Saturday, February 12, 2011

#24 Attached

I knew from the moment I saw him that he would die. I wasn’t going to get attached.

Emmanuel was eight years old. He had just been burned. His ‘brother’ accidentally dumped boiling porridge on him. A big enough pot to feed the whole family. Porridge doesn’t come off easily. He cooked under a thick layer of sticky porridge for quite some time before his ‘parents’ could wipe it all off.

I use quotation marks only because they aren’t really his brother and parents. He was orphaned some years ago, apparently from some accident. Both mom and dad died. He was semi-adopted by some semi-family. They called themselves aunt and uncle, but I’m told that they weren’t really.

Now orphaned and burned. A burned orphan. I’m not getting attached.

I’m an Emergency Medicine physician. I know the statistics. A child with second and third-degree burns over 10% of his body or more has the odds stacked against. In the best burn center in the world. Hopital Adventiste de Bere is not the best burn center in the world.

Emmanuel is covered by what will soon become third-degree burns over close to 40% of his body. His neck, his chest, his arms, his abdomen, his groin, his penis and his thighs. All burned. All eventually third-degree. Emmanuel will die in ten out of the ten best burn centers in the world. He has no chance. All the money in all the world can’t save him. I’m not getting attached.

I look at him. I touch him. I talk to him. He’s alive. He’s breathing. He’s thinking. He’s moving. He’s talking. What am I supposed to do? Keep injecting potassium into his veins until I stop his heart? Keep injecting him with morphine until he falls asleep and doesn’t wake up? I don’t have morphine. I can’t put him to sleep with morphine even if I wanted to.

The only thing I can do is treat him. That’s what I’m trained to do. That’s why I’m a doctor. That’s what I enjoy doing, right? Patient comes in. I give treatment. Patient gets better. I feel good about myself. I remember to give credit to God... sometimes.

I can’t treat him partly. I need to treat him fully. It’s expensive. ‘Family’ can’t pay for it. Luckily the government mandates we treat them for free. I order up fluids, antibiotics, cimetidine, a clean sheet and clean bandages. Oh, and of course pain medications. Tylenol and Motrin. What else can I do? I’m in Nowheresville, Tchad. Of course, I couldn’t really do much in the States either.

The nurses begin to clean him up and I go do other things. I come back a few minutes later and the few bits of skin he had are all gone. The nurses rubbed off all of his skin. I’m livid. That was his last fragile, pathetic defense against hypothermia, dehydration and infection. They just don’t get it. We’ve been down this road before.

He literally has no dermis or epidermis around his neck, from his shoulders to his fingers, from his nipples to his thighs. Nothing.

I’m going home. I’m not getting attached to Emmanuel. I gotta stop using his name if I’m going to remain objective. He’s just another patient. Just another kid who’s going to die in Tchad.

The next day Emmanuel looks pretty uncomfortable. I suppose I can use his name and still remain unattached.

The third day, he’s still pretty uncomfortable.

The fourth day, he’s still alive. Well, he probably won’t die from pulmonary/airway problems at this point.

The fifth day, he’s still alive. You know, maybe he’ll pull through. You’re an idiot. Forty percent third-degree burns. He’s gonna die.

After a week, he’s still alive. Even if he lives, he’ll aesthetically be horrifically deformed. He’ll have terrible contractures. He’ll never be able to use his hands. He’ll need to have his skin continually cut just so he can continue to grow. That scar (if it ever forms) won’t let the skin stretch and grow. He won’t live. He’s going to die. And I’m not getting attached.

It’s been two weeks. I keep hearing words like ‘miracle.’ I’ve even caught myself using it once or twice. What a crock. A miracle would be letting this kid die. He’s suffering terribly, crying nonstop, whenever he has the energy.

During the third week, he gets a fever. It’s malaria. His hemoglobin’s two. We transfuse him. We give him quinine. We prolong the inevitable.

He gets better. From a malaria standpoint. The fever goes away.

We run out of Bacitracin to put on his wounds. We never had silver nitrate. We run out of zinc oxide. It’s a few days before somebody can pick up some more to put on his skin. Eventually, our hygiene/AIDS/tuberculosis director goes to get some. Seriously? We need to send an administrator to get some? Doesn’t he know how futile this is?

