The Writer’s Guide to Burns, Part 1: Depth and Percentage
First, I would like to start this post with a little bit of a disclaimer. Burns are absolutely horrific things. They can destroy our sense of self, of even being able to see ourselves as truly human. They inflict pain in such types and amounts as to be mind-boggling, perhaps even debilitating. This series comes with content warnings for burns, childhood burns, pain, critical illness, ICU stays, and comparisons of human flesh to that of animals. Ultimately, it’s what we are.
A quick image search will turn up horrendously graphic images of people whose lives have been completely changed–some might use the word “destroyed”–by burns. I’m endeavoring to keep the images to illustrations, rather than actual photographs. I may succeed, I may not. I strongly recommend you do NOT search for these images. They’re absofuckinglutely horrific.
For my own part, I’ve collected people out of fires, and not all of them have lived. I’ve done my best to keep them alive and deliver them safely to the burn unit. I’ve also spent a brief amount of time rotating through the burn unit at a major, world-known medical center and have been fortunate enough to get lectures from their staff on a couple of occasions.
Being exposed to people who’ve been burned like that changes you.
It changes the way you’re willing to perceive human lives. We are no longer indestructible. We are knit of flesh, and we roast, just like any other. We are so very, very fragile.
In this series of posts I will do my best to keep these memories out, to stick to the medicine and not the experience. But it may creep in around the edges.
So this series is dedicated to burn victims, to their families, and to the godsdamned courageous Burn ICU nurses and doctors who care for the most-badly burned. Thank you for all that you do.
Burn Depth and Degree
There are multiple ways to classify burns. However, I’ll use the two most common ones, which classify burns based on depth.
Burns are typically classified into degrees, which talk about how far into the skin burns go. I’ll go into detail after this handy illustration, courtesy of Medscape (WARNING: That linked slideshow contains graphic images).
First-degree burns are the least serious. They damage only the top layer of skin (the epidermis), and tend to come from the coolest sources around. The skin may turn red, and be painful, but won’t be permanently damaged. Humans can develop first-degree burns from thermal (heat) sources, or from UV radiation, such as a sunburn.
Second-degree burns are more serious. As you can see above, the dermis, the underlayer of the skin (which contains things like sweat glands and certain nerve endings). Burns like this may blister – this is a relatively reliable indication of a second degree burn.
I cannot overstate this enough: second degree burns are extremely painful, especially across large areas of the body.
Third-degree burns are burns that have made their way through the entire layer of the dermis and into the subcutaneous tissue. These are the burns that destroy underlying blood vessels and cause them to coagulate, that destroy nerve endings.
The tissue itself may look waxy and white in color, or it may char over or turn brown. It may gain a leathery appearance.
Third-degree burns may also continue to burn deeper, causing damage to the underlying muscle and even bone. Burns, under the right circumstances, can cause amputations, though these are rare.
One other thing worth noting about 3rd-degree burns: the center of them doesn’t hurt, because the underlying nerves have been burned away. However, no 3rd-degree burn is isolated. Because that tissue retains heat, it will always burn the area around it. A third degree burn will always have a circumferential a second degree burn around it, and that second degree burn will hurt all to hell.
4th-6th degree burns: You may sometimes see people referring to burns as “4th degree” burns, all the way up to 6th degree burns. This is an older nomenclature; these numbers indicate burns below the depth of the skin, into the muscle tissue and underlying organs. But this is, at least in my service area, outdated terminology. Burns this deep are still categorized as 3rd degree.
Partial- and Full-Thickness Burns
This is an easier way of classifying burn depth. Partial-thickness burns only involve the epidermis and potentially part of the dermis layer – 1st and 2nd degree – while anything worse involves all of the dermal layers (3rd degree). The burn unit I’ve worked most closely with actually prefers this nomenclature, but the other is so well known I had to include it as well.
Common Burn Sources
Burns can come from one of several sources. They may be because of direct heat, such as in a house fire, or from a hot liquid splashing on someone. Critical burns have come from coffee cups and frying pans, especially in small children, who love to grab at things without understanding why grabbing the pot handle on the stove may be a terrible idea.
This blog does not give real world advice. However, if there are small children near you, turn your godsdamned pot handles IN on the stovetop. Childhood burns are preventable. Prevent them.
Yes, I’m willing to break a very strict blog policy I’ve had since day one for this. It’s that important, and it’s that simple. Don’t give them anything to grab.
The Rule of 9s
Estimating burn size is an inexact science, but we’ve sure tried! The Rule of 9 gives a quick estimate of “percent” of the burn – specifically, the percentage of the patient’s Body Surface Area that’s burned (%BSA in medslang).
The chart looks like this:
As you can see, each aspect of the body accounts for 9% of total body surface area, except for the genitals, which account for 1% of BSA regardless of configuration or size. As my EMS instructors like to say, even Ron Jeremy’s 1% is still only 1%.
So a person with complete circumferential burns of one leg would have burns over 18% BSA (Anterior: 9, posterior: 9; 9+9=18%). Meanwhile, if the burns encompassed the abdomen and anterior right forearm, their %BSA would be 13.5 (9% + 4.5%). A burn over the entire lumbar area, half the upper back, and entire left arm would have (9% + 4.5% + 9% = ) 22.5% BSA burns.
For smaller areas, the area of the patient’s palm is equivalent to 1% of BSA.
For writing, %BSA is only important as a throwaway comment, but it’s worth the quick math to figure out how much the character is burned so a medical character can sound like a smartypants. (“Mister Rogerthorn has full-thickness burns over 36% of his body” sounds quite official!)
That’s It for Part 1!
This post is running long, so we’re going to stop here for now. Next time on this series we’ll talk about burn first aid and field care, along with co-morbidities we might see (including inhalation burns and carbon monoxide poisoning).
Thanks so much for your time, and for your attention, and I’ll see you in Part 2!
xoxo, Aunt Scripty
