Burn injuries: Texts Reading A03

Reading A03
Text A
Dressing Minor Burns Adult/Child
- A dressing functions to prevent infection and provide a moist wound healing environment. Choose a dressing
regime which can be completely applied and will maximise patient adherence.
- If the patient is for immediate transfer consult the Burns Unit who may advise to dress the wound with Silver
sulphadiazine and Melolin®
- For superficial or mid-dermal wounds (2nd degree), that are likely to heal without the need for surgical
intervention i.e. less than 2 weeks to close, the following 4 antimicrobial (antiseptic) dressing options are
recommended.
 Silver sulphadiazine cream is easy to apply and easy for the patient to mobilise. Requires daily
dressing change which may cause more pain. Silver sulphadiazine cream should only be used
on advice of Burns Services. Use with caution in children and pregnant women near term.
 Acticoat® is a comfortable dressing. Can stay intact for 3-7 days. Must be kept moist with
water.
 Mepilex Ag® is a very comfortable foam dressing that can stay intact for 3 days. Especially
useful for dressings over mobile areas such as joints and hands.
 Allevyn®. Similar properties to Mepilex Ag® however less conforming and absorbant.

- Switch to a simple paraffin based dressing once wound is pink and no eschar.

Text B
 Reading A03

Text C Analgesia for management of burns

Text D
Recommended Immediate Management for Major Burns

 remove patient from danger (without endangering yourself)

 put out burning clothing e.g. rolling patient on the ground covered with a blanket
 if clothing still smouldering put out with large amounts for cool water
 perform primary and secondary surveys
 remove clothing, rings, watches, jewellery and belts
 immediately cool burnt area for 20 minutes under cool running water
 keep non-infected areas warm and dry
 give o2 to maintain saturation > 93% adult or > 95% child
 if cervical spine cleared, raise head of bed to reduce swelling
 give analgesia
 use cling wrap for initial dressing as it keeps the burn moist and allows easier assessment
 limbs can be wrapped loosely with a non-adherent dressing and a loose bandage
 keep affected limbs elevated to minimise swelling and maintain perfusion
 consult medical officer ASAP as patient may require intubation and fluid resuscitation
 insert 2 x largest possible bore IV cannulas through unburnt skin if possible but if necessary
through a burnt area.
 Burn injuries: Questions Reading A03
Questions 1-7
For each question, 1-7, decide which text (A, B, C or D) the information comes from. You may use any letter more
than once.

In which text can you find information about

1 the administration of oxygen for both adults and children?
2 possible side effects to opioid medication?
3 how long it takes for burns to heal?
4 advice on bore IV cannula insertion?
5 recommended options to dress superficial or mid-dermal wounds?
6 identifying the severity and type of burn?
7 choosing the most appropriate cover for second degree burns?

Questions 8 – 14
Answer the questions, 8-14, with a word or short phrase from one of the texts. Each answer may include words,
numbers or both.

8 What type of scarring may result from a mid-deep dermal burn?

9 What is the maximum overall dose of Morphine that is recommended?

10 What may be applied to the wound if a patient is for immediate transfer?

11 What may be absent in epidermal or full thickness burns?

12 What type of dressing is used once the wound has become pink with no eschar?

13 What may result if an alternative to Morphine and/or other opioids is given?

14 How long should running water be used to cool a serious burn?

 Reading A03
Questions 15 – 20
Complete each of the sentences, 15-20, with a word or short phrase from one of the texts. Each answer may include
words, numbers or both.

15 Repeat doses of naloxone may be given for rare events of .

16 For patients with significant renal disease, a dose of Morphine is

recommended.

17 A red appearance, which is warm to the touch, is the result of an .

18 If clothing is smouldering, large volumes of can be used.

19 Although less absorbent than Mepilex, is a suitable alternative.

20 The use of as a dressing is recommended for severe burns in the first

instance.
 Reading B07

Reading B07

The purpose of the memo is to remind staff of

A the importance of accuracy in measuring morning blood pressures.

B the increased likelihood of blood pressure problems in the morning.
C the procedure to follow in cases of increased morning blood pressure.

