Treatment is a byproduct, not the focus: Inside Bangladesh's largest specialised burn institute 

Md Robin Miah was one of several firefighters who were severely injured in Chattogram's BM Container Depot explosion in June last year. Despite 60% burns on his body, he underwent surgery where skin from his leg had to be grafted to treat the burns on his back.

"I am grateful to the doctors and the hospital," said the 22-year-old firefighter, who had been flown in on a helicopter to the capital's Sheikh Hasina National Institute of Burn and Plastic Surgery (SHNIBPS) for treatment. Twenty-eight days after admission, he left the hospital and resumed duty late last year.

In extraordinary cases like that of Robin, firefighters or victims are flown in. But that is not the rule of thumb. So for someone belonging to the lower-income class, let's say in Rajshahi, it is not possible to afford to be flown in by a helicopter to Dhaka, says Dr Samanta Lal Sen, the Chief Coordinator of SHNIBPS.

"The first 24 hours after an accident is the golden hour for treatment," Dr Sen explained.

To that end, on 4 July 2019, the country's first specialised burn institute – the 500-bed, 12-storey Sheikh Hasina National Institute of Burn and Plastic Surgery – opened, not just to treat patients, but to expand the scope of research, increase the number of specialised doctors and also expand burn treatment facilities across the country.

Given the increasing number of fire incidents in the country and the resulting loss of life, it was a long time coming.

"What year is this?" Dr Sen quipped, "It took us this long, but we are finally here." The first burn unit of five-bed at the Dhaka Medical College Hospital was started by the country's first plastic surgeon Prof. Dr Mohammad Shahidullah in 1986. Dr Sen was posted there by then.

According to Dr Hossain Imam, assistant director at the institute, it is not just a first in structure, but also a first in "thought process". He went on to explain how burn treatment at the institute is a by-product of its operations, but it is not the main focus.

"The main focus is training manpower and conducting research."

A skin bank and other medical interventions

Spearheaded by Dr Sen, a skin bank has been established at SHNIBPS — a first in the country. "And we are the only hospital that is working on this," Dr Sen said.

Skin banking is a process in which skin is removed from a donor's body, tested for suitability as graft material, packaged, stored, and finally reused as a graft. Skin grafts can be autografts (patient's own tissue) or allografts (tissue taken from another person).

"Using artificial skin [known as Integra – a synthetic skin replacement used to reconstruct wounds after elective planned surgery, or after trauma] for grafts is not feasible," said Dr Imam. "10x10cm of Integra artificial skin costs Tk1-1.5 lakh," he explained, adding that this exorbitant price is not sustainable for a government hospital to treat all the patients.

But in the case of a skin bank, it will almost entirely circumvent that cost and work wonders in terms of healing and treatment — which the current dressing materials cannot do.

"We are prepared. The legislation and awareness are the missing pieces. India and Nepal already have a national skin bank," said Dr Imam.

As with any other organ donation such as kidneys, eyes, etc., there is a set of rules, processes and regulations to follow, mainly from the government. More importantly, people are not quite sensitised to the idea of donating skin.

"Abroad, pig skin is generally used for this procedure," explained Dr Sen, "but that will not be possible here. For us to familiarise people with donating skin, it will require campaigns and seminars. If I just go out and start asking for skin donations, I am afraid it will not bode well."

But this is essential for burn treatment, he added.

Among other techniques, the institute is also working on a cheaper dressing material for primary burns. The amniotic fluid found in the placentas (a product of childbirth) is useful in making dressing material.

"And it is cost-effective. We [SHNIBPS] have an MoU with the central Nuclear Medicine Department located in Savar, which collects the placentas and sends them to us.

This promising trial phase, if all goes well, can be put to commercial use in 1-2 years," explained Dr Imam. It will be possibly the first locally produced dressing material (most materials for dressing materials are imported) and cost Tk2-Tk2.5 for 6x6cm of placenta-derived dressing. The current price for the same size of hydrocolloid dressing used now is Tk160-170.

Currently, there are 26 working research papers on specific medical interventions at the institute.

In 2017, Reuters reported on doctors using tilapia fish skin for burn patient treatment. Have you considered it? "We have yet to implement that use. Most definitely, we are considering it," said Dr Sen.

