Consequences of Self Immolation
5/30/2017
Caring For Those Involved in Self - Immolation Cynthia Blank-Reid, RN, MSN, CEN Trauma Clinical Nurse Specialist Temple University Hospital Philadelphia, PA
Objectives • At the end of the presentation, the participant will be able to: – Describe persons at risk for self –immolation
– Discuss the difference between Eastern and Western world cultures in relation to self –immolation
– Construct a plan of care for a person with a self- immolation injury
Self-Immolation The act of setting fire to oneself
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Suicide
• 3rd leading cause of death in 15-44 year old population • 6th leading cause of death in adolescents and young people in US • Individual’s choice of a particular method is affected by the cultural and ethnic characteristics of his/her society
• Mirlashari J, Nasrabadi AN, Amin PM (2017). Living with burn scars caused by self-immolation among women in Iraqi Kurdistan: A qualitative study. Burn 43, 412-423.
Self-Immolation
• Rare in western societies and developed countries, common method of suicide and major cause of severe burns and burn deaths in eastern world. • Method of choice in 27% of suicide attempts in developing countries such as Iran, India and Sri Lanka. • Has become more popular among younger people, particularly females. • 75 % of women who do self-immolation are 14-30 years. • Mirlashari J, Nasrabadi AN, Amin PM (2017). Living with burn scars caused by self-immolation among women in Iraqi Kurdistan: A qualitative study. Burn 43, 412-423.
Self-Immolation
• Iraqi Kurdistan set strict gender-related rules that can lead to domestic violence, honor crimes, forced marriages and prevent women from leaving abusive situations. • Kurdish women and girls chose methods of suicide to escape gender, social or tribal discriminations. Some burn themselves because families do not approve of their marriage. • Some believe they are forms of protest against existing conditions in the patriarchal society. Restrictions set by fathers, brothers and even mothers. • Mirlashari J, Nasrabadi AN, Amin PM (2017). Living with burn scars caused by self-immolation among women in Iraqi Kurdistan: A qualitative study. Burn 43, 412-423.
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Suicidal Burns • Worldwide 8 hundred thousand people die from suicide every year • 2012 - Second leading cause of death among 15-29 year olds globally • Suicide rate in Asia is 30% higher than the rest of the world • Many self-immolations go unreported for social and medico legal reasons • If used with an accelerant, full thickness burns with an inhalation injury
Pediatric Suicidal Burns
• Suicide rates amongst children have increased worldwide and so has self-inflicted burns
• ** Segu S, Tataria R. (2016): Paediatric suicidal burns: A growing concern. Burns 42, 825-829.
Tarek el-Tayeb Mohamed Bouazizi • Born: March 29, 1984 – Tunisia • Died: Jan 4, 2011 – Tunisia • Catalyst for Tunisian revolution and Arab spring • Tunisian street vendor • Times of the UK - Person of year – 2011 • Tunisia gave him a postage stamp
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Tarek el-Tayeb Mohamed Bouazizi • Federal agents took his wares away; did not have money to bribe them • Female officer slapped and spit on him • Dec 17, 2010 - complained to Governor's office; threatened to kill himself with fire • Got gasoline, set fire to himself in middle of traffic outside Governor's office
Tarek el-Tayeb Mohamed Bouazizi • Lived for 18 days • Transferred twice to hospitals with higher level of care • Died: Jan 4, 2011
Religious Rituals
• Self – immolation used for sacrificial purposes
• Judeo-Christian traditions have imagery of fire as cleansing and purifying
• Secular imagery associating fire with evil and condemnation- destruction of witches and heretics
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Political Protest-Sacrificial Suicide for the “betterment of others”
Buddhist Monk -Protest in Saigon, South Vietnam 1963 - Alturistic suicide
Western Countries High Income/Industrialized • More common in those with chronic/pre-existing mental illness (2/3) – Borderline personality/adjustment disorder – Depression – Schizophrenia
• Males- Higher # commit suicide overall and have higher admission rates from self- immolation
• Females- Higher # attempt suicide & have > mortality with self -immolation
Western Countries
• 20-40% of self -immolation patients have attempted suicide in the past • Substance abuse and psychiatric history is stronger in burn population than general population. • Younger age <40 yrs • No specific time of year, all seasons equal
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United States
• High incidence of • In the U.S.: gasoline – > # number of sniffing/huffing immigrants from low – Native Americans income countries are admitted to BICUs – Mexican Americans with self -immolation • Small rural injuries communities
