Introduction

Advances in acute burn care during the past 25 years, in terms of decreased mortality and decreased length of hospital stay, have been truly outstanding and amazing. In 1971, survival statistics at the Institute of Surgical Research in San Antonio demonstrated an LD₅₀ (lethal dose resulting in a 50% survival rate) with approximately 40% TBSA (total body surface area) burn. Thus 50% of the patients with burns of only 40% died. Now, the LD₅₀ approaches 80% TBSA, and, if no inhalation injury is involved, patients with burn injuries greater than 80–90% of their TBSA routinely survive. In almost every burn unit in the United States, the length of stay has decreased from nearly 3 days/% burn to less than 1 day/% burn. The success can be stated simply: patients with larger, more severe burns are surviving; however, are these patients returning to society to become productive citizens? What is the real outcome of massively burned patients? Do pediatric burned patients become functional adults? How do they function socially later in life? What is the long-term effect on the patient’s families and society? Are survival and decreased length of stay really the measure of productivity for our specialty? The real product or measurements of customer service is a patient who can successfully return to society and, even more importantly, be a useful, productive individual who can successfully interact socially within a community. Yes, patients with larger and more severe burns are surviving, but this has created new problems for patients’ quality of life. Although the problems are magnified in massively burned patients, they exist even in smaller burns. These problems are best demonstrated in a pediatric burn patient with a 95% TBSA burn (Fig. 62.1). Cultured keratinocytes were utilized to achieve wound coverage. The child survived; however, when we examined the patient’s current and future reconstructive needs, they totaled 33 potential reconstructive procedures. Thus, the reconstructive problems are monumental in a child with very few donor sites.¹ With regard to survival, the results of this patient are impressive; however, we must ask the question: ‘Has the medical expertise in terms of survival progressed past the ability to reconstruct and rehabilitate patients?’ Unfortunately, the answer is clearly ‘yes’. Are we returning our patients to a society which is not ready financially, psychologically, or socially, to accept them? Again, unfortunately, the answer is clearly ‘yes’.

Figure 62.1 A pediatric burn patient with a 95% TBSA burn.

Although the American Burn Association has made rehabilitation a major emphasis, quality work still remains to be done. It is important and imperative that burn centers evaluate the functional outcome of a thermally injured patient. This is important not only for disability assessment but also for evaluation of our medical management. Outcome studies in the 20th century will not only emphasize survival and hospital stay but also patient satisfaction and ability to return to work. The purpose of this chapter is to review the functional sequelae and disability assessment following thermal injury.

Basic considerations: impairment, disability, handicap

The various terms such as ‘impairment’, ‘disability’, and ‘handicap’ appear in laws, regulations, and policies of diverse origin without proper coordination of the ways in which they are used.

‘Impairment’ refers to an alteration of an individual’s physiological, psychological, and anatomical structure or function that interferes with activities of daily living or a significant deviation, loss, or loss of use of any body structure or body function in an individual with a health condition, disorder, or disease.²

’Disability’, which is assessed by non-medical means, means an alteration in an individual’s capacity to meet personal, social, or occupational demands or to meet statutory or regulatory requirements or activity limitations and/or participation restrictions in an individual with a health condition, disorder, or disease.² Simply stated, impairment is what is wrong with the health of an individual; disability is a gap between what the individual can do and what the individual needs or wants to do. An individual who is impaired is not necessarily disabled. Impairment gives rise to disability only when the medical condition limits the individual’s capacity to meet the demands which pertain to non-medical fields and activities. On the other hand, if an individual is able to meet a particular set of demands, the individual is not disabled with respect to those demands, even though a medical evaluation may reveal impairment.

The concept of ‘handicap’ is independent of both impairment and disability, although it is sometimes used interchangeably with either of those terms. Under the provision of federal laws, an individual who is defined as handicapped has an impairment that substantially limits one or more life activities, including work, has a record of such impairment, or is regarded as having such an impairment. As a matter of practicality, however, a handicap may be operationally understood as being manifest in association with a barrier obstacle to functional activity. An individual of limited functional capacity is handicapped if there are barriers to accomplishment of tasks or life activities that can be overcome only by compensating in some ways for the effect of an impairment. If an individual is not able to accomplish a task or activity despite accommodation, or if there is no accommodation that will enable the accomplishment, then in addition to being handicapped, the individual is also disabled. On the other hand, an impaired individual who is able to accomplish a task or activity without accommodation is, with respect to the task or activity, neither handicapped nor disabled. The concept of ‘employability’ deserves special attention, for, in an occupational setting, if an individual within the boundaries of medical condition has the capacity, with and without accommodation, to meet a job’s demands and conditions of employment as designed by the employer, the individual is employable and consequently not disabled. On the other hand, an individual who does not have the capacity or who is unwilling to travel to and from work, to be at work, and to perform assigned tasks and duties, is not employable.

The first critical task in carrying out a medical determination related to employability is to learn about a job, specifically the expectations of the incumbent, with respect to performance, physical activity, reliability, availability, productivity, expected duration of useful service life, and any other criteria associated with qualifications and suitability. Sufficient detailed information from a job analysis will provide a basis upon which a physician determines exactly what kinds of medical information are needed and to what degree of detail to assess an individual’s health with respect to demand criteria.