Burn Trauma, RN Perspectives and Critical Care - Hennepin County ...

Dear Readers:
In summer 1986, as a very new emergency medicine staff physician (just a few
weeks out of residency), I received a 30 year old man in the HCMC Stabilization
room who was severely burned. He had driven his car at high speeds into the side
of a brick building after leaving a suicide note. The car exploded and burned. At the
scene, the fire was extinguished and fire fighters packed to leave. The man had no
signs of life, so was left for dead. But then he began to moan.
When he arrived in the STAB room, he could not breathe effectively because thick
burns encompassing his entire chest wall restricted his inhalation, and his mouth
was filled with burns. In most places he was burned down to his bones. His arms
were fixed in flexion, and he had no recognizable facial features. He was moaning
and his blood pressure was palpable at 60. We rapidly did a cricothyroidotomy and
escharotomy to help him breath, and then an IV cut down on the dorsum of his left
foot (his only remaining skin surface) to deliver IV pain medications and fluids. His
blood pressure slowly declined and he died shortly afterwards. He is the only case
in my career where I discouraged family from post-mortum viewing. Maybe that was
wrong, but it felt best at the time.
I understand he had a non-survivable injury. Then and many times since, burn
specialists reaffirm this. But the visual distress this patient provoked in the STAB
providers, his extreme pain, the bedside ethical dilemmas about case management,
and our obvious limited ability to “save him” has underscored for me forever the
difficult nature of caring for severely burned patients. The outcomes of the severely
burned patients described in this issue are the direct result of advances
championed by providers dedicated to improving the management of patients who
previously stood little chance of meaningful survival, and an institution willing to
invest resources for these critically injured patients. These local cases benefited
from the coordinated methods of a highly trained and regarded team, who, in my
opinion, perform miracles. Read on-I think you will agree with me.
Sincerely,
Michelle H. Biros, MD, MS
Approaches in Critical Care Editor-in-Chief
Department of Emergency Medicine
Hennepin County Medical Center
®
Every Life Matters

Contents Volume 7 | Approaches in Critical Care | February 2012
Approaches in Critical Care
Editor-in-Chief
Michelle Biros, MD, MS
Managing Editor
Mary Bensman
Graphic Designer
Karen Olson
Public Relations Director
Tom Hayes
Printer
Sexton Printing
Photographers and
Image Sources
Raoul Benavides
Fink Engineering
Aaron Gelperin
Christine Hill
Anne Lambert, MD
Karen Olson
Sheila Ryan Photography
HCMC Department of
Emergency Medicine
HCMC History Museum
Images from the History
of Medicine (IHM)
Clinical Reviewers
Anne Lambert, MD
Events Calendar Editor
Susan Altmann
Case Reports
2 If at First You Don’t Succeed…Try Honey for Burn Wound Resolution
Brandt Becker, MD
5 Limb Salvage in the Setting of a Crush Injury with Chemical Burns
Kourtney Kemp, MD
8 Extracorporeal Membrane Oxygenation without Systemic Heparinization in Patient
with Burn and Inhalation Injuries
Huy Trieu, MD, Brandt Becker, MD, Anne Lambert, MD, Reza Khodaverdian, MD
and Joseph Van Camp, MD
10 Fire Changes Lives for the Better
Ashley Lemere, MD
12 Critical Care Profile
Anne Lambert, MD, Burn Center surgeon
14 Cher Adkinson, MD, medical director of Hennepin’s Hyperbaric Oxygen
Medicine Program
16 RN Perspectives
The Art and Science of Burn Care
Steve Omodt, RN
18 Biomedical Ethics Consultation
20 Calendar of Events
22 News Notes
To submit an article
Contact the managing editor at approaches@hcmed.org. The editors reserve the right to reject the editorial
or scientific materials for publication in Approaches in Critical Care. The views expressed in this journal do
not necessarily represent those of Hennepin County Medical Center, or its staff members.
Copyright
Copyright 2012, Hennepin County Medical Center. Approaches in Critical Care is published twice per year by
Hennepin County Medical Center, 701 Park Avenue, Minneapolis, Minnesota 55415.
Subscriptions
To subscribe, send an email to approaches@hcmed.org with your name and full mailing address.
Approaches in Critical Care | February 2012 | 1

Case Reports
Burn Trauma: Three Case Reports
Severe burns are some of the most difficult
injuries to deal with in the STAB room.
They are visually frightening to providers,
very painful to patients, and likely to
require intense resources with an
unpredictable recovery.
In this issue we present three burn case
studies: an extremely severe bonfire burn
that required treatment to be done in
stages, one with complications from a
crush injury after a tractor rolled over on
the victim, and a patient with severe
respiratory complications.
We also tell the story of a familyʼs
experience when their children were
severely burned and how that changed
their lives forever. The nurses, physicians,
social workers, educators, physical and
occupational therapists, and all the people
who work in this area of health care will tell
you what they do is unique. Burn patients
are highly complex and challenging
because they can experience severe
psychological problems along with their
physical issues. Whole families are
affected and often have to make hard
decisions, as in the case addressed in the
story on biomedical ethics.
According to the American Burn
Association (ABA), 66 percent of burns
catch us off guard in the perceived safety
of our homes. The newly remodeled Burn
Center at HCMC is among only 57 centers
across the country designated by the ABA
as Verified Burn Centers with the
multidisciplinary resources and
reconstructive surgery expertise to
maximize burn recovery. Statistics indicate
that accredited burn centers lower the
mortality rate of burn patients by providing
critical advances in technical resources as
well as expertise in transport and
treatment. Over the last 30 years, the
percentage of survivable burn over a
patientʼs body has risen from 50 percent
in 1960 to 98 percent today.
If at first you donʼt succeed….try
HONEY for burn wound resolution.
by Brandt Becker, MD
Department of Surgery
Hennepin County Medical Center
Case presentation
A 19-year-old male from New Ulm,
Minnesota sustained a serious flash burn
from paint thinner thrown onto a bonfire.
He was immediately transferred to HCMCʼs
Burn Center for treatment of his significant
lower extremity and hand burn injuries.
Upon arrival, the primary surgical
“ABCDEs”, as outlined by the American
College of Surgeons Advanced Trauma
Life Support (ATLS), was completed. The
patientʼs airway was intact and was without
compromise. He was able to speak in
complete sentences and make his needs
known. Breathing was not compromised,
and breath sounds presented bilaterally,
with adequate air exchange. Circulation
was assessed, and the patient was found to
be hemodynamically stable, with extremities
exhibiting easily palpable pulses. Disability
was also assessed. The patient was rated
15 on the Glasgow Coma Scale (GCS); he
answered questions appropriately, followed
commands with all four extremities, and his
eyes opened spontaneously. Exposure was
completed by removing his charred clothing.
He had suffered burns to 40 percent of his
total body surface area (TBSA) with at
least 35.5 percent full thickness burns
(1.5 percent left hand, 17 percent right leg,
17 percent left leg) and 4.5 percent partial
thickness burns involving his face/neck,
right and left hand.
The patient was started on the Burn
Centerʼs fluid resuscitation protocol. The
Hennepin Centerʼs multidisciplinary
approach to providing comprehensive burn
care was immediately set in place.
Physical therapy, occupational therapy, and
nutrition were assessed the morning of this
patientʼs admission. Due to the extent of
the burn injury, multiple staged operations
were required.
2 | Approaches in Critical Care | February 2012

Case Reports
Discussion
His first operation for excision and debridement of his
burn wounds, followed by skin grafting, was
completed October 18, 2010. He underwent fullthickness
excision of the left lower extremity, and
placement of INTEGRA to the left lower extremity,
right hand sharp excisional debridement, and
placement of an AWBAT ® glove, one of several
specialized dressings employed in caring for this
patientʼs wounds. AWBAT is an Advanced Wound
Bioengineered Alternative Tissue that functions as a
temporary skin substitute. It serves as a temporary
wound dressing for coverage of superficial partialthickness
burn wounds, donor sites, and meshed
autografts until healing occurs. AWBAT is composed
of a very thin, porous silicone membrane bonded to
a finely knit nylon fabric, which is coated with a nontoxic
mixture of porcine collagen peptides. The
design allows for exudate removal, gaseous
transmission, control of water vapor loss, flexibility,
conformability and controlled adherence. Another
specialized wound covering, INTEGRA, was placed
over the newly excised wound beds. INTEGRA is a
bilayer matrix wound dressing comprised of a porous
matrix of cross-linked, bovine tendon collagen and
glycosaminoglycan, and a semi-permeable
polysiloxane (silicone layer). The semi-permeable
silicone membrane controls water vapor loss,
provides a flexible adherent covering for the wound
surface, and adds increased tear strength to the
device. The collagen-glycosaminoglycan
biodegradable matrix provides a scaffold for cellular
invasion and capillary growth. 1 The INTEGRA was
then dressed in Acticoat ® . Acticoat is another
specialized wound dressing employed for the care of
burn wounds. Acticoat is an antimicrobial barrier
dressing comprised of a nanocrystalline coating of
silver, and it is effective against a broad spectrum of
bacteria, as well as fungi.
Due his extensive burn injuries, over time the
patientʼs lower extremity wounds became colonized
with resistant Pseudomonas aeruginosa. Systemic
antibiotics and all typical burn topical agents were
employed to combat the wound colonization. He was
also treated with hyperbaric oxygen at HCMC. The
patientʼs wounds showed some improvement with
these methods; however, the wounds continued to
breakdown and have multiple open areas throughout
the grafted areas on his legs. Ultimately, honey
proved to be the topical agent of choice to facilitate
and finally expediate his complete wound healing.
MEDIHONEY is a medical grade Leptospermum
honey, which is considered a “mono-floral” honey. It
comes from the pollen and nectar of the
Leptospermum, or Manuka plant, in New Zealand.
Figure One. 19 year old on admission to HCMC's burn center, full thickness
burns involving bilateral lower extremities
Figure Two. Right leg with graft breakdown
Figure Three. Right leg following treatment with honey as a topical
burn dressing
Approaches in Critical Care | February 2012 | 3