Eastern Countries Low Income • Asia, Africa, Middle East • Self-immolation is third leading cause of death in women in Iran: – Young – Poorly educated – Rural – Married
Dowry Deaths
• Involves bride’s husband and her in-laws – Dominating mother in-law • Poverty and unemployment of husband leads to dependency on parents • Greed and desire of husband to improve social status by marriage • Wife (bride) is given to husband with a dowry and is totally dependent economically on husband and in-laws after marriage • Continuous harassment by in-laws • Increased disparagement of woman leads to suicide, often self- immolation
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Dowry Death cont’d • Other contributing factors: – age difference of spouses – infertility – marital discord – physical and sexual abuse – impotency of husband – psychological disease – chronic health conditions
Dowry Death Case Study
• Young married Hindu woman brought to hospital by in-laws with a burn injury • Delay in seeking treatment • Bride’s family not notified
Dowry Death
• No empowerment of woman, bride appears afraid in presence of husband and in-laws, won’t speak up • Excuse for injury “cooking accident” (but no stove in house) • No one else injured
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Bride Burning
• Continued harassment and torture by husband and in-laws in an effort to extort and increase dowry • “Bride Burning” is setting the woman on fire but disguised as a suicide or accident. • Dowry Prohibition Act 1961-prohibits request for a dowry • Over 2,500 incidents/yr reported by police
Sati/Suttee “Good Woman” • Widowed Hindu woman honors death of husband by self -immolation
• It is an honor to die on husband’s funeral pyre
• Banned by British government in 1829, still practiced in rural India today
Self Immolation • Buddist monks in China, Tibet, India – Thwarted ambitions, sense of alienation, intropunitive hostility leading to protest – Sacrificing oneself to end suffering
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Self Immolation
Self Immolation
Students & Laborers in North Korea – Wanting to form unions – Protesting dictatorship
Contributing Factors of Self-Immolation • Chronic medical conditions • Long term disability • Lack of insurance coverage • Family /Marital problems • Drug Abuse
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Self -Immolation
Motives: – Impulsive behavior?
– Acute psychiatric illness-psychosis?
– Did something go terribly wrong?
Self Inflicted Burns
Self -Mutilation Self -Immolation – Lower mortality – Higher mortality – < # complications – > # complications – Lower % TBSA – Higher % TBSA (<10%) (>25%) – < 30 yrs. – > 30 yrs. – Borderline personality – Inpatient • self harm – Outpatient
Predisposing Factors Substance Abuse & Alcohol
• About 50% of burn • Behavioral features patients have ETOH – Immature levels that are high – Impulsive enough to impair – Manipulative mental capabilities – Violent • Psychiatric history – Depressed – suicide attempts
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Self -Immolation = HATE
• The person might believe they deserve to suffer-the ultimate expression of self – hatred
• Hatred of others-witnesses have lasting memories of the act
Consequences of Self-Immolation • Have 1.5x chance of dying than patients who sustain unintentional burns • Have longer hospital stay and higher mortality rates than unintentional injuries
Priorities of Care
• The patient who • Safety survives self – • Decontamination immolation is one of • No electrical equip the most difficult – No defibrillation, challenges facing bouvies, oxygen (?) nursing. • Crisis debreifing
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Priorities of Care • ABCs / hemodynamic stability • Fluid resuscitation • Ongoing airway management • Wound care /surgical intervention • Nutritional support • Mobility • Psychological care
Determining the Severity of a Burn
• Depth of tissue • Special care areas: damage hands, face, feet, • Percent of body perineum, major joints surface area (BSA) • Age: mortality - involved morbidity • PMH: – pre existing • Electrical and illness chemical burns • Accompanying • Burns with inhalation traumatic injuries injuries
Self -Immolation
• Use of Accelerants – gasoline – lighter fluid – nail polish remover – oils & incense • Ignite dry clothing
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Severe Inhalation Injury • Heat • Lack of oxygen/suffocation/ CO poisoning • Products of combustion • Severe upper body burn • Ingestion & inhalation of accelerant
Gasoline
• 100% volatile • Mixture of hydrocarbons, rust inhibitors, alcohol, lead • Contributes to more burn injuries than any other flammable liquid • Gives off invisible flammable vapors 5 x the density of air (travels low)
Gasoline
• Readily available and • Can lead to multiple accessible organ failure & death – Inexpensive – Legal – Used throughout world – No age limit – Sniffing, huffing, convenience suicide
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Gasoline-Pulmonary Effects