Memo to staff: Morning surge in blood pressure

Cardiovascular events, such as myocardial and cerebral infarction, ischemia and stroke,
are more frequent in the morning hours soon after waking than at other times of day.
Circadian variations in biochemical and physiological parameters help explain the link
between acute cardiovascular events and the early morning BP surge. The clinical
consequences of these haemodynamic and neuro-humoral changes are numerous, and
myocardial ischaemic activity has been documented. The occurrence of stroke and heart
attack is more common in this period than at any other time of the day. It has been shown
that, in older hypertensive subjects, a morning surge in BP — defined as a rise in BP
greater than 55mmHg from the lowest night-time reading — carries a risk of stroke almost
three times that seen in patients without a morning surge.
 Reading B08

Reading B08

The main point of the memo about antiviral drugs for children is that

A the drug of choice is age-dependent.

B prescription guidelines must be followed.
C incorrect dosage may be toxic.

Memo: Dosages of antiviral drugs for children

Treatment dose recommendations of many antiviral drugs for neonates, infants and
children are often based on very small cohort studies of treated individuals. With the
considerable changes in renal, hepatic and gut function during growth and development,
the doses are not always adequately optimised, especially those for infants. Maximising
doses is important for antiviral effect, but this must be balanced with the need to minimise
potential toxic effect. The most up-to-date dosing schedules should be used and, if
appropriate, drug levels may also be measured, for example, for acyclovir or ganciclovir.
Caution is required in interpreting serum levels of drugs that act principally at the
intracellular level. Drug level monitoring is also an essential part in the follow-up of
combination therapy, for example, in HIV infections, to ensure adherence, safety and
efficacy.
 Reading B09

Reading B09

According to the guideline, CT is preferred to MRI when

A urgent diagnosis is required.

B high-resolution imagery is indicated.
C investigation indicates a localised seizure source.

Guideline: Imaging and epilepsy

Magnetic resonance imaging (MRI) and computed tomography (CT) scanning are used to
investigate unexplained seizures. MRI is the preferred procedure in elective situations.
MRI is particularly indicated in those who develop epilepsy in adulthood and have any
suggestion of a focal onset on history or examination. It should be ordered only after
obtaining a good clinical history, preferably including an eyewitness description and,
where possible, after an electro-encephalogram (EEG) that does not show generalised
epileptic discharges. MRI is the preferred modality for high-resolution structural imaging in
epilepsy and is more sensitive than CT scan for detecting intrinsic brain tumours, stroke,
focal cortical dysplasia, mesial temporal sclerosis, vascular malformations and cerebral
dysgenesis. Although MRI is generally preferred to CT, CT should be performed if
intracranial bleeding is suspected because of recent head trauma, coagulopathy or severe
headache.
 Reading B10

Reading B10

The email reminds staff that they should

A never leave linen skips unattended on the ward.

B not enter the dirty linen room without authorisation.
C avoid placing soiled linen in bags unless the skip is already full.

To: All staff

Subject: Recent Accidents (Linen)

In recent days, there have been a number of minor accidents due to overfilled linen skips
being left along the ward in non-allocated areas. This creates an unsafe environment for
our patients, staff and visitors and must be avoided at all costs. Any soiled linen must be
placed in the skips (with a bag inserted) at the point of generation, for example, at the
bedside, and should only be filled to a maximum of three-quarters capacity to avoid
overflow. The linen skips should immediately be transported to the dirty linen room for
collection. Staff handling linen should practice hand hygiene at all times to prevent
contaminating clean linen.
 Reading B11

Reading B11

The guideline says that before going on a short break, the nurse must

A speak to the colleague who will take over care of the patient.
B keep a written record of who has agreed to look after the patient.
C ensure that the patient’s documentation is up to date on the system.

Extract from staff guidelines: short-break and long-break handover

A short-break handover occurs between the nurse responsible for the patient and the
nurse who is assuming responsibility for the patient. This comprises of a short verbal
handover focusing on the greatest risk for the patient, and is essential to uphold patient
safety during this short break. A long-break handover also occurs between the nurse
responsible for the patient and the nurse who is assuming responsibility for the patient.
This, however, comprises of a verbal handover in ISBAR format (ISR) – identification of
patient; current situation and any risks or recommendations for break interval.
Furthermore, documentation of handover and transfer of professional care needs to be
recorded in the Electronic Medical Record (EMR).
 Reading B12

Reading B12

The main point of the memo is to

A specify the rights of patients.

B confirm details of hospital policy.
C inform staff of a new set of procedures.

