Burn injury has been described as the forgotten global public health crisis. Dr Nikki Allorto says that while it may be a neglected issue in South Africa, she is making sure her patients feel seen, heard and cared for. Sue Segar spent time with her on ward and clinic rounds at Greys Hospital in KwaZulu-Natal.
It's a wintry August morning and specialist surgeon Nikki Allorto strides fast along the corridors of Greys Hospital in Pietermaritzburg, greeting fellow staff members in isiZulu.
I'm joining her on her ward and Monday clinic rounds. She's eager to get going after a weekend of not seeing her burn patients. "I need to check that everybody's OK and see who needs a dressing change," says Allorto, who is the head of the Pietermaritzburg Burn Service.
Our first stop is ward G2, the adult surgery ward, which has one cubicle for burn patients. Allorto walks to the bedside of one of four women burn patients in the room - a still, silent figure wrapped in blankets.
"Hello, my angel," says Allorto. "How are your legs today? We're going to have to turn you around. We're doing your dressing today. Lift your head for me. I'm sorry."
The severely ill woman responds almost inaudibly: "I missed you this weekend".
Allorto will return to do the dressings at midday. "It will be a very painful two-hour effort," she tells me.
In April, Allorto says the 19-year-old woman (she was 34 weeks pregnant at the time) got a 60 percent burn from a gas stove explosion. "Generally, I'd palliate a patient like this because I can't treat them," she says.
"However, she was pregnant and we wanted to save the child. We had lengthy discussions with her family and told them we were sure she'd die but we could save the baby. We saved the baby and I thought the mother would die, but she didn't. This meant I had to start treating her surgically."
According to Allorto, the definitive operation for someone with a serious burn wound is a skin graft. "If a patient has a full thickness burn injury, they need a graft, but by and large this is not happening. I'm one of the only surgeons in KZN doing skin grafting," she says.
The World Health Organization (WHO) has stated that "burns constitute a major public health problem, especially in low and middle-income countries where over 95% of all burn deaths occur". They estimate that 180 000 deaths are caused by burns every year.
Children with burns
At the general children's surgery ward, Allorto has one dedicated cubicle for burn patients. There are five babies and a teen in the ward, all with bandages around various parts of their bodies, some on drips, some moaning in pain. All have mothers sitting beside their beds.
In one bed a baby girl is sleeping with a pink teddy. "I operated last week and she's been really sick," Allorto says.
Then she moves on to a teenager who's asking for stronger pain meds. "Did mom tell you I had to sew your eye closed," she asks. The teen recently had a skin graft on her face using skin from her leg. She was burnt at her home in Newcastle after a suspected epileptic fit.
"Epilepsy is the most common underlying problem of my adult burn patients," Allorto says. She has published research showing that open flames and hot water scalding were the most common causes of burns in people with epilepsy.
While we walk to the clinic where Allorto spends most of her day on Mondays, she's speaking on her phone to a colleague at a district clinic who has sent her images of a patient's burn. The images were sent using the "Vula app", an app that helps medical professionals manage referrals. "Vula allows anyone at any level hospital to consult me about a burn patient. They can send pictures, so I reach more patients than I could physically treat. It saves costs and avoids the unnecessary transfer of patients who don't need to come to a high level of care. It also upskills the doctor I'm talking to so I can keep my beds for the people who need them," she says.
High demand for burn care
As we enter the long corridor of patients waiting at the outpatients division, two tiny boys come running up to Allorto. She kneels to hug them. They have come for their checkups after she treated their burns some months ago.
"This is my favourite part of the week," she says, "when the kids who survived their burn come running up to me. That's why I go back to work every day."
"Clinic is where people come and see me as outpatients," she explains. "Either it's checking the wound healing of patients I've operated on, or it's managing their scars and long-term problems like pain and itch. I also see patients referred for an opinion or admission for surgery."