• Lipid soluble • Pulmonary edema and hemorrhage • Rapidly absorbed through pulm system • O2 displacement to circulatory system leading to hypoxia • Hydrocarbons cause • Chemical pneumonitis surfactant inhibition and increase cell membrane permeability
People often douse their heads, inhaling and/or drinking the accelerant. Systemic absorptions leads to multiple organ failure
Severe Inhalation Injury
Normal Post-Injury
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Gasoline-Cardiac Effects
• Rapidly absorbed into • Peripheral circulatory system vasodilation • “Sudden Sniffing • Hypotension Death Syndrome” • Reflex tachycardia – Reaction of heart to • Decrease myocardial adrenaline by hydrocarbons contractility • Bradycardia
CNS Effects of Gasoline
• N/V, Ataxia, vertigo, H/A • Excitement, delirium • Nystagmus, twitching facial muscles, hands, & feet • Depressed sensorium • Cerebral edema, seizures, LOC, coma, respiratory failure
Gasoline Effects on Skin
• Prolong contact, enhanced dermal absorption,stored in fat cells • Breakdown cell walls • Partial & full thickness burns • Increase fluid loss through burns, cell membrane permeability
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Extensive Burns
• Greater size and depth of burn
• TBSA 30-60% or >
• Deeper burns-need for escharotomies
• Need for skin grafting
Commonly Seen: third degree /full thickness upper body burns
Need for Escharotomy • Relieve respiratory distress • Prevent circulatory occlusion
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Need for Multiple Skin Grafts
• Potential for complications and scarring is increased with deeper wounds
• Wounds are extensive enough to require skin grafting
Wounds are deep enough for skin grafting
Surgical Intervention
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Nutritional Aspects of Burn Care
• Increase metabolism, increase catabolism • Need increase calorie intake • Increase protein for healing • Enteral feeds vs. parenteral feeds • Vitamins, antioxidants
Rehabilitation Physical – Mobility – Function – Disfigurement – Scar Management
Psychological Rehabilitation
• Ongoing • Comfort Management psychological – Pain management of – Anxiety current problem – Sleep – Emotional distress
• Emotional support • Adaptation to injury – Family – Coping – Friends – Motivation for recovery – Cooperation
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Complications • Systemic effects of accelerant/organ dysfunction • Infection & sepsis – Pneumonia – Wound infection – Graft loss • Nutritional deficits • Fluid & electrolyte imbalance • DVT • Failure to progress in recovery • Skin contractures • Severe disfigurement and scar formation
Wound Infection/Sepsis
Nutritional Complications
• Weight loss & muscle wasting • Ileus • Constipation • Fatigue-need frequent rest periods • Electrolyte imbalances • Curling’s Ulcer
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Highest Mortality
• 25-80% compared to non-suicidal burns • Mortality highest during acute period 0f injury • Often due to severe inhalation injury
Management of Self-Immolation
• Psychiatric support
• Family support / crisis intervention
Profile of a Young Self- Immolation Patient • Psychotic impulsive act • Setting of escalating harm
• History of chronic & • History of fire setting severe disorders
• Considerable past para- suicidal acts-burning
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Behavior Challenges for Staff
– Abusive, volatile
– Child-like need for attention
– Sabotage care
Behavioral Challenges - Inpatient
Staff splitting behavior!!! – Verbal aggression – Inappropriate comments
R.N. – Excessive demands – Tearfulness • Manipulation of staff – Impede / divert care
Psychological Support – Manage Behavior Family Support - Staff Support • Limit Setting Validate suffering without reinforcing negative behavior: – Provide less chaotic - Have guidelines to respond to environment patient distress – Emotional neutral time - Reinforce/ commend positive – Minimum number of behavior staff to care for patient - Reduce overly compassionate – Be consistent feelings for patient – Manage outbursts - “Matter of fact” manner with minimal discussion
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Discharge Disposition
• Longer LOS • Difficult Placement • Acute Rehab • Acute Psych’ Care – Medical psych’ care
• Boarding home • SNF/NH – Ventilator care • Home • Insurance/costs
Survivors of Self-Immolation
• Advances in burn tx, fluid resuscitation, wound care and reconstructive burn surgery have enhanced survival. • Complications are costly and time-consuming. Painful medical procedures - pts and families have anger, guilt, frustration. • Survivors haunted by nightmares and memories of self- immolation • People who do this and survive, don’t do it again
• Mirlashari J, Nasrabadi AN, Amin PM (2017). Living with burn scars caused by self- immolation among women in Iraqi Kurdistan: A qualitative study. Burn 43, 412-423.