Memo to all staff: conduct concerning handheld devices

This memorandum is a reminder to all staff, including contract/pool agency staff, students
and volunteers, of the rules governing the use of handheld devices within the hospital.
Personal devices are never to be used to record images of residents, patients, or clients. If
such images are needed for purposes of care or training, they must be obtained by
authorised persons only and use the hospital’s own equipment. Any authorised
photographs or images are the sole property of this healthcare facility and the distribution
of these photographs or other images to any person outside this setting without written
authorisation for permissible use is prohibited. Personal phones and other wireless
handheld devices may be used on breaks in the staff room or outside the premises. Any
breach of this policy will result in disciplinary action.
 Blood Transfusion

Countless lives have been saved since blood transfusions were first introduced in the seventeenth
century. Initially, some members of the medical community were hesitant to use them, but
transfusions were soon seen as vital in the replenishment of blood lost through trauma, illness or in
the operating theatre. In many ways, transfusions are a medical marvel, providing a safety net for
times when procedures don’t quite go according to plan. Transfusions also represent a lifeline for
people with inherited blood disorders, with certain rare diseases or who are undergoing
chemotherapy. But the field of transfusion medicine is changing. Instead of seeing it as an inert
recharging of fluid, we’re now coming to appreciate that a blood transfusion is essentially a liquid
‘organ transplant’, which comes with its own risks and drawbacks.

Blood occupies a strange and somewhat privileged position in modern medicine, and it has evolved
as a treatment option without the same level of research scrutiny – at least on the patient outcomes
side of things – that other treatments are subjected to. Nowadays, if you have a modern
pharmaceutical it goes through the whole process of clinical trials before it's registered, but blood
didn't come to health that way. As far back as 1990, studies were hinting that blood transfusions
carried more risks than had previously been thought, and it was quickly becoming apparent that the
mere fact a patient received a blood transfusion was a risk factor and in some instances was
associated with poorer outcomes.

Research up to now has been far from comprehensive. ‘Restrictive transfusion’ studies – where a
transfusion was only given if a patient’s haemoglobin levels dropped to a certain point – did not
appear to leave the patient any worse off. In a perfect world, however, scientists would do a clinical
trial. People would be randomly assigned to one of three groups – some would have a blood
transfusion, others would be given a placebo and others no transfusion at all. Scientists would then
compare how each group fared. But a trial such as this would never get approved, because why
would you give a blood transfusion to someone who didn't need one, even in a clinical trial setting?
By the same token, why risk not giving blood to someone who might well die without it?
Another way of testing the pros and cons of blood transfusion involves consent. Fully informed
patients are well within their rights to refuse a blood transfusion if they feel it conflicts with cultural,
religious and personal beliefs. Such patients have inadvertently served as a sort of test case. This
situation, in which transfusion is no longer an option for doctors, has given rise to some surprising
results when the patient makes a better than expected recovery following surgery. Some
commentators have suggested that the option of transfusion being unavailable may have led
surgeons to proceed in a more cautious manner, which resulted in positive changes in surgical
technique that led to improved outcomes. Another interpretation, however, could be that the
transfusion itself was doing more harm than good.

When it comes to extracting and identifying the negative consequences of blood transfusion,
medical researchers still have a challenge ahead of them. The reason is that if someone is considered
sick enough to need a transfusion, there's a good chance they're already in a bad way physically. This
makes it virtually impossible for anyone to say with any degree of conviction that a patient's state of
health is caused by the blood transfusion or is the result of the illness and trauma that led to them
receiving the blood transfusion in the first place. What is known is that the observational studies
have pointed to a longer time spent in hospital, a higher risk of infection after surgery, an increased
likelihood of needing artificial ventilation, and a greater risk of needing transfer to the Intensive Care
Unit with conditions such as multi-organ failure. Such evidence is tenuous to say the least, and
therefore the jury is still out.

A growing body of research data from laboratory and animal studies is giving insights into what
transfused blood does to the host body. Take the fact that blood transfusions were once used to
prepare recipients for kidney transplant, because transfusions were known to reduce the likelihood
that the host immune system would reject the donor organ. This suggests that donor blood is
somehow modifying the host's immune system; a desirable effect in the early days of kidney
transplants, but less desirable if a patient is in intensive care after an accident and already physically
vulnerable.

There's also the suggestion that the more blood a patient gets, the more problems they are likely to
have. However, even one unit of blood is enough to cause problems, so such concerns may be
misplaced. More significant is the fact that storing donated blood outside the body changes it.
Chemical messengers called cytokines, and other biological substances, accumulate in stored blood,
and there’s the possibility that this may cause issues when the blood is transfused into the patient.
1. In the first paragraph, the writer makes the point that blood transfusion

○
A has an impressive range of functions.

