Taiwan fighter jet crash survivor Karthigayan Ramakrishnan (right) might have succumbed to infection, had it not been for donated skin which acted as ‘natural bandages’ for his injuries. The 24-year-old suffered 45 percent burns on his body following the accident last May. His injuries had to be covered with donated skin in the first few critical weeks (see other story).

According to Singapore General Hospital’s Senior Consultant and Head of the Plastic Reconstructive and Aesthetic Surgery Department Associate Professor Colin Song, cadaveric skin, or skin from deceased donors, may be the key to a burns patient’s survival.

Professor Song who is also Director of the Burns Centre explained, “Not having sufficient skin can cause death as there is no skin to act as barrier to prevent infection. The leading cause of death in severe burns is overwhelming infection. It is our constant worry as bacteria thrives on dead skin. So we need to remove the patient’s burned skin as soon as possible. If there isn’t enough of the patient’s own skin to cover his wounds then we use the next best thing – cadaveric skin – to buy time and culture his own skin for grafting.”

Using cadaveric skin as dressing, or what is termed as allograft, promotes healing and acts as temporary biologic skin for the patient. The allograft can stay on a patient for up to three weeks before his immune system starts rejecting it. Professor Song explained, “The cadaveric skin will start peeling and bacteria can start to invade. But by then, we would have already cultured the patient’s skin for grafting, or we are able to take the patient’s own skin from unburned areas taken previously since these will have healed over.”

Insufficient supply of cadaveric skin

The use of cadaveric skin allograft as temporary biological dressing is practised in many major international Burn Centres. Singapore followed suit in 1998, after SGH set up the Skin Bank Unit.

In Singapore, the demand for skin is far higher than local supply. For the whole of last year, only one person donated his skin upon death. Between 2004 to 2006, the number of donors hovered between two and four. These fi gures are a grim reflection on the poor public response and misconception to the idea of donating one’s skin upon death.

The Skin Bank Unit’s Principal Scientific Officer Alvin Chua explained, “It is hard for people to imagine how something superficial and what we literally see daily like our skin, be taken from the deceased. Donating internal organs is probably easier because people cannot see what has been taken away.”

Skin taken only from selected areas

Contrary to popular belief, skin is not taken from head to toe leaving the donor ‘bare’. Professor Song explained, “On average, we take about 0.2 5mm to 0.4 mm in terms of skin depth, from flat surfaces like the thighs and back. We use a shaver-like device called dermatome to harvest the skin.”

As only the outer topmost layer of the skin is removed, the harvested areas will appear slightly pale compared to the rest of the body where the skin is left intact. As the harvested areas can be concealed with clothing, the donor’s physical appearance would not be affected.

“The strips of harvested skin are then thoroughly rinsed and kept frozen until use. When kept in liquid nitrogen at minus 196º C, frozen skin can be stored up to five years. We have to import skin from Australia, US and recently, the Netherlands because Singapore is not self-sufficient,” said Mr Chua.

But overseas supplies may not always be available for Singapore as Mr Chua pointed out, “Priority goes to patients of countries where the donated skin are from.” He cited the 2002 Bali bombing incident where Australia needed to keep their supplies for injured citizens.

Alternatives to cadaveric skin include skin from animals and commercially available skin replacements. Mr Chua pointed out that each has its disadvantages. “Animal skin while economical, can present potential safety problems like cross contamination. Commercially available skin replacements, while have been proven to be effective, are very costly.”

Urgent need to increase supply

Professor Song noted that the number of burns cases seen at SGH has dropped by about half in the past decade to about 160 a year due to improved fi re hazard awareness. But cadaveric skin remains in demand to save people severely burned in industrial or traffic accidents. And with Singapore having the only comprehensive burns unit in this region, the Hospital also treated badly burned survivors in recent terrorist attacks.