Case Reports
MEDIHONEY aids in creating a moist environment,
promoting optimal wound healing. Its high sugar
content, and resultant high osmotic action, results in
lymphatic outflow, assisting in debridement of
wounds and reduction of edema. MEDIHONEY has a
pH near 3.5, which inhibits bacterial growth,
modulates harmful proteases, and improves oxygen
diffusion. 3 Multiple studies have demonstrated the
effectiveness of medical honey on resistant
organisms, such as Pseudomonas aeruginosa and
Methicillin Resistant Staphylococcus aureus (MRSA). 4,5
The Hennepin County Medical Center Burn Center
has experienced similar results in a clinical setting.
The Hennepinʼs Burn Centerʼs multidisciplinary team
utilized multiple modalities throughout this patientʼs
recovery in providing comprehensive burn care. Due
to the extent of the patientʼs injuries, six operations
were completed. Operative treatment of his burns
continued on October 15th, November 1st,
November 9th, November 23rd and December 20th
of 2010. He was discharged from the Burn Center on
Christmas Eve, 2011. The patient continued
outpatient therapy upon discharge. He was able to
return to work on the family farming operation in
spring, 2010 and attend school by fall, 2010. ■
References
1. http://www.aubreyinc.com/awbat.html
2. http://www.ilstraining.com/bmwd/bmwd/bmwd_it_01.html
3. http://www.dermasciences.com/products/advanced-wound-care/
medihoney/inside-the-u-s/technology/
4. Cooper RA, Molan PC, Harding KG, The sensivity to honey of
gram positive cocci of clinic significance isolated from wound.
J Appl Microbiology. 2002;93(5):857-863
5. George NM, Cutting KF, Antibacterial Honey (Medihoney):
in-vitro Activity Against Clinical Islolate of MRSA, VRE, and Other
Multiresistant Gram-negative Organisms Including Pseudomonas
aeruginosa. Wounds. 2007;19(9) 231-236
6. Villanueva E, Bennett MH, Wasiak J, Lehm JP, Hyperbaric
oxygen therapy for thermal burns, The Cochrane Collaboration.
Published by John Wiley & Sons, Ltd 2005
7. Tibbles PM, Edelsberg JS, Hyperbaric-Oxygen Therapy, The
New England Journal of Medicine, 1996; 334:1642-1648
Figure Four. The patient back to full activities and fully healed
Along with specialized dressings and topical agents,
hyperbaric oxygen therapy (HBOT) was utilized to
assist with graft adherence, reduce bacterial load,
and promote wound healing. Hennepinʼs hyperbaric
medicine team facilitated the patientʼs treatment
HBOT protocol. Hyperbaric oxygen therapy is an
adjunctive therapy that has been proposed to
improve outcomes in thermal burns. HBOT is the
therapeutic administration of 100 percent oxygen at
environmental pressures greater than 1 atmosphere
absolute (ATA). Administration involves placing the
patient in an airtight vessel, increasing the pressure
within that vessel, and administering 100 percent
oxygen for respiration. In this way, it is possible to
deliver a greatly increased partial pressure of oxygen
to the tissues. 6 The postulated mechanisms of a
beneficial effect of hyperbaric oxygen on burn
wounds are: decreased edema, due to hyperoxic
vasoconstriction; increased collagen formation; and
improved phagocytic killing of bacteria. 7
“Ultimately, honey proved to be the
topical agent of choice to facilitate
and finally expediate his complete
wound healing. MEDIHONY aids in
creating a moist environment,
promoting optimal wound healing.”
4 | Approaches in Critical Care | February 2012

Case Reports
Limb salvage in the setting of a crush injury
with chemical burn
by Kourtney Kemp, MD
Department of Surgery
Hennepin County Medical Center
Abstract
The patient presented to Hennepin County Medical
Center with a crush injury to the right lower extremity
with associated chemical and contact burns.
Although the patient did not have associated
fractures, he developed a mild rhabdomyolysis and
significant soft tissue damage to his right lower
extremity. Prior to his injury, he was a very active
farmer. Following his injury, his quality of life was
greatly impacted by his reduced mobility, limited
range of motion, and daily wound care. Through
multiple surgeries, consisting of serial debridements,
wound vac placements, serial reconstructive skin
grafting, and variations in wound care, limb salvage
with return of full function was achieved one year
post-injury. Persistence, patience and flexibility in the
patientʼs care resulted in a successful outcome for
this patient.
Introduction
A good outcome after a crush injury often requires
the use of considerable resources, time, and skilled
personnel to provide the appropriate treatment and
limb salvage of large, soft tissue defects. Function
remains the primary goal in limb salvage, and this is
difficult to achieve in the setting of muscle atrophy
from reduced range of motion, or nerve damage that
can result in temporary or permanent muscle
paralysis. Soft tissue defects in lower extremity
injuries often expose the anterior tibia, as there is
very little subcutaneous tissue coverage in this area.
Tibia bone exposed in the wound must be covered,
and this can present a challenge. If tissue coverage
is not adequate, chronic non-healing wounds can
result. Successful limb salvage of large soft tissue
defects require considerable time, resources,
procedures and good patient compliance.
Case report
The patient is a 65-year-old medically compliant male
with no prior medical history. He has a very active
lifestyle and is a successful large crop farmer. On the
day of his injury, he was mowing his grass, and
looking forward to his “boys” trip the next week, when
he planned to take three grandsons camping in
Montana. His tractor lawn mower suddenly tipped
over, pinning his right lower extremity between the
ground and the tractor. In addition, hot radiator fluid
spilled over his crushed right lower extremity, and the
wound was exposed to the hot fluid for an extended
period of time.
Upon arrival to the Burn Center, he complained of
pain in his right lower extremity, but denied other
injuries/ pain. His blood pressure was in the
140s/60s, pulse in the 80s, and oxygen saturation
was 98 percent on 2 liters of oxygen by nasal
cannula. His primary, secondary and tertiary surveys
revealed isolated right lower extremity soft tissue
injuries. Radiographs revealed no fractures of his
right lower extremity. His distal sensation was intact,
but he had decreased motor function. His initial
creatinine was 1.2, and creatinine kinase (CK) was
4120. He had moderate pain from his knee to his
ankle, but sensation and motor movement was intact
in his toes. He had 4/5 strength with plantar and
dorsiflexion, 3/5 strength with eversion and inversion.
He was initially treated with aggressive hydration for
rhabdomyolysis. In addition, he was taken urgently to
the burn tub room for extensive irrigation of his leg
wounds in the setting of chemical (radiator fluid) and
contact burn damage to the skin and soft tissues. It
was noted that most of his lower extremity, from the
knee to the ankle circumferentially, was nonblanching,
insensate and pale. By the following day,
a thick, tight eschar had developed. His neurological
exam was unchanged, but his pain was increased
from the day before. He was taken to the operating
room for early burn excision. A large area of eschar
was removed and enabled all compartments to be
released through the burn excisional wound.
Upon initial operative debridement and burn wound
eschar excision, there was a large area of tendon/
bone exposed, with a total area consisting of 52 cm
in length extending from just above the knee on the
anterior thigh to just above the ankle level, with a
width of 26 cm at the proximal calf level and 14 cm
at the distal lower leg. Sharp excisional debridement
was performed and INTEGRA was placed and
secured with a wound vac over the wound.
It was noted on day seven that the INTEGRA had
failed, and the patient was found to have MRSA
positive colonization of his wound. INTEGRA was
removed and the patient was discharged with serial
wound vac changes. About a month later, he was
readmitted for skin grafting. His anterior thigh and
knee area appeared healthy for grafting; therefore, a
split thickness skin graft was placed over the
granulating viable wound bed. The remainder of the
right lower extremity distal to the skin graft was
placed back into the wound vac. He was discharged
to home after 80 percent graft-take of his skin graft
Approaches in Critical Care | February 2012 | 5

Case Reports
Figure One: Right lower
extremity degloving
injury shortly after arrival
Figure Two: Right lower
extremity degloving injury
shortly after arrival
Figure Three: Right lower
extremity following treatment
with hyperbaric, grafting and
flap advancement
Figure Four: The patient
and his wife today, back to
full activity, enjoying life on
the farm with his family
and continued with every-other-day wound vac
changes. In clinic, two weeks after skin grafting, the
distal right lower leg being treated with wound vac
had a foul odor and a greenish drainage. Due to
concern for pseudomonas, the patient was placed in
acetic acid dressings twice daily, and eventually
underwent surgical debridement to improve the
wound bed.
Dressing changes for the next six weeks continued
with a variety of wound care depending on his
healing process. By six weeks, his wound care
consisted of lotion over the healed skin grafts, with
twice-daily dressing changes to the right lower
extremity. He appeared to have excellent granulation
tissue at this time, with a large surface area including
exposed bone and tendon. Therefore, he underwent
a rotational flap to cover the defect and provide bone
and tendon coverage. Unfortunately, within one
week, his flap became necrotic and required further
debridement, with the majority of the flap being nonviable.
Two days after debridement of the necrotic
flap, he was taken back to the operating room and
found to have healthy tissues; therefore, INTEGRA
was placed over the exposed tibia with the
application of a wound vac. During the next two
months, his wounds healed quite well, and therefore,
he underwent split thickness skin grafting to the
remainder of his right lower extremity. There was
near 90 percent take of the skin graft, with the small
remaining open area being over the tibia. At nine
months after injury, he had complete closure of his
wound with only a small open area over his tibia.
Subsequent continued wound care consisted of
hydrogel over the tibia.
One year from his injury, this patient is back to
working on his farm with minimal limitation; he is
active and able to walk and work, with no need for
pain medications. He continues to have a two-by-one
centimeter area of exposed bone that he cares for
with twice-daily dressing changes, but he endorses
no limitations of his daily living. In retrospect, despite
his long-course, 11 surgeries, and many hospital
admissions, he is pleased to be in the position of
keeping his leg. His quality of life is greatly impacted
by his mobility. He, is an active and productive
member of his family and community, and is able to
continue pursuing his pre-injury lifestyle despite a
devastating injury.
Discussion
Limb salvage in severe soft tissue defects can be
extremely frustrating to both the patients and
physicians. A multimodality approach with physical
therapists, psychologists, and wound care specialists
provides a platform for successful salvage. The goal
of salvage is providing a functional limb. Large
extremity soft tissue defects most commonly have
required amputations because of vascular and nerve
injuries associated with fractures. In patients without
vascular and nerve injury, amputations are still
prevalent when non-healing wounds become
unmanageable for the patient, when there is a
progression of gangrenous infection, or when
debilitating pain ensues.
Soft tissue coverage is a vital component to the
management of distal extremity injuries. Coverage
provides protection from trauma and infection, aids
in thermoregulation, provides sensory/motor function,
and aids in fluid maintenance. Wound healing begins
at the moment of the inciting traumatic event, and
continues throughout the healing process.
Neovascularization is seen as early as day three
after injury, and fibroblasts begin synthesizing the
collagen framework. Epithelial cells will eventually
proliferate and provide the cover for the new tissue;
however, they are limited in their range of distance.
Therefore, larger wounds are unable to completely
epithelialize without assistance of flaps, skin grafts
or skin substitutes.
6 | Approaches in Critical Care | February 2012

