After facing tragedy on an unparalleled scale in the wake of the deadly Whakaari/White Island eruption, New Zealand doctors and scientists are now working to change the way we deal with severe burns cases. Abbey Wakefield speaks to those at the forefront of these changes.
In an industrial fridge in an Auckland lab sit dozens of plastic bags, all containing small squares of human skin.
Held at a temperature of -79 degrees Celsius, the 100,000 square centimetres is what remains of nearly $1 million worth of donated skin imported into New Zealand.
It’s there, waiting, ready to be used for future burns victims.
These small squares of skin are part of one of the largest orders of donated skin the New Zealand Blood Service has ever had to place.
It came after the Whakaari/White Island eruption which saw victims with incredibly severe burns.
Shortly after 2pm on December 9 last year 47 people were caught in the eruption on Whakaari/White Island. Twenty-one people lost their lives while 23 others suffered severe burns.
The injuries those victims had would be some of the worst medical staff treating them had ever seen.
“Some of them were hot ash burns, some of them hot air burns and there were some that were acidic burns," Middlemore Hospital’s Clinical Director John Kenealy says.
Plastic surgeon Mr Kenealy and his team were presented with an enormous task on December 9 when burn patients arrived at Middlemore Hospital.
Treating burns is a long complex process and one that requires painstaking work to first remove the burn, then protecting the raw wound to prevent infection and fluid loss, says Mr Kenealy. One of the most important parts of this process is using donor skin to cover the wounds, an area which New Zealand is not self-sufficient in.
The number of patients requiring treatment from the eruption was at a scale these teams across the country had not experienced before.
This need for an unprecedented amount of donated skin promoted the New Zealand Blood Service to order 337,594 square centimetres of skin from overseas.
Of that, 228,195 square centimetres was supplied to hospitals around the country for the victims of the eruption.
New Zealand is part of an international skin banking community which works on a mutual support system. Orders totalling nearly $1 million were placed in Australia and the United States following the eruption, with the first shipment of frozen skin arriving within 24 hours.
Operating on a patient with burns is a long process.
For patients with 10-20 per cent of burns on their body, skin is harvested from other areas of their body to cover the burned area.
“If you’ve got a small burn, 5-10 per cent, even 20 per cent, of course 80 per cent of the body is not burnt, so therefore you can use the patient’s own skin to cover the burn,” Mr Kenealy explains.
“If more than 50 per cent is burnt then there is insufficient surface area of the remainder of the body to take skin from to cover that burn in one grafting procedure.”
The average size of a one per cent burn is about the same size as the palm of your hand.
The operations are generally long and complex and tiring for all staff involved, not least because the theatre must be heated above normal room temperature to protect the patient from heat loss.
Mr Kenealy explains the burn is firstly removed, creating a raw area. The wound must then be covered, to protect the patient from infection and fluid loss. This is where the donor skin comes in. The skin will stick to the wound’s surface until it regains a blood supply from the tissue underneath, making the skin ‘alive’ again.
But this is only a temporary measure. The body realises the donor skin is a foreign tissue and will inevitably reject it. The donor skin will start to breakdown and then fall off unless it is surgically removed and doctors must start harvesting skin from other unburnt areas of the patient to cover the wound.
Mr Kenealy says that some artificial skin from overseas was used on the Whakaari/White Island patients, a synthetic layer which connects to the epidermis and gets absorbed by the body.
One of the patients at the National Burns Centre at Middlemore Hospital had suffered 80 per cent burns with only 20 per cent of their body left to harvest skin from.
Treating physical wounds is just the first step in a long recovery process.
“There’s the psychosocial rehabilitation of the patient into the community, even if they only got a very modest burn, a modest scar, it can be surprising how severe it can be on that person’s self-esteem and functioning in the community, even if it’s not visible,” says Mr Kenealy.
The Whakaari/White Island eruption was the first time the national multiple complex burns action plan was activated.
The plan states that patients with burns equal to or greater than 10 per cent are to be taken to the Regional Burn Units and those with burns equal or greater than 30 per cent go to the National Burn Centre.
There are four regional burn units, co-located with regional plastic surgery units in Christchurch, Lower Hutt, Hamilton and Auckland, with the National Burn Centre at Middlemore Hospital.
Following the activation of the plan in December reviews into its effectiveness are underway at the Ministry of Health.
“In this case we've got both that emergency response and then how the National Mass Burns Plan worked in practice. Anything we might need to do to reflect on and refine that and to ensure that next time, if there is a next time and we hope not ... that it works even better,” said Director-General of Health Dr Ashley Bloomfield.
He believes New Zealand was prepared for the Whakaari/White Island eruption, calling it a fantastic response and praising first responders.
However, the New Zealand Blood Service’s Richard Charlewood believes if there were 100 people on Whakaari/White Island then our health system would have been stretched.
Having been at the frontline on the day of the disaster Mr Kenealy questions whether hospitals could have coped with the number of patients if we didn’t have support from other countries in the aftermath of the event.
“It would’ve been a lot more difficult if the Australian government hadn’t moved so quickly to repatriate the Australian citizens,” said Mr Kenealy.
The surge of burn cases on December 9 meant around 250 people across the country had their scheduled surgery cancelled.
“It was a lot of work for everyone involved, virtually non-stop meetings, logistical stuff, all while the theatre was going on 24/7,” said Mr Kenealy.
Currently, the New Zealand Blood Service is struggling with a lack of skin donors.
“All of New Zealand’s skin donations are from deceased donors, and when it comes to questioning the next of kin about donating skin, a lot of people just don’t know, which is why it’s important to have these conversations with your family,” said Dr Charlewood.
Not everyone can donate deceased skin either. The family of the potential donor will be asked questions around the person’s heath, lifestyle and blood tests are done to ensure there is no risk involved in passing on any infection.
After the Whakaari/White Island eruption members of the public called the New Zealand Blood Service to offer their own skin.
“When it became clear that donated skin was going to be needed in large quantities, we had a number of people phone in offering to donate their own skin,” said Dr Charlewood.
Live skin donations are not possible in New Zealand; however, work is underway to explore the possibility of these kinds of donations.
Researchers are also exploring different ways to treat burns patients, including the development of artificial skin using shark and cow collagens.
“There’s a huge amount of work going on around the world,” said Mr Kenealy.
Closer to home, scientists at The University of Auckland are working on how to recreate a total skin replacement.
Currently, the synthetic skin already on the market only connects with the layer of skin called the epidermis. Scientists at the University of Auckland are trying to create an entire skin replacement where the body will accept the dermis (bottom layer) and the epidermis (top layer), therefore cancelling out the need for donor skin altogether.
“They’re quite a long way down the pathway for that, and one of our surgeons is involved with that research.”
“Ultimately, if you didn’t have to use the patient’s own skin, let alone anyone else’s skin, that would be a huge advance,” said Mr Kenealy.
Director-General of Health Dr Bloomfield said the Ministry of Health is always interested in new products if they prove to be effective and improve outcomes.
Three months on from the Whakaari/White Island disaster, victims are still undergoing treatment for their burns.
Six people are still being treated in hospitals around New Zealand and one remains in critical condition.