Hills and Valleys is a podcast that uncovers stories from leaders in healthcare, tech, and everything in between. Straight from the heart of Silicon Valley, we give you a look at the good, the bad, and the future, one episode at a time. Brought to you by Potrero Medical.
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About Dr. Philip Chang, MD
Dr. Philip Chang MD is an Assistant Professor of Surgery in the Division of Trauma Burns and Critical Care and Acute Surgery at Weill Cornell Medical College. He’s also an Assistant Attending surgeon at New York Presbyterian Hospital. He’s a double board-certified surgeon and critical care intensivist. He also specializes in the treatment of burns of all types for adults and children as well as surgical critical care burn reconstruction laser treatment of burn scars and selected skin condition. You can follow him on Twitter @ManhattanBurnDoc
Interviewer: Omar M. Khateeb, Director of Growth at Potrero Medical
Interviewee: Dr. Philip Chang
Khateeb: Hi, everyone! I’m Omar M. Khateeb, the director of growth at Potrero Medical. I’m here in sunny Las Vegas at the American Burn Association annual meeting and I’m joined here with Dr. Philip Chang. He’s been gracious enough to join us and provide his insights on what he’s learning and some exciting things that we’ve seen in the front field of the burn.
Here’s a little background of Dr. Chang. Dr. Chang is an Assistant Professor of Surgery in the Division of Trauma Burns and Critical Care and Acute Surgery at Weill Cornell Medical College. He’s also an Assistant Attending surgeon at New York Presbyterian Hospital. He’s a double board-certified surgeon and critical care intensivist. He also specializes in the treatment of burns of all types for adults and children as well as surgical critical care burn reconstruction laser treatment of burn scars and selected skin condition.
So, Dr. Chang, thank you so much for joining us.
Chang: Thank you Omar. Thanks to you and the audience for listening.
Who is Dr. Philip Chang?
Khateeb: Dr. Chang’s, the first question I want to start is to give us a little bit more about your background because not everybody who goes into medical school decides that they want to go and specialize in burning.
What was it about burn that drew you towards it because these are the most critically sensitive patients in the hospital.
Chang: Absolutely. I was inspired to go into burn surgery after doing a burn rotation at Loyola University Medical Center in Chicago. At the time, I was a second-year general surgery resident and I was very uncertain about what I wanted to do.
I spent six of the most intense and formative weeks of my life in that burn unit and, in that unit, I was very fortunate to meet one of the giants of burn surgery, Richard Gamelli, who, really in my mind was the complete package. He ran a burn unit, took amazing care of patients, formed the burn team that delivered the top-notch care for these patients.
He was an amazing surgeon to watch the operating room. He is also a great intensivist and researcher and I had never seen someone with such deep relationship with patients. There have been burn patients who’ve been following him for two decades and just would hug him every time they saw in the clinic.
After spending six weeks there, I was just hooked on burns and thought, If I could do one tenth of the good that Dr. Emily had done at his time, I would consider my life fulfilled. Thanks to him I was able to start on a career in burns and I’ve just been thankful every day for the chance to be able to care for burn patients all over the US.
Recent Advancements in Burn Management
Khateeb: In your practice. how have you seen the evolution of treatment of burn patients go in the last few years?
Chang: We are in a specially fruitful time over the past years. There are a number of evolutions and revolutions, frankly happening in all aspects of burn care. As a surgeon especially, we’ve been blessed with an explosion of new products over the past 10 years that we in the field are still trying to figure out how to make use of.
A few of these products are being featured here at the American Burn Association, but they include things such as new dermal substitutes, new ways to expand skin including Meeks technique and spray on skin as well as combining techniques in new ways. In addition, we also have new techniques for assessing burn depth more accurately and to really track the quality of improvements and outcomes of all the burn team efforts.
Khateeb: As a surgeon, it’s more than just what you see at the level of the skin. A lot of these patients require a severe intensive treatment and follow-up afterwards.
From the physiological standpoint, what do these patients look like after they get through the traumatic event of the burns and surgery?
Chang: Absolutely. So, this is where there’s stratification in terms of the degree of a burn injury. For patients who admitted with more superficial burns will often heal without scarring. But at the same time, for genetic reason and other factors that we don’t always understand, there can be scarring even for those “less deep” burns. Then for the patients who do suffer the large body burns with, say greater than 40% of the body, these are the patients who often have the disfiguring and life-changing scars that not only affects their appearance but also set their function and their quality of life in so many ways.
