UCSD Burn Unit

Staci Halac, RDN

NUTR 409
Joan Rupp
Journal #1
Dietitians play an integral role as part of the team needed to
successfully treat burn patients. Specialists may include burn surgeons,
nurses, anesthesiologists, respiratory therapists, occupational &
physical therapists and therapists. (1) Burns are a catabolic injury and
therefore have increased nutrient requirements to prevent malnutrition
in the patient. It is the role of the Registered Dietitian to monitor the
nutritional needs of the patient and to then share their feeding
schedule recommendation with the team. A thorough nutritional
assessment is required to determine the most accurate nutrition
prescription for each patient. The RD may also use indirect calorimetry
to determine REE for an estimate of energy requirements. (1)
UCSD Burn Center has met numerous criteria to be classified as a
level 1 burn center by the American Burn Association and American
College of Surgeons. They must excel in areas such as strict
administration procedures, maintain a certain volume of burn
admissions, be prepared for disasters, and have access to ancillary
services such as dietitians, among others. As they are a regional burn
center, this includes San Diego and Imperial Counties, therefore it
admits and treats victims as far as Mexico, Arizona and Orange County.
1

USCD Burn Center admits up to 450 burn victims per year. Led by
Bruce Potenza, M.D., the UCSD burn team boasts experts from areas
such as plastic surgery, social work, pain management, physical and
occupational therapy, child life, psychology and dietetics. In addition,
the burn center offers several support programs for its patients and
their families, and is making important advances in burn injury
research. (2) Additionally, UCSD has the distinction of being a teaching
hospital, therefore they get a new group if interns every July. This
ensures that those with experience can train and share their
knowledge with the interns to better prepare them for their futures in
the field of healthcare.
After a quick tour through the burn unit at the UCSD Medical
Center, (which was much smaller than I expected), we were led to a
large conference room where one of the dietitians, Staci Halac,
explained what she does as the dietitian in a burn unit, and how she
got there.
It was interesting to note that when I imagined they population of
burn patients seeking treatment, I only pictured flame burn injuries. I
was fascinated and surprised when Staci informed us that they treat
soft tissue injuries in general, which include inhalation burns, scalds,
electrocutions, skin infections, Stevens-Johnson syndrome, Toxic
Epidermal Necrosis (TEN), and more. Even more interesting was
researching Stevens-Johnson syndrome and TEN, which are two related

skin disorders that cause painful blistering and necrosis of the

epidermis and mucous membranes, which usually requires
hospitalization. (3) Severe burn victims, who are defined as having
greater than 20% total body surface area affected, also often require
hospitalization. As a consequence, patients with severe burns tend to
lose weight. As mentioned above, burn injuries are extremely catabolic
and therefore require increased protein needs and energy
requirements; up to 2 grams/kilogram of body weight for protein and
increased total energy as determined by either indirect calorimetry
(the preferred method), the Toronto or Ireton-Jones formulas for the
ventilated patients, or the basic Mifflin St. Jeor formula for those with
non-severe burn injuries. (4)
I found it quite interesting that Staci had to learn by trial and
error and researching on her own to determine what formulary and
supplements work best for her patients. It was quite a coincidence that
just that morning we went over different learning styles and I
happened to discover that I was a kinesthetic learner meaning I learn
best when I simply jump in and start figuring things out on my own. As
Staci described her learning process, I could totally see myself in that
exact same position. In fact, I would prefer it. For me, the information
never really sticks unless I have hands-on experience with it, one way
or another.

Because there isnt a lot of research on burns, Staci remains in

close communication with other burn center RDs, such as the RDN at
U.C. Davis in Davis, California. Together they share knowledge and
experience of what they have learned while on the job. Additionally,
Staci follows the European and Australian nutritional guidelines when
treating her patients, as she mentioned there was more information
available on these sites than what is available on ASPEN.
Some interesting nutritional knowledge Staci shared with the
group included that each and every burn patient, no matter how small
of an injury, gets supplemented with a multivitamin, vitamin C and
zinc. Additionally, those with severe burns require additional vitamin D
and copper supplementation. Selenium, zinc, and vitamin A levels are
closely monitored in these patients as well. Prealbumin is also routinely
checked, as the doctors would like to see an upward trend; however,
due to the inflammatory process, this desire is rarely satisfied. Her P/O
patients get to order almost anything they want, therefore she doesnt
necessarily make recommendations in regards to their meals, though
she does encourage them to order a protein source with every meal
service. However, she does utilize nutritional supplements such as
Boost or Ensure, and Pediasure for the children. She also mentioned
that she only had one TPN patient in her three years working in the
burn center.

As far as the treatment of burns, Staci explained the two types of

skin grafts; allographs and autographs. Allographs come from cadaver
donors and autographs come form the victims own healthy,
unaffected skin. While allographs are always rejected, they act as a
protective layer for the site of the burn to allow the skin cells to
regenerate for 10 days while lowering the risk of infection and other
complications.
Finally, Staci gave a little insight on a day-in-the-life of an intern
in a burn unit. She mentioned that there is a lot of communication
between the interns and the doctors, nurses, residents, surgeons and
other medical and ancillary personnel on staff. She encourages the
intern to stay on the floor and gain as much information as they can, in
addition to getting comfortable with the interviewing process of the
patient. What I found particularly encouraging was when she
mentioned that UCSD tends to hire at least one intern every rotation.
One could assume that most hospitals/healthcare facilities may do the
same. In fact, registered dietitians and nutritionist experts job outlook
is expected to grow 16% between 2014 and 2024, which is much faster
than the average for all occupations, according to the Bureau of Labor
Statistics (BLS). (5)
Though I find the treatment of burns unique and interesting, I
doubt if I could see myself at a center such as this for very long. I tend
to believe that I would thrive in a more challenging environment such

as the renal department of a hospital or in critical care. I require

something a little different every day in order to remain motivated and
to prevent myself from becoming bored. However, if I am honored with
getting the UCSD dietetic internship, I look forward to my time learning
in the burn unit alongside their extensive team of experts.

References
1. Burn teams and burn centers; the importance of a
comprehensive team approach to burn care. Clin Plast Surg.
2009 Oct; 36(4): 547554. Doi: 10.1016/j.cps.2009.05.015.
Accessed online.
2. UC San Diego Health Regional Burn Center.
http://health.ucsd.edu/specialties/burncenter/Pages/default.aspx. Date accessed, February 27, 2016.
3. Equations for the estimation of energy expenditures in patients
with burns with special reference to ventilator status. J Burn Care
Rehabil. 1992 May-Jun;13(3):330-3. Accessed online; February
27, 2016
4. Toxic Epidermal Necrolysis.
http://emedicine.medscape.com/article/229698-overview
5. Dietitians and Nutritionists. Job outlook;
http://www.bls.gov/ooh/healthcare/dietitians-andnutritionists.htm