Case Reports
Wounds that are at particularly high-risk for
incomplete or non-healing include: bites (human and
animal), wounds with retained or penetrating foreign
bodies, those with organic matter contamination,
injective wounds, crush injuries, and wounds in
immunocompromised patients, or patients with poor
peripheral circulation and diabetes. Crush injuries
require not only attention to the limb, but also close
patient monitoring for systemic adverse events. All
crush injuries should be evaluated for underlying
fractures and treated early for possible
rhabdomyolysis. In addition, renal function, electrolyte
abnormalities, and compartment syndrome should be
considered and the patient closely monitored for
these complications, with plans for early intervention,
as needed. Crush injuries can have a variety of
presentations, such as with profuse bleeding, little to
no bleeding, and may be painful or painless, with
variations in motor and sensation exams.
Rhabdomyolysis and renal failure are directly
associated with the degree of muscle destruction, as
well as early debridement of necrotic/dead tissues.
There have been few studies attempting to predict
factors associated with limb salvage, but most
authorities believe that the prediction of final outcome
is not possible, regardless of the treatment. Most
physicians believe crushed skin should not be excised
in a limb with crush injury, because it serves as a
barrier to infection and may aid in tissue coverage.
Some advocate this even in the setting of dead skin.
The rationale of such conservative treatment is that
the skin may well be alive, and even if some is not
viable, it is still an effective barrier in preventing
bacterial contamination. Unfortunately, with our
patient, skin salvage was impossible due to the
comorbid condition of the radiator fluid chemical burn.
Chronic soft tissue wounds from trauma or crush
injuries take a considerable amount of time, patience,
and flexibility in patient management to achieve a
good outcome. Patients require frequent surgeries,
months to years of dressing changes, and have
frequent wound infections. Extensive long-term
physical therapies and rehabilitation are also
required. The trauma and change in lifestyle affects
patients emotionally, often resulting in anxiety,
depression, and chronic pain. Most will go through a
grieving process related to the potential loss of a
functional extremity. Patients lose some, if not all, of
their independence, making them concerned that
they are a burden to others. Limb salvage becomes a
time consuming process, but if successful, can
change a severely dependent patient to one with less
debility and more independence.
Our patient is doing remarkably well one year postinjury
and has followed the all-too-common course of
large soft tissue defects, with multiple surgeries,
hospitalizations, intense physical therapy, and longterm
dressing changes. Despite his yearlong battle
with salvaging his limb, he is very happy with his
progress. He is off pain medications, has recovered
limb function and has a full range of motion, and
excellent strength. His wound, which was near 56 cm
in length with exposed tendons, bone and muscle, is
now completed healed, with the exception of a small
2 cm area of exposed bone only. He works daily on
his farm and is actively participating in activities with
his wife, children and grandchildren. ■
“Soft tissue coverage is a vital
component to the management of
distal extremity injuries. Coverage
provides protection from trauma and
infection, aids in thermoregulation,
provides sensory/motor function, and
aids in fluid maintenance.”
Bibliography
Reis ND, Michaelson, DM. Crush injury to the lower limbs. Jrnl of
bone & joint. 1986; 68:414-418.
Robson MC. The role of growth factors in the healing of chronic
wounds. Wound Repair Regen. 1997;5:12-7.
Robson MC, Burns BF, Phillips LG. Wound repair: principles and
applications. In: Ruberg RL, Smith DJ, eds. Plastic Surgery: A
Core Curriculum. St. Louis, Mo: Mosby-Year Book. 1994:3-30.
Eaglstein WH, Falanga V. Chronic wounds. Surg Clin North Am.
Jun 1997;77(3):689-700.
Robson MC, Stenberg BD, Heggers JP. Wound healing alterations
caused by infection. Clin Plast Surg. Jul 1990;17(3):485-92.
Phillips T, Stanton B, Provan A, et al. A study of the impact of leg
ulcers on quality of life: financial, social, and psychologic
implications. J Am Acad Dermatol. Jul 1994;31(1):49-53.
Better OS. The crush syndrome revisited (1940-1990). Nephron.
1990;55(2):97-103.
Ward MM. Factors predictive of acute renal failure in
rhabdomyolysis. Arch Intern Med. Jul 1988;148(7):1553-7.
Malinoski DJ, Slater MS, Mullins RJ. Crush injury and
rhabdomyolysis. Crit Care Clin. Jan 2004;20(1):171-92.
Approaches in Critical Care | February 2012 | 7

Case Reports
Extracorporeal membrane oxygenation
without systemic heparinzation
in patient with burn and inhalation injuries
by Huy Trieu, Brandt Becker, Anne Lambert,
Reza Khodaverdian, Joseph Van Camp
Department of Surgery
Hennepin County Medical Center
Figure One: Chest radiograph
upon admission
Figure Two: Chest radiograh
immediately prior to ECMO
Introduction
Patients with major burn injuries often develop
respiratory complications, including adult respiratory
distress syndrome. Extracorporeal membrane
oxygenation (ECMO) has only occasionally been
used in this setting for adults since the first report of
its successful use in 1998. The risk of major bleeding
may have deterred the use of ECMO in burn patients
who require major burn excision and debridement.
Respiratory complications can account for up to
70 percent of deaths related to burn injuries 1 . The
development of adult respiratory distress syndrome
after burn and inhalation injury is common. Once
ARDS develops, mortality is exceedingly high, with
reported death rates of 50 – 80 percent 2 . Treatment
modalities involve different modes of ventilatory
support. However, with prolonged ventilatory support,
there are concerns of resorption atalectasis with FiO 2
> 0.8 and pulmonary oxygen toxicity beginning at 24
– 36 hours with inspiration of 100 percent oxygen 3 .
Extracorporeal membrane oxygenation (ECMO) has
only occasionally been used in this setting for adults.
However, since the first case report of successful use
of ECMO in burn patients with ARDS in 1998 2 , there
have been sporadic similar case reports among adult
patients. The majority of reported successful use of
ECMO continues to be among the pediatric population,
ages 6-9. The risk of major bleeding may have
deterred the use of ECMO in burn patients who require
major burn excision and debridement 1 . In this report,
a patient with ARDS from extensive burn and
inhalation injury was successfully treated with venovenous
ECMO, with part of the ECMO course not
requiring systemic heparinization.
Case report
TB is a 32-year-old male, with no significant past
medical history, who suffered extensive burns, in a
house fire to his face, neck, back, and both arms,
totaling 40 percent total body surface area. Shortly
after his arrival to Hennepin County Medical Center
via air ambulance, the patient underwent escharotomies
of both arms and hands. In addition to his burns, the
patient had also sustained extensive inhalation injury.
On fiberoptic bronchoscopy a few hours after
admission, the patient was noted to have erythematous
mucosa with soot in the trachea, extending into the
bronchi with thick carbonaceous secretions.
Over the ensuing 72 hours, the patient became
critically ill, with findings consistent with distributive
shock and hemodynamic compromise. In addition,
with worsening ARDS, it became increasingly difficult
to adequately oxygenate and ventilate the patient.
Arterial blood gas (ABG) on admission showed pH
7.39, pCO 2 40 mmHg, pO 2 98 mmHg with FiO 2 0.5
and PEEP 5 cmH 2 0 (See Figure One.) By hospital
day three, it became evident that, despite aggressive
ventilator support, conventional methods were
insufficient to maintain adequate oxygenation and
ventilation. The patientʼs ABG showed pH 7.08, pCO 2
67 mmHg, and PO 2 32 mmHg with FiO 2 1 and PEEP
14 cmH 2 0 (See Figure Two.) At that point, extracorporeal
life support was offered to the patientʼs family as a
life-saving measure.
The patient was placed on veno-venous extracorporeal
membrane oxygenation. Bilateral femoral venous
cannulae were placed by femoral cutdowns. The
drainage cannula was in the left iliac vein and the
return cannula was in the proximal inferior vena cava
(IVC). The patient was systemically heparinized to
keep the activated clotting time at about 200 seconds.
Immediately after ECMO, the patientʼs hemodynamics
improved and his ABGS showed a pH 7.29, pCO 2 45
mmHg, pO 2 52 mmHg. (See Figure Three.)
Four days later, the patient required exchange of his
left femoral cannula, as it was providing insufficient
venous drainage (ECMO flow lower than 3 L/min).
With the drainage cannula repositioned in the distal
IVC, ECMO flow of greater than 5 L/min was
achieved. Six days after initiating ECMO, the patient
required extensive excision and debridement of his
arm burns due to concerns of sepsis. VAC dressings
were applied to the debrided arms. He also had a
tracheostomy performed. With excision and
debridement of his arm burns, the patient developed
significant bleeding, requiring exploration to control
bleeding. Because of the extensive bleeding, the
decision was made to discontinue systemic heparin
on ECMO day nine. By maintaining high flow in the
8 | Approaches in Critical Care | February 2012