○
B is needed now more than ever before.

○
C was developed primarily for use during surgery.

○
D hasn’t always been regarded as a suitable treatment.

2. In the second paragraph, the writer is suggesting that the benefits of blood transfusion

○
A can be outweighed by unreported negative factors.

○
B need to be confirmed by further critical investigation.

○
C have been conclusively established in most medical contexts.

○
D may not always guarantee that it’s the safest treatment option.

3. In the third paragraph, what point is made about research into blood transfusions?

○
A It hasn’t tended to attract sufficient financial resources.

○
B Approval for a full clinical trial has been repeatedly withheld.

○
C It hasn’t been possible to follow accepted scientific principles.

○
D Studies done to date are thought to be adequately representative.
4. In the fourth paragraph, it is suggested that patients who opt not to have a blood
transfusion

○
A may have encouraged the development of surgical skills.

○
B have been identified as a source of data for ongoing studies.

○
C have provided evidence for the general benefits of the procedure.

○
D have stimulated some heated debates amongst medical professionals.

5. In the fifth paragraph, the word ‘this’ refers to

○
A the negative consequences of transfusion.

○
B the decision to give a patient a transfusion.

○
C the challenge of doing research into transfusions.

○
D the state of health of a patient receiving a transfusion.

6. The writer uses the phrase ‘the jury is still out’ in the sixth paragraph to stress that
negative outcomes of transfusions

○
A are likely to vary in different contexts.

○
B are rarely due to the procedure alone.

○
C are difficult to isolate with any certainty.

○
D are often wrongly attributed to the procedure.
7. In the sixth paragraph, the writer mentions blood transfusions during kidney transplants
as an example of

○
A a use of transfusions that has now been questioned.

○
B an unexpected benefit of transfusions that has come to light.

○
C a mistaken assumption about transfusions that has been corrected.

○
D an area where non-human studies have led to new uses for transfusions.

8. In the final paragraph, the writer highlights a problem regarding

○
A how often a patient receives donated blood by transfusion.

○
B the length of time donated blood is stored prior to transfusion.

○
C how donated blood is stored before it is needed for transfusion.

○
D the quantities of donated blood transfused to a patient over time.
 Reading C04

The health benefits of positive thinking

Can a positive attitude extend one’s life, and, if so, can such attitudes be fostered even in
those not naturally disposed to it? Despite the absence of any conclusive evidence, the hints
are tantalizing enough that researchers from Massachusetts General Hospital (MGH) and
Harvard Medical School want to find out. ‘A lot of the long-term research says that if you’re
an optimist, you’re more likely to have better health,’ says Jeff Huffman, an associate
professor of psychiatry at Harvard Medical School. ‘But, and this is the point, let’s say you’re
not an optimist — can we turn you into one? Can we promote that and teach that in a way
that has any lasting effect? And will it really work to improve health? It’s a big and open
question.’

Research over recent decades has shown that exercise is the closest thing we have to a
miracle drug against threats such as cancer, heart disease, and diabetes. Consequently,
Huffman launched the Cardiac Psychiatry Research Program (CPRP) 12 years ago as a
way to curb the anxiety and depression that heart disease can set off. The best chance for a
positive outlook to affect health is by promoting exercise, Huffman says. He began by
treating patients in the cardiac unit at MGH, quickly discovering that his fears of being
unwelcome there were unfounded. Doctors and nurses recognized patients’ psychiatric
needs and were glad to see Huffman attending to them.

The CPRP combines exercises designed to promote positive psychology in the hospital’s
cardiac and diabetes patients with techniques known to change behaviour, such as goal-
setting, to encourage patients to adhere to medication regimens, improve their diets, and
become more active. ‘We tried it on some patients with heart disease and they really liked it.
Since then, we’ve not just been studying observable connections between positive
psychological states and heart disease, but also more active methods of promoting and
cultivating these positive psychological states,’ Huffman said.

CPRP patients can now continue with it even after they have left hospital. Before discharge,
they attend an in-person training session and receive a manual with eight to sixteen weeks
of daily tasks, including writing letters of gratitude, performing acts of kindness, and
reflecting on past successes. Participants also receive weekly phone calls from one of the
program’s trainers, who reviews the previous week, reinforces the positive message, and
encourages exercise and other goals. ‘What we’ve learned so far — small but important
steps — is that if we teach patients how to identify the good things in their life, they feel
better, with increased happiness, decreased anxiety, decreased depression, and better
outcomes’ Huffman said. ‘We feel pretty confident about that’.