It’s also beyond the scars. There are issues with chronic pain and itching as well as the psychological trauma. There are also issues with reintegration back into their family life, communities and social life as well as reintegration back into becoming productive citizens of our society. These are challenges that are not just part of the surgeons as well as all members of the burn team including social workers, nurses, physical therapists, occupational therapists, psychologists and psychiatrists.
It really does take a village of burn specials to care for each burn patient.
Khateeb: Now as a surgeon leading the surgical team, it seems that you’re definitely the point person?the Catalyst?for all of these events to start moving forward successfully. What does it take to be a good burn surgeon, after the surgery is done, in the moments of discharging the patient so that they move forward in these next steps?
Chang: I think every burn surgeon that I’ve been fortunate to train with as well as that I’ve met through the American Burn Association, other burn physicians whose commitment and their passion to really making the lives better for their burn patients.
Steve Wolfe, the current president of the American Burn Association just took the presidential address where he basically challenged the burn team to keep looking for new ways to commit to improving the lives of burn patients.
In a nutshell, that’s what he says is the mission of the burn community in the United States. I think that is the nutshell of what makes a burn surgeon outstanding for the care of their patients?that commitment to making every aspect of the burn survivor’s life better.
Khateeb: Interesting. Why do you think he said that? Why do you think he challenged the associations with that statement?
Chang: In our complex healthcare environment, there are so many distractions that challenge and can distract us from this core mission. Our home hospitals are always challenging us to improve our productivity or to generally find new sources of revenue.
There can also be challenges with electronic health records, not to mention the sheer volume of patients that we see. It’s important to have that shining light to guide us through all these various challenges that are very important to deal with but, at the same time, can sometimes distract us from our core mission of taking care of our burn patients.
Khateeb: We definitely have a lot of medical students and residents who do listen to this program, so generally speaking, how long is a burn patient in your care as a surgeon?
Chang: The rule of thumb that has stood for a long time is that for roughly every 1% of the body surface area burned, we usually assume at least one day in the burn ICU. And this will, Im confident, be modified, especially if the patient has multiple medical comorbidities or if they’re more complex injuries. However, that rule of thumb has held steady for the past five decades.
For example a burn patient who’s suffered maybe 80% TBSA (total body surface area) burns over their body, we roughly expect that they’ll be in the burn unit for two-and-a-half to three months, but that doesn’t include the time that these patients will often need in rehabilitation or patient therapy, and the recovery time where they will need to continue working with outpatient therapist as well as both psychologist and psychiatrist to make a meaningful recovery.
Khateeb: I think all parts of medicine, as you’ll agree, is definitely emotionally laborious work. There’s a lot of emotional labor that goes into it.
It seems definitely so with burn patients because of how traumatic it is. What was the event or what story is there that really turned you on into saying that you want to dedicate your life’s work to this type of patients?
Chang: When I was in Burn Fellowship Training at the Shriners Hospital in Northern California, I had the privilege of taking care of a young boy who had suffered burns over 95% of his body.
He was in the hospital for almost over 400 days and despite the prolonged period in the hospital, he never gave up. He always kept all God’s desire to leave the hospital be able to go back home. It was just so life-enriching and inspiring to see that he was able to survive the grievous injury he’d suffered and to make it back home. I had the opportunity to see him in the outpatient clinic a couple times after he was discharged and I could see that he was able to enjoy a wonderful quality of life with his family, albeit with many challenges.
However, seeing that recovery was possible and that patients’ lives are able to continue was incredibly inspiring to me and it gives me the inspiration as well as the realization that there’s much work for us in the burn community to do.
Khateeb: One paper I read of yours, which I thought to be very interesting and I believe you wrote when you were a resident was a paper on fluid resuscitation.
Tell us a little bit about it. What are some of the important keys and hallmarks of good fluid resuscitation when it comes to these burn patients?
Chang: Past pioneers in the burn field, notably Charlie Baxter and Tom’s Shires, had established a lot of the key work back in the ‘60s detailing the need for massive fluid resuscitation for patients with large burn injuries. I was really one of the key pillars that helped dramatically improve burn, the realization that fluid resuscitation was necessary. Over time, we’ve had a number of debates and changes in the field in terms of what fluid we should be using.