Case Reports
Figure Three. Chest radiograph
immediately after ECMO.
Figure Four. Patient recovering with
his family at his bedside.
ECMO circuit, the patient remained off systemic
heparin for the remainder of his ECMO course.
The patient made gradual improvement and, by day
12 after initiation of ECMO, the patient was
decannulated from ECMO. He went on to have
multiple excisions, debridements, and skin grafts of
his extremity burns over the following three weeks.
He recovered from his ARDS and was discontinued
from mechanical ventilation assistance 10 days after
ECMO decannulation. His tracheostomy was removed
two weeks later. Five weeks after discontinuation
from ECMO, the patient was discharged to acute
rehabilitation (See Figure Four.)
Discussion
This patient rapidly developed ARDS, mandating an
immediate decision for aggressive treatment. The
decision to institute ECMO early in the development
of ARDS afforded the patient respite from pulmonary
oxygen toxicity related to prolonged high FiO 2 and
from pulmonary barotrauma. This allowed for rapid
pulmonary recovery once the inciting injuries
improved. There has been retrospective data to
suggest that there is a direct correlation between
length of mechanical ventilation before ECMO and
mortality rate from ARDS 4 .
Immediately following initiation of ECMO, the patient
experienced only a modest improvement in his
oxygenation. This was in part due to the drainage
cannula being in the left iliac vein, limiting circuit flow.
In addition, the patient was quite hyperdynamic, with
a cardiac output of 14 – 16 L/min, resulting in a
large portion of venous return diverted away from the
ECMO circuit. Efficiency of veno-venous ECMO
relies on minimizing this shunt fraction. This was
demonstrated when the patientʼs drainage cannula
was repositioned in the distal IVC instead of the iliac
vein; thereby, decreasing the shunt fraction.
In addition, the decision to discontinue systemic
heparinization during extracorporeal circulation also
contributed to the patientʼs recovery. The patient
initially received systemic heparinization. However,
after his arm burn excisions were complicated by
excessive bleeding, systemic heparinization was
discontinued. The plan was to resume systemic
heparinization if signs of clotting become apparent in
the extracorporeal circuit. Previous report of venovenous
ECMO with systemic heparin described
excessive bleeding from chest tube sites and excised
burn surfaces, requiring extensive transfusion of blood
products 1 . Prior reports of ECMO use in burn patients
included systemic heparinization to keep activated
clotting time at about 200 seconds. In addition,
previous reports have recommended delaying ECMO
in patients who require major burn debridements 5 .
The discontinuation of systemic heparinization in our
patient resulted in minimal need for blood products,
which facilitated his respiratory improvement.
Conclusion
In caring for patients with major burn and inhalation
injuries, we advocate the early institution of ECMO
for patients with ARDS refractory to conventional
mechanical ventilatory support. For patients with
veno-venous ECMO, systemic heparinization can be
withheld for excessive bleeding from major surgical
procedures while on ECMO. ■
References
1. Kornberger E, Mair P, Oswald E, Hormann C, Ohler K, Balogh
D. Inhalation Injury Treated with Extracorporeal CO2 Elimination.
Burns. 1997; 23 (4): 354 – 9.
2. Patton ML, Simone MR, Kraut JD, Anderson HL, Haith LR.
Successful Utilization of ECMO to Treat an Adult Burn Patient with
ARDS. Burns. 1998; 24 (6): 566 – 8.
3. Barash P, Cullen B, Stoelting R. Clinical Anesthesia, 5th ed.
Philadelphia: Lippincott Williams & Wilkins. 2006: p1393.
4. Sasadeusz K, Long W, Kemalyan N, Datena S, Hill J.
Successful Treatment of a Patient with Multiple Injuries Using
Extracorporeal Membrane Oxygenation and Inhaled Nitric oxide.
Journal of Trauma –Injury Infection & Critical Care. 2000; 49(6):
1126 – 8, 2000.
5. Thompson J, Molnar J, Hines M, Chang M, Pranikoff T.
Successful Management of Adult Smoke Inhalation with
Extracorporeal Membrane Oxygenation. Journal of Burn Care &
Rehabilitation. 2005; 26 (1): 62 – 6.
6. Ombrellaro M, Goldthorn J, Harnar T, Shires T. Extracorporeal
Life Support for the Treatment of Adult Respiratory Distress
Syndrome after Burn Injury. Surgery. 1994; 115(4): 523 – 6.
7. Goretsky M, Greenhalgh D, Warden G, Ryckman F, Warner B.
The Use of Extracorporeal Life Support in Pediatric Burn Patients
with Respiratory Failure. Journal of Pediatric Surgery. 1995; 30(4):
620 – 3.
8. Lessin M, El-Eid S, Klein M, Cullen M. Extracorporeal
Membrane Oxygenation in Pediatric Respiratory Failure secondary
to Smoke Inhalation Injury. Journal of Pediatric Surgery. 1996;
31(9): 128 – 7.
9. Askegard-Giesmann J, Gesner G, Fabia R, Caniano D, Preston
T, Kenney B. Extracorporeal Membrane Oxygenation as a
Lifesaving Modality in the Treatment of Pediatric Patients with
Burns and Respiratory Failure. Journal of Pediatric Surgery. 2010;
45(6): 1330 – 5.
Approaches in Critical Care | February 2012 | 9

Case Reports
Fire changes lives for the better
by Ashley Lemere, MD
Department of Surgery
Hennepin County Medical Center
All it takes is a spark to start change. This statement
was never truer than on April 29, 2010, for the
Hendrickson boys, their parents, and everyone involved
in their care. Caden and Camren Hendrickson were
living with their father, Michael Hendrickson, and
mother, Virginia Shmiganowsky, in Ostego, MN.
Virginia and the two children had recently reunited
with Michael after a six-month period of separation,
during which time she had been living with a boyfriend
who was a methamphetamine dealer. Their only
option for housing was an outdoor tent on Michaelʼs
employer's property. The tent where they slept
consisted of sleeping bags on the floor for Caden, a
pack'n play for Camren, and an air mattress on a bed
frame for the parents. The family awoke as usual that
fateful morning, and the boys and Virginia played
until about noon. She put them down for a nap and
left the boys to get some food. Michael and Virginia
were both talking to Michael's boss when they heard
Caden screaming "FIRE! FIRE!"
Michael Hendrickson describes it this way, “When I
heard Caden scream, I ran to him and then saw that
the tent was on fire. When I got to the tent, I couldn't
see Camren, but I could hear him screaming. Right
before I was about to jump into the flames, I saw
Camren out of the corner of my eye. Caden had
pulled him out and leaned him against a chair before
coming to get us.”
Caden told his parents that the space heater in the
tent had tipped over and that he had pushed it under
the mattress. Virginia immediately called 911 and the
fire department and emergency medical services
quickly arrived on the scene. The children were
transported separately to Hennepin County Medical
Center―Caden by ambulance and Camren by
helicopter. Both boys sustained very serious and lifethreatening
burns.
Caden was brought to the emergency department ,
where he was initially thought to have partial
thickness second degree burns to face, back, trunk,
left thigh, right thigh, and third degree burns to the
left arm, which all together equaled a 22 percent total
body surface area burn. He was transported to the
Burn Center, where his burns were promptly debrided
and placed into dressings and topical medications.
Camren was very obviously more seriously injured
and was unstable en route to the hospital. Due to the
Caden, top, and Camren, bottom, enjoying playing outside in the snow.
severity and nature of his injury, he was intubated on
arrival to the stabilization room to protect his airway.
He was quickly stabilized and transported up to the
Burn Center. Shortly following his arrival, he became
profoundly hypotensive with a rapidly diminishing
heart rate. Full CPR with chest compressions was
initiated. He quickly regained a perfusing rhythm,
was started on an aggressive burn fluid resuscitation,
and was placed on multiple pressors to maintain
adequate mean arterial pressures. He was inspected
and was found to have full thickness burns to his
feet, legs, buttock, back, arms, head and face, which
equaled a total burned surface area (TBSA) of 70
percent. To prevent the formation of extremity
compartment syndromes from the tough, leathery
burn eschar, Camren immediately underwent
escahrotomies to his right hand, right leg, right foot,
left leg, and left foot. He was in critical condition and
was monitored closely by a large multidisciplinary
team of doctors and specialists.
On May 3rd, Caden underwent full thickness excision
of burn to his left arm, left shoulder, left hand, left
chest and left flank, with placement of INTEGRA.
INTEGRA is a two-layer skin regeneration system.
The outer layer is made of a thin silicone film that
acts as the skin's epidermis. It protects the wound
from infection and controls both heat and moisture
10 | Approaches in Critical Care | February 2012