But realistically, there is limited potential in this procedure. "Brazil has not been able to commercially use this procedure as of yet," said Dr Tanvir Ahmed, Plastic, Aesthetic and Hand Surgeon and Associate Professor at SHNIBPS.

"With such medical innovations or practices, there is research involved. And more importantly, there is a lot of retrospective involved in making it available for general use," he said, adding, "The tilapia fish that is available in our markets are skinned in a way that makes it futile for fish skin graft procedure. If you look closer, Brazil cuts their fish in a different way. Even so, if the fish is cut in the correct way, for realistic general use, whole new systems need to be put in place to make the fish available for use in burn institutes. There is a limited time frame too."

The shortcomings

But a pressing issue lingers — the number of doctors specialising in plastic surgery.

"Burn treatment is a big part of plastic surgery," said Dr Sen. "The equipment is there, but we need more trained doctors to fill new specialised burn institutes and to treat an increased number of patients."

Although the number of doctors completing the five-year course, Master's in Plastic Surgery, has significantly increased over the years, there is still a lot of room to fill.

"Annually, we used to get say four students in 2012-2013 [from Dhaka Medical College]. This number has increased to approximately 20 students per year [from the institute]," said Dr Imam.

"Moreover, we have 2,000 posts. But [some of] these are new posts, meaning, more specialised job designations have to be created," he added, explaining the bureaucratic process of garnering more doctors and support staff on payroll. "It goes to the [health] ministry and then the finance ministry for approval."

And support services, especially nurses and doctors who look after the dressing after the surgery, are an integral and crucial part of burn and plastic surgery, the physician added.

And "We are at nearly full capacity at the moment [in early June]," informed Dr Imam, "and unlike other public hospitals we do not admit patients beyond our allotted beds."

There is an increased number of patients almost "every other day" from various accidents. "There was the Gulistan fire, the Bangabazar one; you name it, and every time, we are treating these patients," said Dr Sen.

There is also no database to record how many burn patients are being treated across the country. "This is why we have started a national burn registry," said Dr Imam, adding, "The idea is that every case [patient] treated in any burn unit across the country gets recorded in this database. And we [SHNIBPS] can track or see the status of the patient."

Prevention, however, is most certainly better than cure, opined Dr Sen, who is invested in working on creating awareness among people about how to prevent burn-related accidents in the first place.

Another issue at the institute is maintenance.

Recently, many have observed the fall in cleanliness and maintenance of the hospital. Some even asked out how the most modern public healthcare facility can have unclean bathroom facilities. On a recent visit, I too came across broken mirrors, locked stalls, muddy floors and out-of-use sinks in the bathrooms.

So why such a dire state? "You see, the maintenance is not my territory [jurisdiction]," explained Dr Imam, "I cannot even change a light bulb." The government has given the responsibility to the Public Works Department and Health Engineering Department – the maintenance of the physical structure falls under their jurisdiction. "There's certainly weakness in the policy," he added, "but our hands are tied."

How does the management work?

"See put it simply, when you walk into private hospitals such as Square or the United Hospital, you will of course see the difference from public hospitals. Their management [staff] is different from that of practising doctors. I am a plastic surgeon and also very much part of the administration. We have to run the show. We are making the best use of the manpower we have," Dr Imam said.

Expansion is key too

"The idea of a centralised burn unit, meaning this [SHNIBPS] is the one institute that will serve and treat the whole country's population, is not quite realistic," said Be-Nazir Ahmed, former director of Disease Control at the Directorate General of Health Services (DGHS).

"The budget proposal and budget allocation [for such institutes] are important [as well]," explained Dr Ahmed. This year's national budget for health rings typical, experts say, as only 5% of the total budget had been allocated for health.

And this brings us back to the primary concern: How there is a need for more specialised burn and plastic surgery institutes across the country.

To that end, a 150-bed specialised burn institute is under construction in Chattogram, which will open in two years, said Dr Sen, adding that as many as more four 100-bed institutes will be opened in Faridpur, Barishal, Rajshahi, and Rangpur. "The idea is to have a specialised unit in every divisional headquarters," Dr Sen added.

"For any healthcare initiative to be successfully implemented, first you need the political will, more than anything else, and I believe Dr Sen, who the Prime Minister appreciates, has that," concluded Dr Be-Nazir Ahmed.

burn institute / Burn Victims