Should we be using albumin? More recently there have been developments in terms of using computer-guided algorithm systems such as arches navigation to help guide fluid resuscitation. One of the most exciting developments that was just talked about this meeting yesterday was the fact that there is a multicenter clinical trial being sponsored through the American Burn Association to really look at this issue. Questions like what are the benefits of adding colloid and crystalloid resuscitation for burn patients and can we definitively show the benefits of a mixed approach?
Despite this, there are still complications that occur through our aggressive fluid resuscitation such as compartment syndromes, lung injury, sometimes acute kidney injury as well as other organ failures.
So, there’s still much work to be done in terms of our knowledge and use of fluid resuscitation for burn patients.
Khateeb: Let’s talk about that and rope it back to the theme about the challenge that was put to the ABA of constantly innovating. Compartment syndrome, let’s start there.
What’s the issue with compartment syndrome in terms of the complications?
Chang: Especially for our medical students in the audience, there are a number of compartments in the body which are enclosed either with a tight fascial covering such as the muscle compartments in the lower extremity, our abdomen which is encased in the peritoneum or our brains which are encased with scalp and.
With large fluid resuscitation, there’s often edema that forms in these various compartments. If you have this expansion, but you’re limited by the tight sheath, the increased pressure in turn can block off venous outflow. Then if the pressure’s a little tight, it can block an arterial inflow and this can lead to permanent damage to muscles and nerves in the case of the lower extremities. In the case of the abdomen, that can lead to damage to the kidneys as well as impairment of respiration while in the case of the brain, it can lead to permanent brain injury. So, all of these compartments are at risk when a patient is receiving massive fluid resuscitation.
To put things in perspective, say a 70-kilogram adult suffers like 70% TBSA burn might end upwards of more than 20 liters of IV fluids in the first 24 hours of their fluid resuscitation. If you think about it. that’s adding almost 50 pounds of water to the patient’s intravascular space. For almost any other patient in medicine, giving more than two liters of fluid it can often make clinicians nervous.
When you’re delivering dozens and dozens of liters of fluid, that can really affect the patients for the physiology adversely.
Khateeb: Interesting. I could completely off on this number, but I think a regular human being physiologically expels 20 liters of fluid a day of fluid more or less, right?
Chang: For a normal person not doing sets of exertion, we assume like 2 liters in total.
Khateeb: 2 liters in total? Okay. So, it’s a lot less. You also mentioned that a lot of times in fluid resuscitation you give upwards of 20 liters. What kind of pressure and stress does that place on the body and specifically the kidneys if they’re not working as well?
Chang: It’s a great question. One aspect of burn patients that makes them different is the fact that the reason they need this extra fluid is that their capillaries become permeable and leaky in a state that really is unmatched by almost any other disease state of apart from maybe acute pancreatitis.
Let’s say you give a leader of IV food, maybe only 10% of that food will stay in the intravascular space. The remaining 90% of that food will go out into what we call the first space; the interstitium or other body compartments. So, even though you give a lot of this food, the key organs such as the heart, kidneys and the brain only see a small percentage of food. That’s why there’s such a need for massive food in the first 24 to 48 hours of these patients.
Khateeb: How burn physicians start to look to overcome some of the complications have you discussed? Actually, let me take a step back. What happens if we don’t find ways to accept that challenge at finding ways to innovate over these current obstacles?
Chang: Currently we have surgical means of treating compartments syndromes once they’re identified in terms of doing various releases such as escharotomies, fasciotomies or exploratory laparotomy to open up the abdominal compartments or ask our neurosurgical colleagues to do craniotomies in order to help relieve the pressure. However, prevention is always far easier than treatment.
One of the challenges often faced is diagnosing when a compartment syndrome is about to happen. Probably the best step would be to avoid getting to situation where compartment syndromes can form and that in turn goes back to third space. Is there a way we can give enough resuscitation to our burn patients without risking these potential sequelae of too much fluid resuscitation?
Khateeb: One of the things that I’ve heard a nephrologist mention was that a lot of times when they have patients?whether burn or not?who have high abdominal pressure, it’s hard to get surgeons to come in and check if the abdominal pressure hasn’t reached a certain level at which by that time, it’s already too late.