Case Reports
loss. The inner layer is made of a complex matrix of
cross-linked fibers. This material acts as a scaffold
for regenerating dermal skin cells, which enables the
re-growth of a functional dermal layer of skin. Once
the dermal skin has regenerated, the silicone outer
layer is removed and replaced with a skin graft.
Cadenʼs initial attempt at grafting on May 20th did
not take secondary to infection, so he returned to the
operating room on May 31st. His wounds progressed
well in INTEGRA and he was re-grafted on June
10th. He had excellent take of grafting at that time
and his wounds healed well.
Camren underwent multiple operations in an attempt
to close his extensive burn wounds. He had his initial
debridement and excision of his wounds on May 3rd,
with placement of cadaveric skin on the wound to
protect it and allow it to heal. He made many trips to
the operating room for multiple wound debridments,
application of INTEGRA, dressing changes under
anesthesia, and eventual placement of split thickness
skin grafts.
they were followed by the child life volunteer for play
therapies to allow them to grow and develop under
stressful conditions. Child Protective Services was
involved, and due to issues of neglect, the children
were placed into a medical foster family.
The boys blossomed under the constant care and
attention. Their giggles and smiles welcomed staff
and visitors to the burn unit. They were constantly
learning, growing, and healing. Caden was discharged
62 days after admission, and Camren was discharged
89 days after admission. They are currently living
with their initial medical foster care family.
Their father, Michael, was traumatized by the
situation, but took the experience and turned it into a
positive life-changing event. He sought treatment for
his chemical dependency and has been clean for
over a year now. He enrolled himself in Twin City
Rise, which is a career development program. While
in speech class, every talk he gave was about the
boys and their experience. He used his speeches to
bring light to the fact that the local fire departments
were being forced to employ fewer firefighters, due to
budget cuts, while the need for them had increased.
He now has earned his commercial driverʼs license
and is currently applying for employment. He and
Virginia are separated, but his boys continue to be a
constant positive force in his life. He attributes them
for turning his life around and states that they are his
constant motivation for personal improvement. He
loves visiting with them whenever he can.
The firefighters who arrived at the scene of the fire were
so moved by Cadenʼs life-saving act that they established
a fundraiser to collect money for children in the
Minneapolis burn units. Half of the money raised
goes to Regionʼs burn center and the other half goes
to the Hennepin Burn Center.
Caden and Camren are off and running during physical therapy.
The brothers were cared for by a multitude of
providers during their stay. They had daily dressing
changes and minute-to-minute care by the burn unit
nursing staff. They had daily sessions with both
physical and occupational therapists for stretching
and splinting, to avoid contractures in the injured limbs
and to maintain and regain their functional abilities.
Pediatric dieticians followed the boysʼ nutritional
status to give them the necessary building blocks for
healing. Child psychologists evaluated them, and
Both boys face many challenges. They attend
occupational and physical therapy sessions and wear
face masks and splints to prevent scar contracture.
They must have scar revisions to address the
continual care of their grafts as they grow physically.
Their experience has touched a spark to many
wonderful and positive changes to all those who
have been involved in their care, and hopefully, will
continue to do so for many years to come. ■
Editorʼs note: Our sincere thanks to the Hendrickson
family for giving permission to share their story.
Approaches in Critical Care | February 2012 | 11

Critical Care Profile
Q and A withQ and A with
Anne Lambert, MD
Anne Lambert, MD
Dr. Anne Lambert graduated from the
University of North Dakota Medical School.
She completed her surgical and surgical
critical care residencies at Hennepin
County Medical Center, where she also
completed a burn fellowship in 2011. From
2005-2009, she was the assistant director
of trauma at Regions Hospital in St. Paul.
Today, she is one of the leaders of the
Burn Center at Hennepin County Medical
Center. Dr. Lambert grew up in Casselton,
North Dakota, and she feels a special
bond with patients from her home state.
Physicians make rounds at the Burn
Center every day, and Dr. Lambert said,
“Patients get to know who you are, and
many of them find out I am from North
Dakota.” Last year, during a trip back to
North Dakota, she even picked up a “Pizza
Corner” pizza for a patient who was
missing this familiar pleasure.
Why did you choose to work with burn
patients?
My first interaction with burn patients was
at Hennepin County Medical Center as an
intern and resident. We had a rotation
through the burn unit. I went on to get a
fellowship in surgical critical care and also
in burn. I saw all kinds of patients–cardiac,
trauma, burn, everything. I chose burn care
because it was the most challenging.
When I saw my first burn patient, I was
horrified. But soon, I started to see the
person and not the injury. Most outside
physicians would come here without
experience seeing serious burns, because
these burn patients are sent only to HCMC
or to Regions.
What is most challenging and unique
about the needs of burn patients?
Burn care is multi-faceted. If you are not in
a Verified Burn Center, you wonʼt have the
full array of services that patients need―
therapists, psychiatrists, nutritionists, and
more. Only a Verified Burn Center would
have all of these resources. Even some
hospitals arenʼt aware of all the needs burn
patients have. Our patients have posttraumatic
stress disorder, because they
have suffered tremendous losses―their
appearance has changed dramatically, and
they may carry guilt about the cause of the
burns and be themselves involved in
alcohol or drugs. Some of our patients
even burn themselves intentionally, again
and again.
Whatʼs it like working with children in
the Burn Center?
I work with lots of them. I just see the kids,
not the burns. They are so resilient, even
with burned feet; they are up running
around again as soon as possible. Kids do
their own occupational therapy.
Are there laws you would change to
keep children safe from burns?
Yes, I would treat fire with the same caution
that we treat water. Fire pits and bonfires
should be fenced-off, like swimming pools.
Kids, the elderly and people under the
influence of alcohol canʼt protect themselves.
In addition, manufacturers should make hot
water heaters safer by regulating the
temperature. Many burns are caused by
scalding. There are also more scalding
accidents now that microwaves are used
more often than stoves.
What are some new and exciting
breakthroughs in treatments and
technologies for burns?
Honey is an old remedy, but it has been
found to break down biofilms, a defense
mechanism of bacteria, and to effectively
kill drug-resistant bacteria, such as
pseudomonas. We plan a study to look at
the efficacy of honey-based wound dressings
in the future.
Advances in fluid resuscitation, nutrition,
and wound care have doubled the survival
12 | Approaches in Critical Care | February 2012

Critical Care Profile
Dr. Lambert with patient
during wound care
procedure in the
Burn Center.
past three decades. Now a person with burns on 90
percent of their body can survive. Getting the proper
amount of fluid into a burn patient is key to their
survival. Too much or too little, and they will die. We
have learned a great deal about how best to gauge
the patientʼs fluid needs by carefully watching their
urine output.
Nutrition is another factor. The skin is the bodyʼs
largest organ, and the body uses so many calories
when trying to heal that patients wonʼt heal if they
canʼt get enough of the right kind of calories.
Grafting and wound care have also become more
refined. Patients are being released at higher acuity
levels. Dressings are better and can be left on longer
because of their built-in, antimicrobial properties.
Grafts can be secured with newly developed skin
glues that can eliminate the need for painful sutures
and staples. There is less scarring and less pain.
Pain medication has also improved, and patients do
not experience the levels of pain that resulted from
burns in the past. This is much less stressful and
leads to better healing.
Only a select number of burn centers in the U.S., 57
in all, have met the criteria to receive “verification” by
the American Burn Association and the American
College of Surgeons. Besides availability of all the
special services and therapists a burn patient may
require, we have a very experienced nursing staff
whose members have been working together for a
long time. We have a large, new, state-of-the-art
inpatient unit and the Acute Burn Clinic is available
to outpatients 24 hours. Burn Center providers are
also willing to answer questions and consult with
anyone, anywhere, and at any time. Hennepin
Connect has made it possible for questions to go
directly to our physicians.
What is your vision for the future of burn care in
our region?
It would be ideal to have a more cooperative
relationship with the Verified Burn Center at Regionʼs
Hospital in St. Paul. We both have the same
education needs and could combine our efforts in
that area. We could also coordinate with Regions to
offer our patients support groups. ■
What makes the Burn Center at Hennepin County
Medical Center a world-class program?
The burn center has all the components necessary to
achieve a good patient outcome. We are the right
place for burn patients.
Approaches in Critical Care | February 2012 | 13

Critical Care Profile
Interview withQ and A with
Cheryl Adkinson, MA, MD,
FACEP–Hyperbaric Medicine
Cheryl Adkinson, MA, MD,
FACEP-Hyperbaric Medicine
Indications for Hyperbaric
Oxygen Therapy
Air or Gas Embolism
Carbon Monoxide Poisoning
- Carbon Monoxide
Poisoning Complicated
by Cyanide Poisoning
Clostridal Myositis and
Myonecrosis (Gas Gangrene)
Crush Injury, Compartment
Syndrome and other Acute
Traumatic Ischemias
Decompression Sickness
Arterial Insufficiencies
- Central Renal Artery
Occlusion
- Enhancement of Healing
in Selected Problem
Wounds
Severe Anemia
Intercranial Abscess
Necrotising Soft Tissue
Infections
Osteomyelitis (Refractory)
Delayed Radiation Injury
(Soft Tissue and Bony
Necrosis)
Compromised Grafts
and Flaps
Acute Thermal Burn Injury
Dr. Cheryl Adkinson has been full-time
faculty in the Hennepin County Medical
Centerʼs emergency medicine department
for 27 years and is associate professor of
emergency medicine at the University of
Minnesota. She is board certified in
Emergency medicine and the subspecialty
of undersea and hyperbaric medicine. A
native of Bellingham Washington, she
graduated from the University of Washington
School of Medicine. She said she came to
Hennepin County Medical Center for her
internship because Hennepin has the
reputation of being one of the best
teaching hospitals in the nation. She
stayed here to complete her residency in
emergency medicine in the days when Dr.
Ernie Ruiz was the department chief and
Dr. Joseph Clinton was residency director.
For the past 25 years, she has served as
medical director for hyperbaric medicine at
Hennepin. She is actively involved in
research and education, serves as the
fellowship director for undersea and
hyperbaric medicine, and sees patients
with emergencies and chronic conditions
requiring hyperbaric oxygen treatment.
Her special interests are carbon monoxide
poisoning and radiation tissue damage.
What was the hyperbaric medicine
program like when you first arrived?
This grand facility was 20 years old then
and nearly in mothballs. It had been the
pet project of Dr. Claude Hitchcock, then
chief of surgery, and he was still overseeing
its operation, with the assistance of
Dr. John Haglin, a senior surgeon, and the
long-term support of Dr. Ernie Ruiz. The
three multi-place chambers, like several
other academic hyperbaric centers in the
U.S. built in the mid 1960s, were designed
to allow major surgical procedures to be
performed inside them, under hyperbaric
conditions. The inspiration for constructing
this facility was European research
demonstrating good results with open-heart
surgery in a hyperbaric oxygen chamber.
Dr Hitchcock, along with his surgical and
nephrology colleagues, studied experimental
lung and kidney transplants, significantly
advancing the science of organ
transplantation. An interesting fact is that
the first successful baboon-to-human
kidney transplant was performed in this
facility. However, when more efficient
technologies were developed to keep
organs oxygenated for these procedures,
scientific interest in hyperbaric oxygen
waned all around the country.
I first became involved, as I recall, as a
result of a minor assignment by my chief:
to schedule residents to accompany
patients in the chamber during treatments.
Not many patients were being treated, just
an occasional patient with gas gangrene,
some with carbon monoxide poisoning, an
occasional diver with decompression
sickness, and a rare patient with arterial
gas embolism. Surgical procedures were
no longer being performed in the chambers
and the only dedicated personnel were the
two ex-Navy divers who operated and
maintained the facility. Some small animal
studies were going on and the neurology
department was just finishing a large
randomized controlled trial of hyperbaric
oxygen treatment (HBOT) for multiple
sclerosis, which turned out to show no
benefit from the treatment. Otherwise, not
much was happening, which was good,
because I knew nothing about hyperbaric
medicine! I felt some responsibility asking
residents to go inside the chambers, so I
set about taking courses and going to
meetings to learn what I needed to know,
first about compressed air diving, and then
about non-diving medical applications of
hyperbaric oxygen.
The timing was perfect, because there was
a resurgence of interest nationally in new
14 | Approaches in Critical Care | February 2012