Professor Song said, “Of the 160 to 180 burns patients we see each year, about 85 percent will need skin grafts. After the Bali bomb blasts, we treated 16 patients, mostly expatriates with an average of 20 percent burns. For the Jakarta bombing, we had 15 patients. The most severe cases had 46 percent burns.”

As part of Singapore’s plan to deal with mass casualties, there is an urgent need to beef up its supplies of cadaveric skin, hence the need for more people to pledge their skin for donation upon death. Mr Chua said, “Skin obtained from one donor could be used on two burns patients with 50 per cent burns. To increase the donated skin’s surface area up to six times its original size, a ‘meshing’ method is used.” This means creating ‘tiny holes’ in a small piece of skin so that it can be stretched to cover a larger wound.

Potential donors must sign up

As skin is not covered under HOTA, hospital staff need to obtain consent for skin donation from family members of a deceased person. Such requests are often turned down and may possibly be due to low public awareness on the benefi ts of skin donation.

As part of its ongoing public education efforts, the Hospital recently organised a public forum to spread the word on skin donation. Those willing to donate their skin upon death need to sign up.

Mr Chua said, “Potential skin donors must make their pledges under the Medical Therapy, Research and Education Act. We hope that the public can take a holistic approach and pledge any of their organs or body parts to be harvested upon death. We can then harvest the skin from suitable donors. This way, we can increase our own supplies and be less dependent on overseas skin banks”. 

Badly burnt but soldier is on the mend  It has been a long road to recovery for Third Sergeant (NS) Karthigayan Ramakrishan but the 24-year-old remains optimistic after his brush with death I was finally discharged from SGH after two months. For nearly six weeks, I was unconscious but I could actually sense the presence of my family members, friends and well-wishers. My family and friends kept vigil throughout my hospital stay. My dad said when I was airlifted back from Taiwan, my head was two-anda- half times its normal size. There were so many bandages and medical apparatus attached to me when I was admitted at the SGH Burns Centre. In the fi rst few weeks, I was constantly running a high fever due to infection. At one point, my heart was functioning like a man twice my age. It was a touchand- go situation. My doctors fought to save me – I was subjected to a dozen surgeries including multiple skin grafting. They used donated skin to cover the wounds in the initial treatment phase to help prevent infection. One day I opened my eyes and realised I was in a hospital. I felt pain and was sore all over. My throat was parched. I knew then I was really awake and not hallucinating. I asked the nurses for a drink. I could not swallow liquids directly because of the breathing tube down my throat. But I was able to have ice chips. The nurses froze my favourite carrot juice so that I was able to at least suck on flavoured ice chips. After I came out of sedation, the nurses had a hard time changing my dressings. I was burnt on my limbs and there were superfi cial burns on my face. So every time they changed the dressing, I felt sharp pain whe the dressings were removed. One of my most memorable moments in hospital was when volunteers from the Burns Support Group visited me. One of them is a Lieutenant Colonel in the Army who was badly burnt in a plane crash. He told me, ‘Son, you are a soldier and you are scarred. It’s okay. Wear your scars with pride. We are survivors.” The physiotherapist taught me how to walk again and the occupational therapist helped me with simple everyday tasks like feeding myself. A psychiatrist also kept a close watch in case I suffered from post-traumatic stress disorder. Now I am not on any strong medication but I have to wear pressure garments for 23 hours a day to keep scarring minimal. Putting them on is a tiring process and requires a lot of discipline. First I have to moisturise my skin with cream because burnt skin lacks moisture. Initially I was quite upset because I was quite reliant on family members for help. But after some time, this has become second nature to me. I cannot leave home without my pressure garments as they keep me comfortable. Occasionally I get stared at when I am travelling in the MRT or bus. Maybe there is a lack of awareness of what a burns patient goes through and the treatment required. But I have learnt to take all this in my stride and am overcoming all obstacles. I am grateful to the many wonderful people who came together to do their best and help me back on my feet again. I believe the human spirit is indestructible. Yes, my life has changed but definitely for the better.