Do you feel that one of the issues right now is that a lot of these things are being caught when it’s too late?
Chang: Yes, for very systemic reasons or various variations and how the care of burn patient is organized, especially if it’s that cares not being handled at a burn center or if the hospital only sees one or two burn patients every year.
Sometimes, the carrying providers are not aware of these potential consequences of compartment syndromes or too much fluid resuscitation. Oftentimes, when the compartment syndromes are diagnosed too late, there can be lasting effects on the kidneys. To go further talking about acute kidney injury, not only is an issue of sometimes inadequate fluid resuscitation or too much fluid resuscitation in the case of compartment syndrome, but there also seems to be what we call the cytokine storm.
With a large burn injury, there is a massive cytokine release that occurs and it’s well known that a number of these mediators will often firstly affect blood flow to the kidneys. This in turn will magnify the effects of kidney injury. We’re very fortunate that our nephrology colleagues do have dialysis and every hospital. Our nephrology colleagues have been eager and willing to help support our burn patients that get into renal failure; however, the renal failure complicates the care immensely and prolongs their hospitalization.
Unfortunately, that can lead to lasting effects in their kidney function. I have had a number of burn patients who continue to require dialysis for months to years even after they have finished healing from their burn injury.
Khateeb: Interesting. The thing that’s really fascinating about dialysis?and in a scary way?is that to my knowledge, it’s the only chronic condition that you can get discharged from the hospital with; and beyond a machine for. You don’t usually see patients on ventilators or anything like that being discharged when they have a chronic condition.
For you to be able to better manage that, what do you think would be the kind of technologies or at least techniques that are needed? It seems like there’s more of a call to have more cross cross-functional collaboration between departments and it seems to be happening, but I don’t seem to see it too much at the conference level.
Chang: Within the American Burn Association community, there’s been cutting edge research by Dr. Kevin Shank out of the Joint Base San Antonio Burn Unit there. He has pioneered the use of early hemofiltration in burn patients often within the first days after burn injury to before they’re showing signs of fulminant kidney injury to basically filter out these cytokines that are injurious to the kidney.
By filtering out the cytokines using dialysis machines, in some of his research studies he’s been able to show us ways to decrease some of these harmful consequences of the burn injury.
Khateeb: So, you’re saying that the patients who come in with burns are put on dialysis even if though they don’t need it, just to filter out these cytokines?
Chang: Exactly.
Khateeb: Wow, that’s fascinating. Of the cytokines are there any specific ones that are more damaging to the kidney than others or has that not been identified yet?
Chang: There are several. I will confess that off top my head, I am a little unable to remember.
Khateeb: So what are some of the exciting things that you’ve seen so far here at the ABA conference?
Chang: Every ABA conference, I think, shines for its multidisciplinary approach. We’re very blessed that we are one of the few middle conferences were we really have every discipline that attends; from physicians, nurses, physical therapists, occupational therapists, pharmacist, nutritionist, psychologist, psychiatrist firefighters, burn prevention advocates and burn survivors. It’s really one of the few meetings that I’m aware of where you really get every specialty that attends and talks to each other at the various breakout sessions and meetings, so that we can collaborate in identifying new areas and new challenges that need to be tackled.
At this particular ABA, so far, there have been a number of sessions that have really looked at this issue of how do we assess what quality burn care is. That is definitely one of the kinds of raging issues that’s going on in our field. There have also been a number of discussions about how are we using some of these newer skin products to really help treat our burn patients’ injuries and to get them out of the hospital faster. So, it’s an exciting time in the burn field.
Khateeb: Interesting. In your current practice, in terms of techniques and new approaches, has there been anything that you’ve adopted in the last few years that just made a major change in the way your patients have been doing?
Chang: Hmmm. Currently we are working with a couple of these product companies. We’ve had the opportunity to use ReCell which is a means of expanding skin grafts. For the past several decades, we’ve been using mechanical means to do what we call “mesh our grafts” so that we can expand them to 2 to 1, 3 to 1 or 4 to 1, which allows us to cover more wound with the same amount of skin.