Critical Care Profile
“Practicing hyperbaric medicine and
emergency medicine is a great
combination professionally. I get the
variety and urgency of medicine in the
emergency department, and I have the
satisfaction of program development
and pleasure of continuity of care in
my hyperbaric practice.”
applications for hyperbaric oxygen, and organizational
efforts were underway to encourage further research,
to self-regulate the field to insure evidence-based
application of the treatment, and to establish
standard qualifications for providers in the field.
Hyperbaric medicine has grown tremendously
between then and now. Compared to around 25
civilian U.S. hyperbaric facilities in the early 80s,
there are now close to 1000. Since then the
American Board of Medical Specialties approved
subspecialty board certification in undersea and
hyperbaric medicine and there are now 873 board
certified physicians in the U.S. There is now a formal
pathway to board eligibility through ACGME certified
fellowships in the field (Hennepin County Medical
Center has one such fellowship position). There is
also a training course and qualifying exam for
certifying hyperbaric nurses and technicians. And
finally, there is a voluntary accreditation for
hyperbaric medicine programs in the U.S. modeled
after the Joint Commission accreditation of hospitals,
and the Joint Commission has officially recognized
this accreditation as a “Complementary Accrediting
Program”. Of note, the Hennepin program was one
of the earliest to be accredited, and in 2010, was
re-accredited “with distinction”. Clearly, hyperbaric
oxygen treatment has joined mainstream medicine.
How is the new Center for Hyperbaric Medicine
going to be different?
Currently we are two blocks away from the hospital
and very short of space for patient care outside of
the treatment chambers. The new site is in the main
hospital building and will solve both problems,
allowing us to provide better and safer care in a
patient friendly environment. In the new facility,
critically ill patients in the emergency department,
operating room, or intensive care units will not need
to be loaded into an ambulance to go to have their
hyperbaric oxygen treatments. Standard hospital
services will be immediately available, such as lab,
X-ray, pharmacy, code teams, and security services.
The location will be ideal for dropping off outpatients
who have mobility issues. There will be private
spaces for evaluation, procedures, and dressing
changes. There will be bathroom and changing room
space sufficient for the growing number of patients,
and a place for family to wait. This is exciting!
Even more exciting, we will have the most thoughtfully
designed multi-place chamber ensemble in the world
for delivering critical care. It will surpass all others in
monitoring, communication, environmental control,
and gas delivery systems. The arrangement and
individual capabilities of the three connecting
chambers will provide maximum flexibility to manage
simultaneously multiple combinations of critically ill
and stable scheduled patients. This is a dreamcome-true.
It is a feather in the cap of Hennepin
County Medical Center, which has continuously
provided 24-hour availability of hyperbaric oxygen to
all Minnesotans 365 days a year for the past 48
years. And, it is a tribute to the foresight of the
Minnesota State Legislature, which allocated federal
stimulus funds to remodel the hospital space for this
facility, allowing Hennepin to carry on its long history
of service.
How Does Hyperbaric Oxygen Work?
There is a common theme to all of the indications for
hyperbaric oxygen treatment: poor oxygen delivery to
tissues of the body. Hyperbaric oxygen treatment is
designed to remedy this. When the patient needing
treatment goes into the hyperbaric chamber, the air
pressure in the chamber is increased by forcing more
air into the confined space, achieving the needed
treatment pressure-anywhere between 1.5 times
normal atmospheric pressure and 6.0 times normal
atmospheric pressure. Usually treatments are at 2.4
or 3.0 times normal pressure. The patient breathes
100% oxygen from a mask, hood or ventilator while
resting comfortably inside the chamber. There are
usually other patients in the same chamber and there
is always a medical attendant inside the chamber.
The combination of being under pressure and
breathing 100% oxygen is what makes the lungs
give more oxygen to the blood. The oxygen actually
dissolves in the liquid part of the blood, instead of
being limited to transport by the hemoglobin
molecule. That way, wherever the blood is going, it
takes much more oxygen to the tissues. ■
Approaches in Critical Care | February 2012 | 15

RN Perspectives
Steve Omodt, RN and
Burn Center Nurse
Manager Sheila Elledge.
RN Perspectives: The Art and Science of Burn Care
by Steve Omodt, RN
Hennepin County Medical Center
Burn care is complicated. It requires
multiple disciplines working together as a
cohesive team to ensure optimal outcomes.
For that reason, care is usually centralized
in burn centers that have the dedicated
resources needed for treating this difficult
injury. (Light, 2009)
For a newly minted nurse, more than two
decades ago, Hennepin County Medical
Center offered a unique opportunity to treat
and care for burn patients. While my nursing
training and education wasnʼt specific to
burn care, my experience included time
spent as an emergency medical technician
and a Red Cross volunteer. I had seen
trauma, helped treat trauma, and thought
burn care would pose an interesting
challenge for me.
Challenging and complex health care issues
are standard fare in burn treatment; as a
nurse, you will expect a burn patient to be
a highly challenging medical case that will
require exceptional technical nursing skills,
combined with the ability to manage a
complex web of interdisciplinary skills.
For example, I cared for a 45-year-old
carpenter who had suffered serious burns
over 80 percent of his body from a
gasoline fire. He came into the burn center
as a man who had lost everything―his
health, ultimately his legs, and his identity
as a man and a person. Everything he
believed he was before the accident was
gone. I was part of the team of caregivers
who secured his health, returned him to
the workforce, and helped him regain a
sense of himself.
Burn care requires a holistic approach
At Hennepin County Medical Centerʼs burn
unit, we practice family-centered care and
take a holistic, multidisciplinary approach
to the care we provide. The most important
members of the team are the patient and
the patientʼs family. We also involve many
members of the healthcare team, including
the surgeons, nurses, advanced practice
providers, pharmacists, as well as
nutritionists, physical and occupational
therapists, social services, psychologists,
the chaplaincy, and other supportive
services. The goal of our care is to return
each patient to the highest level of function
by attending to the physical, psychological,
social, and vocational aspects of their lives.
16 | Approaches in Critical Care | February 2018

