Tulane University, LA, USA
The seriously burned patient needs psychiatric help from the time of injury to full recovery, and this need is increasing as modern burn centers are dramatically improving survival rates. Hypnosis is the psychiatric treatment of choice, possibly because these patients come to the emergency room in a focused state that is the equivalent of a good trance, and all that is required is to insinuate oneself into the trance and then guide away from terror into confidence. I predict that it will not be long before a Burn Centre is considered inadequately staffed without someone competent in the use of hypnosis.
In the United States, it is estimated that each year 731000 people visit Emergency Rooms for burns (Frank, Berry, Wachtel & Johnson, 1987). Some 60 900 of them are hospitalized at enormous cost, and many still die in spite of vast improvements in the technology and sophistication of care.
Seriously burned patients run the gamut of negative emotions. (Ewin, l978). Both the burn and its treatments are excruciatingly painful, and fear of the next treatment sets in early. The accident is usually caused by carelessness (of the patient or someone else), so either guilt or anger intervenes. A sense of helplessness and hopelessness resulting in depression is common. Metabolic rate increases as much as 100%, and nausea and anorexia hinder the increased food intake necessary to meet metabolic demands. It is easy for these patients to become sullen, obstinate, and uncooperative. Curtis Artz, first President of the American Burn Association and one of the early advocates of separate burn centers, is quoted (Dahinterova, l967) as follows:
The well-motivated individual did extremely well after even the most severe burn injury, whereas individuals without these resources had considerable difficulty adjusting to the result of a massive injury.
Hypnosis can provide this sense of security and motivation, and a number of clinical reports describe burned patients on critical, downhill courses who reversed direction and healed promptly following hypnosis (Cheek, 1962; Crasilneck, Stir-man et al., 1955; LaBaw, 1973; Pellicane, 1960).
Early hypnosis (within the first 2 hours after burning) is particularly valuable in limiting the amount of inflammatory reaction to the thermal injury. Brauer and Spira (l966) showed that up to 4 hours postburn a standard 'full thickness' experimental burn could be excised and used as a skin graft, demonstrating that deeper dermal layers are not killed by the heat, but by the inflammatory progression of the wound (Hinshaw, l963). Chapman, Goodell & Wolff (l959a) showed that the signs of inflammation (heat, pain, redness, swelling) are affected by the patient's attitude to the thermal injury. The thermal stimulus goes to the central nervous system, and it initiates the inflammatory response. A hypnotically imagined burn 'stimulus' can evoke an actual burn, that is, a painful blister (Bellis, l966; Chapman, Goodell & Wolff, l959b; Johnson & Barber, l976; Ullman, l947; Spanos, McNeil & Stam, 1982). Likewise, after a true burn stimulus (but before the natural response has occurred), hypnotic suggestions of cooling and anaesthesia limit or prevent the inflammatory response, just as actual icing of a burn limits the progression of a burn. De Camara, Raine and Robson (1981) used electron microscopy in a controlled study of standard scald burns (second degree) on guinea pigs treated by ice-water immersion for 30 minutes at 10 minutes postburn. At 2, 8, 24, and 96 hours compared to controls the cooled burns showed less edema, less swelling of dermal axons, and lack of infiltration by polymorphonuclear leucocytes. At 96 hours in the untreated burns 'the damaged epidermis sloughed ... large numbers of polymorphonuclear leucocytes had invaded the dermis forming areas resembling microabscesses ... nerves compared with normal nerves showed degranulation of the axons and extensive fragmentation of the myelin sheaths.' In the treated group at 96 hours postburn, 'the cooled burn wound appeared almost normal by light microscopy' except that fragmentation of myelin sheaths was pronounced and no different than that observed in the untreated group.
A burned patient who has accepted the suggestion that his wounded area is 'cool and comfortable' is easy to treat, optimistic, and heals rapidly (Ewin, 1978, 1979). This is particularly evident in burns of less than 20% of the body surface. In larger burns, inflammatory response is not fully blocked by hypnosis, but the edema is limited, as shown by the fact that with early hypnosis, these patients may require as little as 50% of the fluid calculated by formula for resuscitation (Margolis, Domangue, Ehleben & Shrier, l983). During the first 48 hours following a sizable burn, large amounts of fluid shift from the bloodstream into the injured tissues, causing local edema. When a patient requires a large volume of fluid to maintain blood pressure and urine output during these first 2 days, he must later mobilize much of this back into the circulation. In older patients with weak hearts, this can result in fluid overload, pulmonary edema, and heart failure. To safely cut in half the amount of fluid given during shock resuscitation is potentially life-saving.
Van der Does and Van Dyke (1989) have correctly noted that my clinical observations on limiting inflammatory progression of burns are only case reports, and the data have not yet been confirmed by a convincing controlled study. While awaiting such a study, I implore the reader to try it—you'll like it (Ewin, 1996).
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