The Recell technology which is developed by Fiona Wood in Australia was just recently approved for use in the United States a few years ago. It gives us the opportunity to expand the skin up to 80 folds. Basically, with say a 2cm X 2cm square of skin, we?in theory?could cover 320 square cm of skin which would be huge because donor sites cause significant pain as well as healing issues for patients. So, if we are able to cover patients’ burns with just a small amount of their own skin, that would be a huge advancement. And some of the early uses have been very promising so far.
There are also other products in terms of what we call dermal substitutes such as bio temporizing matrix, another product that has emerged out of Australian research that were using to see if we can prove the quality of our skin grafts. One of the challenges we have is that in our current paradigm, we often use split thickness skin grafting which will take the epidermis and part of the dermis to cover wounds. The difficulty with this is that the quality of skin is heavily dependent on how thick we take the dermis and for various logistical reasons, we usually take very thin dermis, which is good for donor site healing but leads to problems down the road in terms of scarring for the grafted areas.
Khateeb: You mentioned the use of certain paradigms and one thing that we’ve heard from a variety of physicians is this bias called the Semmelweiss bias. So for those you don’t know him, someone watches a famous physician who discovered hand-washing but it took literally two to three decades and sometimes four or five in certain places for it to be adopted. The issue is that medicine has this habit?and for good reasons?of holding on to old paradigms.
Are there any old paradigms that the burn community might be holding onto and needs to let go?
Chang: That is an amazing question. I will say briefly Semmilweiss there is a phenomenal biography describing his challenges that was written by Sherwin Nuland, a surgeon who was a great historian of surgery at Yale.
I would highly recommend that book
Khateeb: I will leave that in the show notes for sure.
Chang: Thank you. In terms of some of the paradigms that are probably subject to change this time given the rise of new products such as next to bridge, recell, and others, we may be at a point where rather than excising and grafting every wound, frankly, it may be better to breed the wounds, go for less surgery and allow the patients to heal up with the recell. Then with some of the reconstructive advances that have been made with laser treatments and other reconstructings, we might be able to deal with the scars more readily now than we could have 20 to 30 years ago.
There’s some talk at some of the Shriners hospitals that, perhaps especially for kids with smaller burns, rather than subjecting them to surgery in order to excise and graft the wounds, we allow the wounds to heal with scarring and then treat the scars. That can be less traumatic and provide better functional outcomes for the kids. That is one major paradigm that is changing from a burn surgeon point of view.
Another paradigm that have been kind of forced to positive in terms of change has been the use of our opioids. I think you would find that most in hospitals, their burn unit is probably one of the highest users of opioid just because burn injuries are one of the most painful experiences any human can experience. However, given the concerns of the opioid crisis in our country, we’re having to find new and different approaches to help address a patient’s pain without the deleterious effects of opioids.
Khateeb: You said something very interesting that I have to point out. You said that one of the paradigms is getting away from the surgery and excision of the skin and allowing it to heal.
As a surgeon, you’re saying that we might have to let go of doing surgery focus more on healing which is impressive. I think Osler said it that: “The first duty a physician has is to educate the masses not to take medicine,” right?
Chang: Mmm mmm.
Khateeb: So, do you feel like the advent of new technology and new techniques, is allowing physicians and surgeons alike to go back to whence they came, which is less about procedures and more focused on healing?
Chang: I think it’s both a step back like you said, in terms of really focusing on what’s best for the patient, as well as the future in terms of turning our attention to some of these long-term challenges that burn patients face. I had it described by my mentors that surgery is a powerful tool, but in the end we are all doctors and our mission is to heal and to treat our patients.
So,maybe if we’re using our surgery toolbox less often, we can use other tool boxes to help our burn patients with other aspects of their condition.
Khateeb: Overall, in terms of letting go of old paradigms and moving forward, do you feel like the burn community is a little bit better than other areas of medicine moving forward on this? Or is there still some resistance?
Chang: I think the burn community is like other communities of medicine in that we are all very much reliant on our previous experience to take care of burn patients and it can be very difficult to break away from this paradigm as long as we know those techniques work for keeping our patients alive and getting them to a point where they can return to the community. Other challenges are that it’s a relatively small community. There are only about 125 burn centers in the United States and that each burn center has about 2 – 4 burn surgeons.
So, maybe there are only about 600 of us practicing in the U.S. and not all of us practise burns full-time. We’re often also covering trauma, doing general surgery or plastic surgery careers. That’s another challenge, but it’s also an opportunity because with our different backgrounds, we can bring in new advances from different fields to this issue of the burn patients.