RN Perspectives
Taking care of a patient presenting with a burn injury
can be a challenge, because burn care is both complex
and multidimensional. The initial accident is only the
beginning of a process that can take many years to
resolve. Nurses who specialize in treating burn
injuries are often required to have a comprehensive
base of knowledge in all aspects of care and needs
of the burn patient. A proficient burn nurse will have
the clinical knowledge, expertise, and skills that
incorporate many areas of traditional nursing, such
as adult and pediatric critical care, adult medicalsurgical
care, and rehabilitation. At a minimum, the
nursing care is delivered in a professional, skillful,
and directed manner.
Science is not enough
However, it is not enough that the burn nurse have
sound knowledge of the scientific aspects of
medicine. The nurse must also treat the psychosocial
and emotional needs of the burn patient. Often, the
burn patient has suffered a tragedy that can devastate
the patient both physically and emotionally. The
nurse must deliver care to burn patients from a
perspective of caring and a true sense of empathy.
Often, the patients suffer from physical pain, which is
treated with potent narcotic analgesics. Other times,
however, the patient suffers from the emotional or
spiritual pain that sometimes comes after a debilitating
accident. The skillful and caring burn nurse is
accustomed to dealing with such human responses
to various life experiences, and often supports the
patient in finding positive meaning to their health
challenges. The caring nurse offers compassion and
hope during the patientʼs entire hospital stay.
To my knowledge, there is not a single
undergraduate or graduate course that
adequately addresses the unique and
complex nature of the burn patient.
There is not a course named
“Burn Nursing 101.”
So, let me reflect on the patient I mentioned earlier. I
spent four months as one of his primary nurses. As
most burn nurses know, these patients have an effect
on us, too. Their lives change our lives. Their courage
inspires us. This patient not only returned to work as
a carpenter, he did so without legs or the assistance
of a wheelchair. He now works on building homes
with the strength and skill of his upper body, aided
only by prostheses. The force of his mind and spirit
would not let him give up. He has come a long way
from the man I first met who had given up on life and
himself. His caregivers didnʼt and wouldnʼt let him
quit. He didnʼt let himself or us down. Now, he builds
homes and dreams for others.
Burn nursing is learned through experience
Burn nursing is a specialty that is not taught in
academic nursing schools or universities. Burn care
is often seen as a specialty care process that
typically is provided only at consistently high levels,
such as at Level I Trauma Centers or burn centers
that have the necessary equipment and trained staff
to successfully treat these patients.
To my knowledge, there is not a single undergraduate
or graduate course that adequately addresses the
unique and complex nature of the burn patient. There
is not a course named “Burn Nursing 101.” Most of
the nursing training, then, comes in the form of onthe-job
training from other experienced burn nurses.
Nurses who are inexperienced or who are new to our
specialty are matched with a preceptor, and this
preceptorship serves as the basis of the burn
training. This form of training is competency based,
and is variable in tenure, but generally lasts three to
six months. At its core, burn nursing requires each
nurse to be highly motivated, intelligent, responsible,
and accountable.
What I want to emphasize, however, is that there is
both a science and an art to burn care. Burn care is
not a title, nor is it an event. Care is in the manner of
treating the patient as a real, whole person. True, our
nursing staff uses science as a basis for our
professional practice, but we try to deliver this care
with care, compassion, and empathy. In an ideal
world, all health care team members share an
altruistic attitude toward the persons they serve.
Many persons enter the nursing profession because
they genuinely care about others and have a desire
to help others in time of need. (Hood, 2010) As such,
I feel that burn care is best delivered with both the
clinicianʼs brain and the heart. ■
References:
Hood, Lucy J. Leddy & Pepperʼs Conceptual Bases of
Professional Nursing, 7th edition. Philadelphia, Pa. Wolters
Kluwer Health, Lippincott Williams & Wilkins, 2003: p 4.
Runyan SW, Casteel C (Eds.).The state of home safety in
America: Facts about unintentional injuries in the home, 2nd
edition. Washington, D.C.: Home Safety Council, 2004. Available
at: http://www.cdc.gov/homeandrecreationalsafety/fire-prevention/
fires-factsheet.html
Light, Timothy, and Latenser, Barb. 2009. Journal of Burn Care
and Research. Vol. 30, No. 5: 776.
Approaches in Critical Care | February 2012 | 17

Biomedical Ethics Consultation
“Getting
people
together is
the right
thing to do.
You can’t
leave it up to
the doctors,
even if they
know what
the humane
and caring
answer is.”
Biomedical Ethics Consultation is Key in
Making Difficult Decisions
by Mary Bensman
Hennepin County Medical Center
Her prognosis was dire. A middle-aged
woman was burned on over 85 percent of
her body in a house fire. She had been
stabilized in the emergency department at
Hennepin County Medical Center and
physicians at the burn center were trying to
determine what to do next. Without
aggressive intervention, she would quickly
die. Estranged from her family and friends,
the woman had no one who could speak
for her preference to die, or to live in an
extremely painful and altered state.
Her physicians knew what the road ahead
might be for her if they intervened and
began treatment. “Burns of this magnitude
are hard to treat,” said Ryan Fey, MD, the
burn specialist who handled her case.
“There is not enough skin left for grafting
and there is a likelihood of infections, and
dozens of operations to cover the body.
Then, three years of rehab would probably
be needed. Most adults do not choose to
go forward in a situation like this.”
A consultation with the biomedical ethics
committee was called. The doctors were
able to spell out what the womanʼs future
might hold, but they needed assistance to
discover and honor the patientʼs wishes.
Because of her clinical state, the patient
could not make decisions for herself, so
the burn staff looked for a surrogate
decision-maker―ideally a family member
―who knew the patient and could speak
on her behalf. However, family was
unavailable, so the ethics committee
searched the nearby community for
someone who might have known her over
the years. Confidentiality issues were
overridden by the need for assistance in
making this crucial decision.
Eventually, a group of people who knew
her was assembled, including an old friend
and a social worker who had a relationship
with the womanʼs family. As they talked, a
picture began to emerge. The woman had
a history of chemical abuse and mental
18 | Approaches in Critical Care | February 2012

Biomedical Ethics Consultation
illness. She had alienated her friends, family, and
even her children. Recovery from this burn could
mean she might be in the hospital for a year,
followed by many years of rehabilitation. The process
would be extraordinarily difficult, even with a strong
support system. Without one, it would be nearly
impossible. No matter what, she would face
permanent disability and disfigurement, threats from
repeated infections, and significant pain controllable
only with narcotics.
As the ethics committee listened to people talk about
this severely burned woman, the course became
clearer. Not only were there insurmountable
obstacles ahead, but even successful treatment
could not preserve her beauty, something she valued
tremendously. She wouldnʼt want to live that way.
Finally, they all agreed that this woman would ask for
her life support be withdrawn and that she be kept
comfortable until she died.
“These situations traumatize everyone,” said Ann
Russell, an attorney and social worker who is
Hennepin County Medical Centerʼs lead ethics
consultant. “This is a first-time experience for most
everyone taking part in a consultation like this.
Getting people together is the right thing to do. You
canʼt leave it solely up to the doctors, even if they
know what the humane and caring answer is. It is
ideally a consensus process. As people talk, the
picture becomes clear and helps lead to the
conclusion.”
In many medical situations, physicians can allow
circumstances to play out over time. Conditions like
burns, traumatic brain injuries, and strokes are
potentially devastating, and the physician must make
the best possible decision as quickly as possible,
based on the facts at hand.
According to an article by Martha McCusker, MD,
published in the December 2009 issue of Approaches
in Critical Care, ethical dilemmas in medicine
typically involve one of four basic ethical concepts:
“...it is always a good idea to
prepare an advance directive in
which you appoint someone to act
on your behalf and give them
guidance...it is very important to
have a conversation with your family
and friends...”
In this case, patient autonomy was preserved.
Russell said, “Locating a person who knows the
person well and is in a position to tell us what the
patient would want is not always possible. Even if a
family member or friend is available, it is sometimes
difficult for them to know what the patient would
want. For this reason, it is always a good idea to
prepare an advance directive in which you appoint
someone to act on your behalf and give them
guidance. Even if you donʼt prepare a directive–many
people do intend to, but donʼt get around to it–it is
very important to have a conversation with your
family and friends to tell them what is important to
you, and what you would want if you were facing an
illness or injury with little likelihood of a meaningful
recovery. This can be immensely helpful to those
who may need to speak for you.
A request for an ethics consultation can come
from anyone, including a family member, nurse,
patient or physician. The ethics committee will
conduct a chart review and then facilitate a
meeting to help those involved craft an ethically
appropriate plan of care. The ethics phone is
available 24 hours at 612-873-9717. ■
Autonomy–the innate right of a patient to make
choices affecting his life and welfare free
of coercion.
Beneficence–the health care providerʼs obligation
to act in the best interest of the patient.
Nonmaleficence–the physicianʼs obligation to
refrain from providing ineffective or harmful
treatments.
Justice–treating like patients alike and ensuring
the socially just allocation of goods in a society.
Approaches in Critical Care | February 2012 | 19

Calendar of Events
MS
2012 Course Dates
Basic, Refresher
& Advanced
w w w . h c m c . o r g / e m s . h t m
Advanced Cardiac Life Support for Providers (AHA)
February 14 and 15, March 27 and 28, April 17 and
18, May 15 and 16, (G1 Residents: June 12 and 13,
14 and 15, 19 and 20)
__________________________________________
Off-Site Advanced Cardiac Life Support for
Providers (AHA)
March 6 and 7–Redwood Falls, TBA–Marshall,
TBA–Marshall
__________________________________________
Advanced Cardiac Life Support Provider Renewal
(AHA)
February 16, March 29, April 19, May 14
__________________________________________
Advanced Cardiac Life Support Provider Renewal
(ASH) for Hennepin Staff
February 8, April 4, May 10, June 5
__________________________________________
Advanced Cardiac Life Support for Experienced
Providers (AHA)
February 22
__________________________________________
Advanced Cardiac Life Support Instructor (AHA)
March 15 and 16
__________________________________________
Advanced Cardiac Life Support Instructor
Renewal (AHA)
March 16
__________________________________________
Advanced Pediatric Life Support
March 20 and 21
__________________________________________
Advanced Trauma Life Support
January 26 and 27, March 13 and 14, May 1 and 2
__________________________________________
Pediatric Advanced Life Support for Providers
(AHA)
January 31 and February 1, February 28 and 29,
May 3 and 4, June 26 and 27
__________________________________________
Pediatric Advanced Life Support Renewal (AHA)
February 2, March 1, April 11, May 8, June 28
__________________________________________
Pediatric Advanced Life Support Instructors
(AHA)
May 24 and 25
__________________________________________
Pediatric Advanced Life Instructor Renewal (AHA)
May 25
__________________________________________
Trauma Nursing Core Course Reverification
February 23
__________________________________________
Basic EKG/ACLS Preparation (EKG I)
January 19
__________________________________________
EKG Interpretation (EKG II)–Basic 12-Lead EKG
February 9
__________________________________________
EKG Interpretation (EKG III)–Basic 12-Lead
Beyond the Basics
March 19
__________________________________________
International Trauma Life Support (ITLS)
February 9 and 10
__________________________________________
20 | Approaches in Critical Care | February 2012