A young boy, here for a check-up after surgery, complains of severe itching. Itching is a huge long-term issue for burn patients, as are contracture (tightening of skin, muscle, and other tissues), scarring and, of course, the chronic pain that goes with burns. The hospital doesn't supply the ointment required to reduce itching, so Allorto has arranged to fund it through a charity.
A young man arrives with a serious burn wound from a low-voltage electrical injury, which Allorto says is "a common problem, caused by bad electrical connections in homes".
Then there is an old man in a wheelchair pushed by his wife. He needs an operation urgently but Allorto has to turn him away as there's no space in the ward.
And so the day continues, the demand for burn care clearly outstripping what Allorto and her colleagues have the capacity to offer.
Allorto says burns is a common, and "hugely neglected", problem, both in KZN and nationally. She says that about 3.2 percent of the population is burnt annually. (The 3.2% figure is widely quoted in the literature. It appears to originate from a South African Medical Research Council study published in 2004. We were not able to find the study online.)
There are burns units at some large hospitals like Tygerberg in Cape Town and Chris Hani Baragwanath in Soweto. An audit by Allorto and colleagues published in 2022, found that "there are a total of 17 burn units with 511 beds and 8 140 admissions per year across the country".
"There are pockets of people trying to do good things, but, mostly, it's grossly neglected," she says.
Coming from far and wide
One thing that many people who arrive at the clinic have in common is the big square plastic bags they carry, containing blankets. Allorto says the rural patients who come and see her have invariably slept in the rural hospital they came from.
"They probably left on a bus at 2am to arrive at hospital at 5am; they've waited to be seen ... and then they're back on the bus, to the district hospital they came from, where they probably sleep another night before travelling home."
As with many issues in the public healthcare system, much depends on what care is provided where and when patients are referred and when not.
Allorto says regional hospitals should provide the basic care, including skin grafting, for burn victims but not nearly all hospitals in KZN are doing this. She says: "There needs to be an upliftment of the whole system of care so that minor and moderate burns are handled at district level. Burns requiring skin grafting should then be handled at a regional hospital, and major injury or complex burns should be handled by tertiary level/burn unit level."
Last year, she says they received 1 200 referrals to the Pietermaritzburg burn service. "We can only admit about 450 patients a year," Allorto says. "There are never enough beds, so people die at district hospitals. We don't have enough resources to manage all the patients and the magnitude of the injuries."
Where it started for Allorto
"I believe that, for people who decide to become burn wound surgeons, there's always a 'patient zero' to whom you're exposed in your career," says Allorto. For her, that was a three-year-old girl called Amahle. She met Amahle when she was doing her surgical training at KwaZulu-Natal's Edendale Hospital [now Harry Gwala Regional Hospital] in 2007.
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"I decided there and then I'd spend my career fixing this," Allorto recalls. "Every day I'd go to the back of the ward and see that children were not getting analgesia, and not being operated on. I don't know how people lived with that. I realised I couldn't live with it. I had this overpowering feeling that this was just not right."
This defining experience eventually led to Allorto driving the establishment of a burn service in Pietermaritzburg, in a system which, in her words, "remains without burn unit infrastructure, budget or permanent staff". She has also helped build a multidisciplinary team linked to the University of KwaZulu-Natal for the training of burns specialists.
A strong heart
And how does she keep it all together given the never-ending demands of the job and the suffering she can't always do something about?
Allorto says it is the values that her mom instilled in her. "My father was a soft-hearted romantic, and my mother taught me the accountability, perseverance and hard work which prepared me for this job," she says.
That doesn't mean it is easy.
"I've had my heart broken many times," she says, adding that she does powerlifting to ensure a "strong body and a strong heart".
"You develop a bond and a love for your patients because they're in hospital for such a long time," she says."You get to know each personality because you spend time with them every day on their journey to recovery. If it's a child, you know the mom. If I fail them, I'm devastated, it's like losing my own child."
*This article is part of Spotlight's 2024 Women in Health series featuring the remarkable contributions of women to medicine and science.
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