This is another work post; apologies if it's too graphic. I want to tell you about
dressing change days, and about skin.
Mondays, Wednesdays and Fridays bring dressing changes in the burn unit. This means that every patient—as many as 42, plus
the many others who come in from home just to get their dressings
changed--line up at the end of the hallway and wait their turn, while 3-4
intrepid nurses unwind and wind miles of bandages, slather ointments, and
squirt morphine into their mouths. Except when there is no morphine. Then it’s
diclofenac, which is, I imagine, the equivalent of getting a swig of ibuprofen
right before you get scalped alive.
Walk with me. From the outside, down a dark hallway filled with people, toward the light at the back and up the stairs, three flights. The
staircase is open to the outside and on each flight there's a big window with a
view of the city--today it's hazy and hot, so the buildings are distant under a
screen of red dirt and smog--but it's not airy or breezy. The stairs are worn
from countless people walking up and down it for years, and on the second flight a
woman wearing yellow wellington boots is mopping, with a broom that's seen
better days and concrete-colored water. On the third floor we briefly bump
along behind two policemen, big guns swinging freely, talking
exuberantly and walking oh-so-slooooooowly—and finally we arrive
on the third floor, and walk down the hallway to 3B, the burn unit.
Before you open the door, take a little deeper of a
breath, for you're about to experience that smell. On a good day you
manage to take 3 steps inside before it hits--the odor of maize meal cooked
into grits-like porridge, or a paste, or a hard cake (nsima); of bodies, urine and boiled cabbage, dirty wounds, feet,
doughnuts, and fear--and then you see the mother carrying her five year old
daughter wrapped up like a mummy with an IV tube sticking out of her neck--and
you feel ashamed for even noticing the smell.
There are six rooms, 4 beds each, lining the
hallway to your right. Linking them is the
open breezeway down which you’re walking, which opens onto a shared courtyard
where people dry their laundry and family members cook their meals. On the
other side of the rooms is another hallway, the khonde, or “outside,” which becomes another long communal room
during the months when there are more patients in the unit than there are beds.
During the cold season—June, July, August—the khonde is full.
Two boys, aged four and six, one with a bulky
bandage around his leg and the other with a belly dressing, are playing with a glove
balloon, and you toss it back and forth with them for a little while, their
smiles lighting up the day.
Are you procrastinating? We have to keep walking down the hallway, to
the room at the end, where all those people are queued up, since that’s where
all the action takes place. Each mother dons a protective plastic gown and
gloves and takes the child—the median age here is 3—on her lap. The mothers
hold the children down. The first trial begins, that of forcing the morphine
into the children's mouths. Most take it willingly, especially ones who have
been here a while, but sometimes they purse their lips, or cry, or swat with
their arms. It doesn't matter if the morphine trickles inside or outside of
their mouths--there is no refill and the dressing change happens with or without
it.
Next, the nurses soak the bandages in saline to
help with removal. Since there are 42 patients and 3 nurses, waiting for a
complete soak would take way too long. Some of the kids start screaming in the
hallway; some when the mothers take them on their laps; some with the morphine;
but all of them are screaming by this point. These kids are burned over 10-40%
of their bodies, on average; over all possible body parts; in two main ways:
they scald themselves or catch themselves on fire. It's the cold season in
Malawi, no one has heat at home, and very few people have stoves; cooking
happens over open fires, outdoors, and accidents happen frequently. Malawi is burnin', y'all:
Skin gets so much criticism. We stare at our
pimples as teenagers and wish them away; at our wrinkling faces as adults, and
hate their testament of the passage of time. We scrutinize moles and massage
cellulite; we want elasticity and spend millions on creams and lotions that
promise to keep us looking young. Even as we enjoy skin's gift of touch, in
embraces, caresses, and kisses, we resent and focus on its fragility, its
ability to hurt, and too often, its color. We don't appreciate scars. Skin
should be blemish-less and baby-soft. Not at all like the skin I see in front
of me--discolored, twisted, partially healed, in some cases with the tell-tale
cheesecloth appearance of a healed skin graft. This is beautiful skin
because it works in its intended way: not as pretty packaging but as a barrier
to infection and pain, as the selectively permeable wrapper that allows the
rest of the body’s functions to proceed uninterrupted and unthreatened, with
just enough openings to allow a regulated exchange with our environment.
It's the absence of skin that exposes its absolute
necessity. This six year old girl being unwrapped now has full thickness burns
(what we used to call third degree) over 55% of her body: anterior and
posterior thorax, both legs, both arms, a bit of face and neck, buttocks. Her
big, deep brown eyes look at me with tears trickling down her cheeks as her
mother’s helper raises the IV bag above her head and arranges it so the tubing
is not kinked. This is a bad burn: flame generally causes deeper burns
than hot water, and in this case, it looks like her clothes were on for some
time, and the contact did a lot of damage. Like countless others, she was
playing with her friends and tripped into a fire, where her clothes caught the
flame. She cries, but not much: a bad sign. Although we teach that full
thickness burns are insensate, since by definition the heat has destroyed the
skin's sensory apparatus, not everything burns to the same depth, and partial
thickness areas surround most full thickness burns—and those do feel
pain. Her name is Chisomo, meaning Grace. She will die in 3 days.
I think about the ones we can’t save, back home, and here. I hold on to
them for motivation to keep studying, keep waking up, keep leaving
my family, and keep trying—and to honor their memory, although I see them usually
only in a dehumanized form, although I know them usually only as bodies wrapped
in dressings and not as children chasing goats, eating mangoes or diving into
the lake. Knowing what makes a patient human makes me a better doctor but it
also hurts more—and many times I don’t want to admit they are people because
doing so makes me transiently incapable of returning to work. It’s like this in
the States and it’s definitely like this here. The constant blur of activity insulates
you from processing both the good and the bad, but both stay with you, and
sometimes when you get a breather it all comes out, and it’s very hard to
figure out what to do with all of it—so I try to just notice it and not cry, and
carry on, because in the end, there are more of the ones who get to be human
again than the ones who don’t, and so you keep going. As shown by the parents and
patients in this burn unit, every day, with their smiles, their high fives, and
their endurance, despair is a luxury. Ain’t nobody got time for that.