Survivors of Self-Immolation
• Regretted their decision. Problems more complicated once scars developed and disfigurements appeared after hospital d/c. • Cried, blamed themselves for loss of beauty, regretful. • Increased sensitivity to noise, intolerance of crowded environments and instances of aggressive behavior. • Blamed God or fate for what had happened. Were angry and stopped praying.
• **Mirlashari J, Nasrabadi AN, Amin PM (2017). Living with burn scars caused by self-immolation among women in Iraqi Kurdistan: A qualitative study. Burn 43, 412-423.
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Burden on Healthcare Resources
• Utilize greatest # of hospital resources
• Highest LOS in ICU and hospital
• Highest costs in burn care
• Poor outcomes
Can Self-Immolation Be Prevented? • Consequences for the individual are great.
• Consequences for the family are great.
• Impact on society is great.
Prevention Measures
• Access to mental health care – Inpatient and out-patient – All self-inflicted injuries must receive mental health referrals – Up to 1/3 of self-inflicted injuries will try again
• Screenings for depression when recovering from trauma and disabling conditions
• Suicide prevention programs in trauma settings
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Prevention Measures
• Know common methods of suicide in your geographical regions • Refer individuals to psychiatrist/mental health professional which will help reduce future episodes • Recognition of warning signs of suicide – Verbal, written, behavior, environmental
Warning Signs of Suicide-Verbal
• Talking /writing or reading about it • Threatening suicide • Direct/Indirect conversation
Warning Signs - Behavior
• Prior history • Seeking access to a killing device (pills, gun, fire, etc.) • Mood changes – Withdrawn/isolation – Increase anxiety/ restlessness/rage/recklessness • Loss of interests • Giving away possessions • Insomnia
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Warning Signs-Environmental
• Family history of suicide • Domestic violence • Work problems • Increase/recent personal stress
Self-Immolation Summary
• Found worldwide • Injuries are serious. Care is complex. • Do not down play self-inflicted injury regardless of the size. • Have greater costs, complications, and a higher mortality. • Need for psychiatric attention ASAP!
Questions
• Thank you for coming. • Enjoy the rest of the conference. • See some of Pittsburgh – it is a great city. • Safe travels home. • Be safe!
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References
• Caine PL, Tan A, Barnes D, Dziewulski. (2016). Self- inflicted Burns: 10 year review and comparison to national guidelines. Burns. 215-221. • George, Javed, Hemington-Gorse (2016). Epidemiology and financial implications of self-inflicted burns (Burns, 42, 196-201) • Khelil MB, Zgarni A, Zaafrane M, Chkribane Y. Gharbaoui M, Harzallah H, Banasr A, Hamdoun M. (2016). Suicide by self-immolation Tunisia: A 10 year study (2005-2014). Burns, 42, 1593-1599.
References
• Mirlashari J, Nasrabadi AN, Amin, PM. (2017). Living with burn scars caused by self-immolation among women in Iraqi Kurdistan: A qualitative study. Burns 43 417-423. • Segu S, Tataria R. (2016): Paediatric suicidal burns: A growing concern. Burns 42, 825-829.
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