Calendar of Events
To register and for more information, visit
www.hcmc.org/ems.htm or contact
Joni Egan in the medical education department
at Hennepin County Medical Center at
(612) 873-5681 or email joni.egan@hcmed.org
unless another contact person is provided.
Classes are at Hennepin unless otherwise
indicated. Many courses fill quickly; please
register early to avoid being wait-listed.
Advanced Medical Life Support (AMLS)
March 8 and 9
__________________________________________
Paramedic Refresher–
48 hour National Registry
24 hours classroom/24 hours online
January 21, February 11, February 25
__________________________________________
Emergency Medical Technician Basic
January 9-March 7 (Online), March 26-May16
(Online), April 9-27 (South Lake Public Safety,
Excelsior, MN)
__________________________________________
Emergency Medical Technician Refresher
January 23-25, February 13-15, March 20-22 (South
Lake Public Safety, Excelsior, MN); March 17, 24 and
31 (HCMC)
__________________________________________
TEMPO TM (Tactical EMT Refresher)
(Law Enforcement Only)
February 21, 22 and 23, March 13, 14 and 15, April
3, 4 and 5 (South Lake Public Safety, Excelsior, MN)
__________________________________________
Healthcare Provider Cardiopulmonary
Resuscitation
March 5, April 16
__________________________________________
MD Cardiopulmonary Resuscitation
for Hennepin Staff
February 3, March 2, March 14, April 6, April 18, May
4, June 1, June 13
__________________________________________
Cardiopulmonary Resuscitation Instructor
April 2
__________________________________________
Cardiopulmonary Resuscitation Instructor
Renewals
April 2
__________________________________________
Cardiopulmonary Resuscitation/Basic Life
Support for Hennepin Staff
January 25, February 7, March 7, April 10, May 9,
June 6
H
Wilderness EMT Upgrade
May 21-25
__________________________________________
First Responder
April 23-27
__________________________________________
First Responder Refresher
March 22 and 23
__________________________________________
Rapid access to Hennepin physicians
for referrals and consults
Services available 24/7
1-800-424-4262
612-873-4262
Approaches in Critical Care | February 2012 | 21

News Notes
News Notes
Swirling shapes,
restful colors and
interesting views
of downtown
Minneapolis
landmarks give the
new Burn Center a
healing and familyfriendly
ambiance.
New Burn Center offers patients
superior care and comfort
A great Burn Center just got better. In late
November, Hennepin County Medical
Center opened its newly remodeled Burn
Center, a premier 16,000 square foot
facility designed to serve the upper Midwest.
The expanded Burn Center is double the
size of Hennepinʼs previous facility and
houses 17 private rooms―10 with roll-in
showers―tub rooms, family-friendly
gathering areas, and other amenities that
improve the care experience for patients.
An adjacent ambulatory clinic provides
burn care expertise to patients who donʼt
require hospitalization.
A new hyperbaric oxygen chamber
completes the centerʼs offerings and
makes Hennepin one of the only facilities
in the Twin Cities to have such a chamber
available 24 hours for emergency hyperbaric
treatment. The use of hyperbaric oxygen
treatments is a proven measure to promote
healing for certain wounds, including burninjured
skin.
“Our commitment to serving this
communityʼs burn needs comes at a time
when many hospitals are forced to cut their
burn care units, due to federal funding
shortages,” says George Peltier, MD,
reconstructive surgeon at Hennepinʼs Burn
Center. “Weʼve been treating burn injuries
for 30 years, and with the remodeled and
expanded Burn Center, we can offer
superior, comprehensive care and comfort,
both during and after treatment.”
A multidisciplinary team approach is used
for all burn unit patients. Inpatient care
includes access to general and plastic
surgeons, burn intensive care unit nurses,
adult and pediatric specialists, rehabilitation
22 | Approaches in Critical Care | February 2012

News Notes
services, and dietary and nutritional support to
promote healing and recovery.
After discharge, the staff participates in coordination
of care with community social services, school
counselors, and other personnel to ease patientsʼ
return to everyday life. A chaplain and other
psychological support services are also available.
“We have a burn-trained physician or physicianʼs
assistant present every day, including most holidays,”
says Hennepin burn surgeon Anne Lambert, MD.
“This intensive, coordinated and consistent care is
why our Burn Center is so successful at its ultimate
goal–restoring the lives of our patients.”
The average patient census in the burn center is
approximately 10-11 patients per day with burn injury,
frostbite, hypothermia, inhalation injury, plastic
reconstruction, complex wounds, road rash, surgical
procedures, and epidermal loss from various medical
conditions. Approximately 30% of those patients are
under 18 years of age. An increase in patients is
expected with the expansion.
Hennepinʼs Burn Center is one of 57 centers across
the country designated by the American Burn
Association as Verified Burn Centers.
Part of the centerʼs mission includes community
education and outreach. In addition to providing
instructional materials on burn first aid, scalds,
sunburn, frostbite, and holiday safety, burn center
staff members conduct burn and fire safety
prevention programs in schools, and speak at
various health care events to help educate other
health care professionals.
The Burn Center at Hennepin County Medical Center
is nationally recognized for its expertise in treating
burn patients of all ages. A special website has been
created to promote burn safety: hcmc.org/outdoors.
Hennepin County Medical Center
provides critical care in
critical times
Hennepin County Medical Center (HCMC) is a
provider of care to all who need it. Serving patients
from across Minnesota, not just Hennepin
County—last year nearly 20% of HCMC patients
came from 86 other Minnesota counties.
HCMC provides trauma and critical care services,
teaches tomorrow's health care professionals,
coordinates disaster preparedness and is a
community educator.
The careful stewardship of public resources has
allowed HCMC to continue to provide the highest
quality medical care. For 15 years in a row, HCMC
has been on U.S. News & World Report's list of
“America's Best Hospitals.”
Minnesota relies on HCMC to provide critical care
in critical times. Your support and advocacy are
critical too. Learn more about HCMC's statewide
impact and sign-up for the HCMC Network to lend
your voice in telling our story.
Join The HCMC Network.
http://www.hcmcimpact.org/
HennepinCare Link is a tool that provides real-time web access to
the Hennepin County Medical Center electronic medical record
system. It provides access to patientsʼ clinical data and also facilitates
electronic communication with HCMC providers through secure
messaging. Health care professionals can use HennepinCare Link to
track clinically important events at HCMC and view their patientʼs lab
results, medication information, and visit-specific clinical
documentation. For more information, http://hcmc.org/hclink
Approaches in Critical Care | February 2012 | 23

News Notes
Top: Cher Adkinson and
Ernie Ruiz watch as new
hyperbaric chamber is
unloaded at HCMC.
Top right: Hennepin
County Medical Centerʼs
new hyperbaric chamber
on the loading dock in
Australia. Kraus-Anderson
Construction Company is
building the new addition
to house the new
hyperbaric chamber.
Lower left: The new
chamber was transported
cross-country by semi in
November.
Lower right: The medical
centerʼs original hyperbaric
chamber was delivered by
train (photo circa 1963).
New hyperbaric chamber delivered in fall, 2011
Will serve Wound Care and Hyperbaric Center
patients in April, 2012
Hennepin County Medical Centerʼs new hyperbaric
chamber arrived just before Thanksgiving. The 48-
foot, 120,000 pound chamber was manufactured in
Australia and carried by ship and semi before it was
finally unloaded and placed inside the 10,278-square
foot addition to Hennepin County Medical Centerʼs
purple building (near the 716 S. 7th St. entrance) on
November 17th.
Hennepin County Medical Center currently has the
only multi-chamber hyperbaric oxygen facility in the
state that is used 24 hours, 365 days a year for
emergency treatment of critically ill patients, often
victims of carbon monoxide exposure. Hyperbaric
oxygen therapy is used to treat radiation injuries,
diabetic ulcers, air embolism, and to heal chronic
wounds. In addition, the new chamber will be used
for research that shows promise to improve
outcomes for patients with traumatic brain injury.
Hennepinʼs current hyperbaric chamber is 48 years
old and located two blocks away from the downtown
campus. The new Wound Care and Hyperbaric
Medicine Center will open this spring.
__________________________________________
Did you train at Hennepin?
We’re looking for you.
You are an important member of an exclusive group
of physicians who share Hennepin County Medical
Centerʼs expertise and knowledge with the people of
the Upper Midwest. Hennepin is committed to
continue a learning and sharing relationship with our
alumni and would like to stay in touch.
Please submit your contact information at
HCMC.org/alumni.html
or to R. Hoppenrath, 701 Park Ave., Mpls, MN 55415
24 | Approaches in Critical Care | February 2012

For more information
To download additional resources for
critical care physicians, please visit
the Approaches in Critical Care Web
site at www.hcmc.org/approaches.
There, youʼll find:
An electronic version of
Approaches in Critical Care that
you can email to colleagues
Protocols, educational materials,
and many other resources from
past issues.
®
Every Life Matters

701 Park Avenue, PR LSB-3
Minneapolis, Minnesota 55415
PRESORTED
STANDARD
U.S. POSTAGE
PAID
TWIN CITIES, MN
PERMIT NO. 3273
CHANGE SERVICE REQUESTED
The main cover image is from the History of
Medicine, entitled “Standing Flayed Cadaver”.
It is an engraving by artist Odoardo Fialetti
from an atlas of anatomy published in 1627.
The small inset image on the cover as well as
on the back cover is an engraving from the
Historia de la Composicion del Cuerpo
Humano published in Rome in 1556. It is by
Juan Valverde de Amusco, a Spanish
physician. This is one of his most striking
images, depicting a muscle figure holding his
own skin in one hand and a knife in the other,
which has been linked to Michelangeloʼs Saint
Bartholomew in the Last Judgement section of
the Sistine Chapel.
Hennepin County Medical Center is a Level I
Trauma Center and public teaching hospital
repeatedly recognized as one of Americaʼs
best hospitals by U.S. News & World Report.
As one of the largest and oldest hospitals in
Minnesota, with 469 staffed beds and more
than 102,000 emergency services visits per
year at our downtown Minneapolis campus,
we are committed to provide the best possible
care to every patient we serve today; to search
for new ways to improve the care we will
provide tomorrow; to educate health care
providers for the future; and to ensure access
to health care for all.