Words, Words, Words – Does It Really Look Good?
By Dr. Robert Klein, MD, FACS
Robert Klein, MD, FACS, is the medical director of the Children’s Hospital of Akron. This article was based on a presentation at the World Burn Congress 2002 in Phoenix, Arizona.
Words, words, words . . . when a thermally injured person first enters the hospital for burn care, the first encounter with the medical staff is crucial. Words are used to explain what is wrong with a patient; the severity of the injury; whether the patient will live or die; and what kind of disability might be expected. The words used will often set the tone for the entire hospital stay.
And what is a word? A word is a combination of sounds that symbolize a meaning. A meaning is an idea that conveys something to the mind. A word is something that is said. It is a statement, an announcement, a pronouncement, an assurance; and sometimes it can be interpreted as a guarantee or a promise of something to come. A word is also a statement that’s weight and worth depends upon the veracity and the authority of the person speaking.
WHAT DOES IT MEAN?
It is very important to gain the confidence of patients and their families when discussing the burn injury, their prognosis, and the plans to ensure the patient’s recovery and re-entrance into society. Most of the time patients and their families are searching for the words we speak that will give them hope and assurance that everything will be all right. It is, therefore, very important for the medical personnel to try to make certain that the words they speak are clear and that the meaning of the words is understood. This often means that we should and will have to repeat the things that we tell patients over and over and over again. Sometimes it is beneficial to write down what has been said. We must be careful that we use words that indicate that we are being truthful. If things are not likely to go well for the patient, then this needs to be stated clearly; while leaving hope that things will go well.
One of the most common statements that a patient hears is, “It looks good.” What does it mean when we say, “It looks good?” A patient’s interpretation of a burn wound that looks good and the medical personnel’s view of the burn wound looking good can be 180 degrees apart. It is very important to consider what the patient thinks is important when health care providers are speaking to them about their injury. Is the patient considering the cosmetics of the wound; the pain involved with the wound; the graft and how it really looks? Is it better than the patient anticipated or does the graft look worse than what they anticipated?
WHY DEFINE OUR TERMS?
The truth of the matter is that wounds that are grafted and in various stages of healing or even healed still never look as good as the patient’s normal skin did before the injury took place. So, when we say, “It looks good,” we better be mindful of the terms we are using and be careful to explain what the terms mean to us so that the patient understands why we are using those particular words.
For example, a small child comes into the burn unit with a burn on his chin and anterior chest from pouring hot liquid down the front of himself. The child is met by medical personnel who look at the wound, evaluate the injury, and then state, “It looks good.” We have to explain to the family why it looks good to us. Our interpretation is that the wound is red; it is painful; and it is swollen, but the depth of the wound is going to be superficial enough that the wound should heal in 10 to 14 days without any long-term scarring. The family may look at that wound and think otherwise, so it is very important for us to explain what we are saying.
Another patient, for example, may come into the burn unit with a deep burn that involves an area of the back, leg, or another portion of their anatomy. We look at the wound. It is clean; it is not infected; it looks like the wound could be excised and grafted with complete healing and no residual functional problems. Again, we may say to this patient and their family, “It looks good.” However, after the wound is grafted, there is irregularity of the graft, some thickening along the margins of the wound where the graft is joining normal skin or maybe another adjacent section of the graft may be raised up, but again we tell the patient, “It looks good.” We must explain that It looks good to us because the wound is covered; it is no longer draining; it is not infected; there are no open, raw areas left; and the function of that area is normal. In reality the patient may not think it looks good, but they would probably agree that the wound is not infected; the wound is not open; the wound area does not hurt as much as it did before; and their range of motion is good even though it still may not look good to them. We must define our terms and explain very carefully why we think, “It looks good.”
Another scenario is a patient is seen a year or two after the injury. Grafting has been completed; the wound has healed; it is not painful; the area has excellent range of motion; the skin can be touched and rubbed without pain or injury to the healed area. Once again, we will tell the patient, “It looks good.” Even at this late date the truth is that it probably does not look very good to the patient; however, the patient is at the point where they are willing to accept the wound as it is whether they like its appearance or not.
It is my humble opinion, when we speak to our patients, we need to be very careful of our choice of words. We need to make absolutely certain that patients understand where we are coming from when we state that something looks good. We also need to understand why we say that something is looking bad so that the patient can be aware of the difficulties we are facing with the management of that particular wound. It is also a fine idea to tell the patient why the wound looks good to us and be willing to admit that it probably does not look good to them, because the wound does not look as good as normal skin. By doing this, the patient and the family will have a clear definition of what we are talking about. We always have to admit the fact that we know the wound, no matter what the state of healing, does not look as good as it did before the injury. If we are up front and honest with our patients and listen to their words as much as they listen to ours, our patients are more likely to have confidence that what we are telling them is the truth as best we can tell it.
This story is an excerpt from The Phoenix Society’s® Burn Support News, Spring Edition 2003, Issue 2. Burn Support News is a quarterly publication that contains articles on the emotional, psychological, and social aspects of burn recovery. All Rights Reserved.