The fourth week somebody has the brilliant idea to bring a bucket of water to the bedside to wash him in. We try to tell the staff that it’s not necessary, but what do we know. He cries every time they put him in the water. I can’t imagine his pain. He thinks washing is what’s good for him, so he bravely scrubs away at his body where he has no skin. He whimpers while inflicting pain on himself. He’s so brave. No. I’m not getting attached to Emmanuel. I can’t.

The hospital runs out of free products for Emmanuel. The family can’t pay. The same administrator starts paying the bill himself. What’s wrong with this guy? Isn’t enough enough already? I know his salary. He doesn’t earn but $200-$300 in a month! How can he sink all his money into this hopeless case?

Today makes week five. At 7AM, the same administrator drags me to Emmanuel’s bedside. He’s out of it. He’s barely breathing. They still want everything done. I sit down on the bed across from him and notice how pale he is. I scribble on a piece of paper the orders for an IV, dextrose, a blood transfusion, quinine, ampicillin, gentamicin, metronidazole and cimetidine.

He has a hemoglobin of two again.

The nurses can’t find a vein. I go to my office and return with an intraosseus needle and five grams of magnesium. I recognize the risk of respiratory depression and give him a couple grams of magnesium intramuscularly anyway. I then set about manual screwing a long metal needle into the shin-bone.

I get my needle into the bone marrow before the nurses get theirs into a vein. We start the medication. I’m still objective. I’ve given my orders. I can’t do anything else. I need to leave before this becomes personal. I’m not getting attached to Emmanuel. Not to this hopeless cause.

I come by later. He’s still alive. He’s breathing with more vigor, which the nurses find encouraging. I just think he’s probably more acidotic and giving it a final go at correcting the acidosis with his lungs.

I’m in the office doing ultrasounds. I hear a wail. I know what’s happened. I see Tammy walking out of the surgical wards. She’s crying. I leave my office and walk outside. Tammy confirms what I already know. Benzaki, that very same foolish administrator who never gave up, walks up. We walk to the patient’s bedside together.

Emmanuel’s already lying on a stretcher, covered by a sheet, ready to be carried to the family’s home.

I ask them to stop and put him back down. I want to look at him again. I want to pull back the sheet. I want to say goodbye to this boy who didn’t speak a word of English or French. I am attached.

I can’t tell them it’s ok to pick him up and walk out. I know the words in French. I even mouth them out. I know my voice will betray me if I try to make a sound.

I ask a nurse to pray in the local language. I have no clue what he says but my vision is pretty blurry when I open my eyes.

I walk outside with Benzaki. His wife is sitting on the concrete slab we treat as a bench. She too, had taken an unusual liking to this boy. She’s crying.

I sit down beside her, unaware that she’s about to pummel me with questions I’m unprepared and unable to answer.

‘Tell me, Dr Olen. Tell me why did he have to die? What is the purpose in his suffering? What is God trying to tell me?’

The story comes out. The Benzakis had agreed to adopt this boy in December. They had already been paying for his schooling. In their 40s and without the children that make you a person of worth in this culture, his story came to them and after much prayerful consideration, they decided to adopt him. They had never thought about adoption before. They signed the papers and were about to take custody.

Then Emmanuel was burned. They visited him every day. They paid for his medical expenses. They drove on their motorcycle long distances to find the medications for him that we had run out of. They showed Emmanuel what the love of a parent is, something he had never known before.

God came to this Earth in human flesh. God watched as His Son suffered, able to intervene, but unwilling to risk all of humanity. God never gave up on a race that the rest of the universe deemed an unworthy cause, a hopeless case. Ugly, deformed, helpless and broken.

And this morning, after waking up early to finish preparing his room for the day in the future when he might be able to come home, Mrs Benzaki visited her future son and took his hand and listened to him call her ‘Mama’ for the first time. And them she lost him.

‘Tell me, Dr Olen. Tell me why? We agreed to adopt him in his perfect form. And after he was so badly burned, we still wanted him. We didn’t care how deformed or ugly he might be. He would still be our son. Why, Dr Olen? Please tell me why?’

I wanted to scream at her, ‘Don’t you get it? It was hopeless! He was a lost cause! And his suffering! Can’t you rejoice that his suffering is finished? I don’t know what God’s reasons are. The rules that govern the battle between good and evil are things that I don’t understand. But maybe God is required to allow the Devil a little leeway in order to be fair. And yet we just turn around and tell God that he isn’t fair. And don’t you know that you’ll see him again in Heaven, with his brand-new perfectly Heavenly skin?’

But I didn’t. Instead, I hugged her. Together, we cried under the mango trees.

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