The Last Patient of the Day is Always the Hardest
July 8, 2010. Port Antonio, Jamaica.
I have time to think about some of the patients we saw in Haiti. I told my mom about a burn victim—a guy who had, 32 days before he saw me, fallen and been knocked unconscious for 7 hours, left lying on the metal deck of the boat he was working on alone in a Santo Domingo boatyard.
The HOT metal deck…cooked him. In Ireland, I used to see cases of elder neglect. Elderly people, especially over-medicated or with dementia, would fall asleep with their leg or body against a radiator. Overnight, they’d get terrible burns. This guy had burns on his right buttock, on both calves, his ankle and on the back of his head.
On a day I was doing mobile clinics, he came to the clinic very disoriented, completely covered in his own feces, and having seizures. He got cleaned up a bit at the clinic, and then was sent to the general hospital for the seizures. A couple of days later, as I was wrapping up a really, really busy day, he came wandering back in with no memory of having come previously. I got the bare bones of what had happened and saw he had a bunch of dirty bandages, so I said ‘Let’s take a look.’
Then I got the bandages off…and saw the burns and the dirty bandages fully grown into the tissue. Flies buzzed around his legs. I needed help fanning them away as I explored the wounds, gave antibiotics and pain relief, scraped away dead tissue, cleaned and dressed the horrific wounds.
In the States this guy would be an inpatient and receive skin grafts. If outpatient, he would certainly receive home wound care and debidements, adequate pain medication, regular checkups, a social worker to help get home care and financial help, ambulances and patient transport. A nutritionist would be available. He would have a CT scan at the least and neurologic assessment and treatment and monitoring if needed.
In Haiti, there is pretty much none of that. This guy was trying to recover at home, after being treated in Santo Domingo 32 days before. Once or twice, he had somehow got the bandages changed in that time, but they were pretty dirty, falling off—held on, in fact, primarily by having been absorbed deeply into healing tissue and becoming part of his new leg skin. Getting the old bandages off was pretty unpleasant.
My mom asked what was I thinking about when, all of a sudden, the bandages are off and you see how bad it really is, and start working. To be honest, one thing I was really thinking about was how hungry I was; I hadn’t eaten yet and was surviving on a giant mug of Haitian coffee and getting a little weak. There was food waiting in the other room, but some things can’t be rushed. It took about an hour to clean and dress the burns.
It’s hard to explain the thought process when you find yourself in that situation. The actual cleaning, debridement, and bandaging of the wounds happens not quite on autopilot, but it is not necessarily dominating your attention. The search for information is what I focus on.
Fritz came to interpret. The guy spoke some English, so, as I was working, I was talking to him—just chatting to try and take his mind off the debridement—but also searching for information that could help guide my treatment decisions. Trying to find out what his home situation was like, what resources (if any) could be found near him, and could he afford it if there were any? What family were available for support? Could he afford to lie on his stomach to heal, or will he have to work to keep from starving? How can I find a way to help this guy avoid secondary infection? What is his awareness of his seizures, what other neurological symptoms are there? What should I do? What should I get this guy to do to get the best chance for healing in his current circumstances?
All this and more is swirling through your head. New information coming in guides the next questions asked or directs conversation to find more data. This, plus any new discoveries or assessments made while working with the wounds, causes the treatment plan to evolve in my head.
For this guy…few financial resources or family support, no hospitals nearby, almost no awareness of his seizures…and huge open burns. Walking around in sandals in the mud. This is a treatment nightmare. I did everything I could. I soaked off the ingrown gauze and wiped away dead necrotic tissue, cleaned and bandaged everything. I gave him antibiotics. I showed him how to clean his wounds and bandage them. I gave him a supply of material to do it for himself or for someone else who could do it. I gave him the name of a Haitian doctor I met in the hospital when I brought the guy with the machete wound in, and who, I think, would see this guy and change his bandages. I explained what would need to happen for the wounds to heal. We discussed what he could do to try and comply as best he could. I explained symptoms to watch for in case his neurological problems worsen. I gave him some pain medication to use when getting dressings changed. I arranged for his dressings to be changed at the clinic if he can come there.
You do the best you can, and the result is out of your hands. I wish it were otherwise. In this situation, a lot of dismay goes through my head, as the potential options get more and more limited based on information from our conversation.
I wish that poor guy the best of luck. I hope he is able to get through such a terrible injury. He has so many things working against him, but the body can be an amazingly resilient thing. How he made it 32 days without getting an overwhelming infection is extraordinary; and that gives me hope that he will get through this. He now has the tools and knowledge to keep it safely dressed for many weeks. I am hoping this gives him a head start on healing if he can’t get to the clinic. He is another person, another story very much on my mind.
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