Award Report - Daisy Ryan

Daisy Ryan reports on her medical elective to Perth, to which the alumnae fund contributed.

I travelled to Perth, Western Australia to complete my medical elective – a compulsory part of my six-year medical degree that I am undertaking at Brighton and Sussex Medical School with an intercalated research year at King's College London.

The Elective:
At the top of the Royal Perth Hospital is the Telstra Burns Unit. It is a relatively new department, having been opened in February 2008 following the completion of the Inpatient Burns Unit in December 2007 – affiliated with the adjacent new state trauma unit. The biggest driver in the development of these specialist facilities was the 2002 Bali bombings where 23 patients with up to 80% TBSA (total body surface area) burns had to be airlifted to RPH for life saving intervention. Vast media coverage following the events highlighted the team's tireless effort to deliver uncompromising care in an unprepared environment- sparking enormous funding for RPH and the development of their specialist units. Professor Fiona Wood (my supervisor) headed the disaster relief and has been named Australian of the Year as well as Australian Woman of the Year and “Most Trusted Australian”, for her intervention, research and public education. With such a high profile mentor, the weeks ahead were daunting to say the least!

The department itself was made up of three Consultants, a Burns Fellow, Registrar and Resident Medical Officer as well as nurses, physiotherapists, occupational therapists, a dietician, a social worker and a clinical psychologist. The McComb Research Foundation as part of the Telstra Burns Charity is linked to RPH to provide clinical research staff for the Burns Clinical Research Outcomes Project (BCORP) – I used data gleaned from this database in a research paper I compiled on behalf of the unit.

With Western Australia being Australia's largest state, access to specialised healthcare is challenging. To overcome this, Flying Doctor Services act to select patients in remote areas deemed in need of specialist intervention. The Burns Unit in RPH, however, only has on average 250 inpatients a year. This is due to the existence of the Telehealth Service where specialist consultations can take place from the RPH nerve-centre to peripheral hospitals close to the patient.

Burns are the ninth commonest cause of death in WA, yet are deemed the most preventable. This provided the perfect environment to pursue my learning objectives: to understand the interventions and preventions used to improve burn injury outcome and work in a coherent team with a plethora of subspecialties not covered at my university. The majority or burns I encountered were upper limb, torso and facial as a result of adding flammable liquids to a bonfire. This caused flash burns in conjunction with smoke inhalation. Due to the burn's multifaceted presentation I was able to assist in patient physiotherapy for upper limb - optimizing functional outcome and reducing debilitating scarring. I scrubbed in and assisted in cases on the Burns/Plastics list where I watched pioneering autologous skin cell harvesting Recell, developed by Professor Wood and her team.

Partaking in pioneering CO2 laser ablation and steroid treatment of hypertrophic scars enabled me to write a descriptor of theatre setup and staff care in laser cases - which was added to the scarring outcome poster presented in Perth at the ANZBA (Australia and New Zealand Burns Association) conference. I was also lucky enough to follow a patient embarking on tissue expansion to treat circumferential hypertrophic scarring to her upper arm, where an implant was surgically inserted under the skin and slowly filled with saline over 8 weeks. This enabled her to grow new skin that would be able to cover her scars in a second surgery. Being a difficult concept to communicate to patients regarding scarring, I developed a leaflet on behalf of the consultants to aid patient understanding. This is currently being used throughout WA.

Attending bi-weekly sessions of high level teaching from specialists in niche hospital settings aided my understanding of the difficulties to be overcome when working in a large and sparsely populated area. Ad-hoc teaching from specialist burns nurses regarding wound care and infection control; physiotherapists involved in maximizing patient mobility and doctors debriefings following surgery furthered my knowledge. The weekly burn Grand Round meant I observed the multidisciplinary team in action and understood community care following patient discharge after extensive burns. I now feel confident taking a burn history from a new patient as well as understanding their progress in follow-up meetings from the clinics I was in and the patients I clerked.

Having spent eight weeks of my elective in the clinical setting, I spent the last four weeks in the research suite. Here I had the opportunity to compile my case report of a patient that had an unusual presentation of Sweets Syndrome following scalds. This gave me the chance to work closely with the burns team, plastics team and the dermatology team when it came to the patient diagnosis and treatment plan of such an unusual complication following a simple partial thickness burn to the dorsum of the hand. I will be presenting my findings at the annual BAPRAS conference in Edinburgh in April 2014. I also completed a long term follow up paper using the BCORP data collected over 11 years at RPH to generate a predictor for a patient's time-scale in returning to work (RTW) post burns. The data showed the main determinant of time to RTW was burn location, %TBSA and employment status prior to injury. The paper is currently being edited by both my clinical and research supervisors prior to publication in conjunction with a poster presentation I have been invited to attend in Singapore.

My time spent in RPH was incredible. It was a setting in which I was able to improve my research and communication skills and I would like to thank the LEH Alumnae Award scheme for their generous donation, allowing me to complete my elective. Without their help I would not have had the chance to stay for so long and pursue the opportunities I had. It has allowed me to experience a new clinical setting and further my portfolio and career prospects.

Daisy Ryan, LEH 1997-2008


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