1
 Reading C04

Pankaj Shah joined one of the CPRP’s studies last October, after finding himself in an
operating room getting stents placed in the arteries around his heart. At 51, he was carrying
95 kilos on a 152-centimetre frame, having largely given up exercise after graduating from
college and joining the working world. Not until his forties, however, did he give up smoking.
And then there was a family history of heart disease. Shah, who was awake for the
procedure, remembers something of a revelation in the operating room. When he was asked
to participate in the study, he didn’t hesitate. Since then, he’s lost about 18 kilos. His
exercise void has been filled with long weekend walks and four-hour bike trips. ‘I’m feeling
more at ease with myself,’ Shah said. ‘I used to think, ‘Why would people climb Mount
Everest?’ Now I know. I never had that feeling in 51 years. I’m discovering a person I never
knew existed inside my body.’

Sceptics might look at Shah’s transformation as that of a man who heard a loud and clear
rumble of mortality. And Huffman, for his part, wouldn’t disagree with that. He says there are
two standard responses to his work. One is that it’s bound to work. ‘How can it not help
people to feel happier and experience more self-esteem? You don’t need to do a study
about that.’ And then another other group of people is saying: ‘This is nonsense. These are
people with a real disease, what are you doing having them write letters of gratitude?’
Huffman himself reserves judgement. He says that promoting people’s happiness and
optimism simply seems like a good idea. However, he also says that while there are
observational studies to support its positive impact, he admits that he doesn’t actually know
if this can be done in a sustainable way. It is an unknown.’

A clinical outcome would represent an exciting development in the battle to promote a

healthier society, Huffman believes. Unlike expensive drugs and medical equipment, the
techniques are relatively cheap and easy to deploy. The ultimate goal, as he sees it, is not
just to increase exercise levels, but ‘to have the downstream effects of having fewer cardiac
events, being hospitalized less, of reduced health care costs. If we can achieve that and, in
so doing, reduce health care costs, that would be amazing.’

2
 Reading C04

1 The ‘big and open question’ being addressed by Jeff Huffman focuses on

A exactly how effective a positive attitude is in improving health.

B why a positive attitude tends to result in better long-term health.
C whether learning to have a positive attitude can result in better health.
D the accuracy of existing research into the health benefits of a positive attitude.

2 What led Huffman to found the Cardiac Psychiatry Research Program (CPRP)?

A demand from staff in the cardiac unit of his hospital.

B knowledge of the emotional benefits of regular exercise.
C first-hand experience of the mental impact of serious illness.
D a desire to gain acceptance for his theories amongst his peers.

3 How has the work of the CPRP changed?

A It now supports the work of a variety of other hospital departments.

B It no longer concentrates on achieving behavioural changes in patients.
C It has started to work with patients with a wider range of medical issues.
D It has adopted an increasingly interventionist approach to patient attitudes.

4 In the fourth paragraph, it is established that the CPRP has convinced Huffman that

A patients can benefit from developing the right mental focus.

B keeping patients busy is the secret to maximising their happiness.
C regular human contact is vital to any patient’s long-term prospects.
D patients need extended post-hospital support if they are to fully recover.

5 What made Pankaj Shah decide to join the CPRP?

A He realised that he needed to lose weight before an operation.

B He was inspired to do so by the surgeons operating on him.
C He had a moment of clear insight while receiving treatment.
D He was encouraged by members of his family.

3
 Reading C04

6 Huffman feels that some people criticise his work with patients like Pankaj Shah
because they think that

A the patients would have recovered anyway.

B he is failing to take the patients seriously enough.
C the patients’ role in their own recovery is being ignored.
D there is a need to examine the evidence in greater depth.

7 In the sixth paragraph, the word ‘It’ in the phrase ‘It is an unknown’ refers to

A physical recovery from illness.

B boosting long-term emotional health.
C one view of Huffman’s work with patients.
D the lack of data to back up Huffman’s ideas

8 What does Huffman see as the main goal of his approach?

A to give certain sections of the population a chance of longer-term good health

B to see particular types of disease become almost a thing of the past
C to promote the range of benefits associated with physical activity
D to reduce overall rates of spending on effective medical care