Another aspect that also provides a challenge is the fact that there are advances in a lot of these other fields and sometimes, it takes time for that knowledge to disseminate within the burn community. For example, there’s been an explosion in the number of wound care products available in wound care clinics. However, a lot of burn centers don’t do wound care, you know in terms of dealing with patients with chronic wound care. So, sometimes the sharing of knowledge from those fields takes time.
Khateeb: With the burn patients, what are some of the major hurdles in terms of complications that come up that prolong and complicate the process? Because you have enough already to deal with speaking of the burn itself.
What other complications come up that make it a much more serious matter than it should?
Chang: The burn injury is fascinating from a pathophysiologic point of view in that it’s an injury to the skin, but that injury to the skin can have effects on pretty much every organ system. Oftentimes burn patients who are involved in a house fire or a fire to control these will have inhalation injury where the smoke and the toxic chemicals of the heat of the smoke can cause quite traumatic and severe injury to the lungs. The other downstream consequences like cytokine storm from the burn injury which affects the kidneys, the liver and even muscle mass can lead to a hypermetabolic response which causes catabolism breakdown of lean muscle mass. If the patients are not being adequately exercised or given hyper metabolic agents, this can in turn lead to them not having the strength to get out of bed just within a matter of few weeks.
Other challenges can be the need for nutritional support in these burn patients. They sometimes need twice as many calories as an uninjured person so it’s not uncommon for us to need to place feeding tubes and for burn patients to receive several months of nutritional support through that feeding tube. I’ve fed burn patients up to 5,000 calories a day just because they needed that much energy and extra protein in order to handle the hypermetabolic response of the wound-healing needs of their injuries.
Khateeb: Along with that you usually administer a lot of fluid resuscitation as well?
Chang: In the initial phases, yes. Then the challenge we face after that initial 24 to 48 hours is how do we give them enough fluids that we can account for the insensible losses that patients are losing from their open wounds but at the same time, not so much fluid that we can cause problems with pulmonary edema or other issues?
Then in the long-term, making sure that we can account for the changing fluid situation of our patients because as their wounds get closed with skin grafts and other means, their insensible loss is decreased.
Khateeb: Interesting. In dealing with these patients, is it is the first 24 and 48 hours that you’re most concerned? What keeps you up at night as a surgeon? I know I often ask something similar to a Pandora’s Box question. [Both laugh]
Chang: No, it’s a great question. In that first 24-hour period, very much how the fluid resuscitation is going is of great concern. We follow a number of parameters when we’re watching our patients in that initial 24-hour period including the urine output of laboratory markers such as lactic acid, base deficit, and creatinine. We’re also looking at hemodynamic parameters such as mean arterial pressure. A number of different birth centers use different invasive means to assess the intravascular fluid status as well as the cardiac function of the patient, for example, they either use pulmonary artery catheters or what we call pico catheters.
Some centers are now starting to use serial ultrasound assessments of the vena cava as well as the heart to assess how our resuscitation is going as well as the effects of cardiac function. So, there are a lot of tools in our tool kit, but it’s also so much data to integrate periodically. We’re always mindful of the risks of compartment syndrome.
On top of all these, oftentimes there’s delay in the families of these patients being able to find out about how injured the patients are on arriving to the hospital. That is often a different challenge that we face; communicating and reassuring these families simultaneously about the gravity of the injury and the need for prolonged hospitalization. And, at the same time, giving them hope that we have the means to help these patients.
Rarely for those patients that are so severely burned that it’s clear that medical efforts are futile, a different challenge emerges in terms of communicating with families that no matter how much we do there really is no hope for their loved one. We have to help them through that process of changing their goals of care to come from management.
Khateeb: While you’re doing the fluid resuscitation and they’re getting all these different labs markers you mentioned earlier, is there any in particular that are the gold standard which you teach your residents to always look at?
Chang: You asked a great question. There is no one lab marker that has been shown in any burn clinical trial to be the gold standard. That being said, I think every burn center definitely follows urine output even though there are difficulties with using urine output as the sole marker.
Khateeb: Why is that?
