the back of the thighs. The take home lesson for me from that case was I probably should have gotten either Clinitron bed, or I probably should have done what Bill Hickerson does and put the patient face down and put Billy lights on it to get it to dry out. Because truly the skin graft adhered everywhere else, except for the fat. Fat is very, very, very unforgiving. It's hard to do.

Dr. Crombie:

So you started mentioning a little bit of the physiology of, it dies off it kind of bubbles there and then invites bacteria. And then you and I are always constantly battling biofilm. How…what are you looking for in the wound to say that, oh gosh, I've got some biofilm here and then what do you do about it?

Dr. Jeng:

I'm not as good as you about reading the biofilm, the talisman that I have for that biofilm and the bacterial overgrowth is the failure for the cadaver skin to adhere. If the cadaver skin becomes adherent, I know that my bacteria count is in zone. And I know that my arterial supply is adequate. So to me, it's adherence of the cadaver skin. I also find that if I'm in a tough situation, like these cases we're talking about, meshing two to one is very nice. To not have puddles forming under sheets. It's very, very, very nice.

Dr. Crombie:

That’s excellent. To pivot to an analogous topic, one of the other expertise that you have is really managing some complex wounds. How is that different in terms of say a necrotizing fasciitis, different from a burn and how you would approach that in your debridement and what are you looking for in the wound?

Dr. Jeng:

The wounds are—boy, are they complicated. You need to look at multi-azimuth problems and knock each one out in detail. First, you need to make sure that it's not diabetes driven. And if it is diabetes driven, then you need to get good control of the diabetes and A1C. If it's not diabetes, then you need to make sure that there's not a venous drainage issue because venous pooling is just going to rain on your parade. And then finally you have to worry about arterial inflow. And that's why the vascular surgeons are so very important there. Also radiation wounds, you can't win in radiation wounds. There's nothing you can do about that. So I think with wound care, I think you need to recognize early on that there is a large subset of the people that you take care of who are basically maintenance patients.

You're never going to close them, and you don't want to hold out hope for them that they're going to be closed one day, but you sell to them the fact that, Hey, we're maintaining this quite well, and it's not crimping your lifestyle. And by the way, we like to see you every one or two weeks for the social visit. 

So it's really patient selection with wound care. And then once you get the right subset that's healable, it's the same basic stuff with the wound bed preparation. The only other sneaky trick that I have from three decades is my understanding that in a hostile recipient bed, mesh graft doesn't work very well. It's kind of like the lost colony of Roanoke in North America. When you're trying to colonize in a hostile recipient site, you need to have a large colony because if the colony is not large enough, when the supply ship comes back from England, 12 months later, the colony's dead and died.

Chronic wounds tend to be hostile environments, no matter what you do to prep them. What I find is that a large plug of tissue like a punch graft, or even post-it stamp grafting, seemed to work better in a hostile recipient site. I learned when we had some 95, 98% burns in Washington DC, that were in hospital for a year or a year and a quarter. They became so highly colonized towards the end of the year that you couldn't get anything to graft on them except for these larger colonies of post-it stamp grafts. 

Dr. Crombie:

Those are amazing. As we're talking, I'm just amazed that the tool bags that you have in your back pocket to kind of face a lot of challenging situations.

Dr. Jeng:

Marion taught me very well.

Dr. Crombie:

Yeah, and I realize that. And I think about just the purpose of having this discussion and talking about education. What do you think is the biggest challenge that you and I have? Our world as surgeons have changed. There's a pandemic, there's currently a war. As we talk about our specialty, whether it be burns or reconstructive plastic surgery, wound debridement. What do you think is the biggest challenge that we are facing?

Dr. Jeng:

Well, the first thing that I'd like to say is that we are in a true crisis mode. You know that I do a lot of disaster preparedness and civilian defense. We are really in deep trouble because the training pipeline for burns was cut off almost 20 years ago now, and the young trainees do not have exposure to burns as you alluded to. It's just the young faculty members who have no interest whatsoever and no burn fellowship, and they're just stuck doing it, right? So that needs to be reversed at the highest level of urgency with the American Burn Association in conjunction with Organized American Medicine, AAMC, et cetera, et cetera. You need to return the pipeline of burn training, formal burn training, to the American surgical craft.

The other remedy to these problems has to deal with mentorship. And one of the most valuable things that I did as a young burn surgeon was to go on the traveling fellowship. And the American Burn Association has this traveling fellowship, which is pretty much yours for the asking, which allows you to go around the country and see how things are done by different shops. There's 20 different ways to skin a cat. And I've never visited a burn shop and I've traveled all over the globe, visiting burn shops. I've never visited a burn shop that I didn't walk away with something that was a real gem, that I added to my bag of tricks.

And even my young associate right now, I keep trying to get her to sign up for the traveling fellowship. We are all responsible for educating our following generation of burn surgeons. And I think cross pollination of ideas—by actually getting them into people's different ORs—is beyond measure in terms of its value. There's a lot of art that's disappearing with old farts like me, and we want to transmit the knowledge before we're in the grave.

Dr. Crombie:

Well, thank you for sharing your thoughts.

Dr. Jeng:

Sure. My pleasure. We learn them by making mistakes, too. 

Dr. Crombie:

Understood. And we actually talked about that. I think we all made a lot of mistakes, right? 

Dr. Jeng:

You have to be humble.