Chang: You know, in our society, we have a number of patients who live with the chronic kidney injury. So, we often get a patient who’s already on dialysis based on who gets injured in a burn injury. Then all of a sudden we are no longer really able to use urine output as a way to assess resuscitation in that patient. In addition, it’s not a direct correlation between the intravascular fluid status of the patient and the urine output that aforementioned cytokine storm seems to affect some patients more than others
Some patients with damaged kidney function can be seriously depressed for several hours after the injury. So there’s not always that correlation between giving more fluid and seeing increased urine output.
Khateeb: March was kidney months. We spent a lot of time learning a lot about the kidney and we were really surprised to see how important urine output was.
But, in the event where you don’t have a patient with chronic kidney failure and you can’t have reliable urine output, is it in fact reliable? I even remember this back in medical school, it seems like that’s the last vital sign to be really automated. There are all kinds of tools and digital technologies for things like that except, right now, for urine output; although there are different companies coming out with things for it.
If you have access to urine output, is it actually reliable right now? If so, why? And if not, why?
Chang: I would say that all of us in the field use urine output for those patients that had a normal kidney function prior to the injury, but I think most hospitals also know that sometimes it doesn’t always correlate perfectly with the resuscitation efforts of the patient.
So, I would say we use it with an asterisk as it were. Again, this is an area that is in need of greater research in terms of being able to identify from the start of the injury which patients are those upon which we won’t be able to use urine output perfectly. This is where I think genomic screening is going to come in.
There’s only been talk in the trauma community of doing genomic screens of trauma patients once they arrive. I suspect that in 5 – 10 years from now, it will be part of the standard for burn patients as well. It’s already been a great work done by Ron Tompkins and other folks to really look at this genomics profile of injury. Although it is taking time to really use the fruits of that clinically, I think that is one advancement of future that I look forward to it using.
Khateeb: Now that’s surprising. I’ve never heard that before. What do genomics and a burn patients have in common though? That’s interesting. For other infectious disease and disease in general, we’ve heard a lot about genomics, but this is the first time I’m hearing it with a traumatic event that it’s important. How would you use genomics?
Chang: Trauma and burns classically would focus on the impact of the injury on the patient assuming that all patients have the same physiologic responses to injury. What we haven’t been able to really appreciate until very recently was how much we vary in terms of our responses to injury. Such as in terms of how much, for example, do we secrete in response to this level of injury, how much you know TGIF is involved in terms of healing costs down the road
This is where I think the advanced come in terms of translational research from the basic scientist to the bedside in terms of understanding the implications of a new genomic screen for the expected hospital, of course, for our patients. And in turn, using that knowledge to really custom tailor treatments for our patients.
It’s the dream of precision medicine basically; to truly customize the medical care for each patient’s unique physiology and pathophysiology. We’re not there yet, but there are definitely efforts being made in a number of centers to truly get to that point.
Khateeb: Fascinating. Do you feel like at some point in the future there’s going to be more computer science- and data science-based lectures in medical schools so that medical students started learning how to apply and use these sort of things?
Chang: It’s already there. In fact, every time I talk to pre-medical students who I mentor, I tell them definitely make sure they’ve got their statistics training and that they have some comfort with data science.
If they have any interest in it, I encourage that students should think about doing that at least as a minor if not a major because I think those medical professionals who have the comfort with data management and data sets will be the pioneers of the next revolution in medicine.
Khateeb: Fantastic. We’re getting close to wrapping up and we really appreciate you spending time with us. For those who want to follow you and engage with you, where’s the best place to find you online?
Chang: Absolutely. You can find me through a number of ways. I’m accessible via Twitter, my handle is @Manhattanburndoc. I also use LinkedIn. I use Instagram to a much lesser extent, but I’m also available through the Weill Cornell website. I can be reached via email there and I welcome increase especially from pre-medical students and medical students who might be interested in looking at a career in burns. I was inspired by a burn surgeon over 15 years ago to get into this field.
One of the challenges we have in our field is that it’s not a field that a lot of clinicians: A, know about; and B, are drawn into. So, we are always looking to cultivate that next generation of burn specialists. If you have any interests, please reach out to myself and other burn care specialists around the country, and we will be more than eager to welcome you to our community.
Khateeb: Wonderful, Dr. Chang. Thank you so much, we greatly appreciate it.
Chang: Thank you Omar for this opportunity.
