Devastating Burns

I wrote the following post while working in a hospital in West Africa:

Hospital work has been pretty challenging.  I did not expect anything different.  If you go to a hard place, it will be hard.  I will try to articulate one of the challenges of operating as a surgeon in a resource-limited environment.  I think it is worthwhile to understand some of the hardships.  For the time being, I am a short-term surgeon looking for the right place to commit long-term.  I profoundly respect those who have carried on in this work for years.   

One scorching Saturday morning, I walked into the hospital to help the on-call surgeon.  I was expecting to do operations, but there were none.  Instead, there were eleven burn patients.  One individual had 100% of his body surface area burned.  He was talking, but it was in Hausa, and I could not understand him.  A surgical resident asked me what I thought.  I told him to treat the patient's pain.  The patient would die.  Burns greater than 30% to 40% are fatal in this location.  At the best burn centers in the world, a 100% body surface burn is 100% fatal.  My 18-year-old son came in and helped us with a few of the patients.  The second patient had 24% burn, and the third had 23% burn.  The last had 48% burn.  The other physicians and staff treated the other burn patients.  The smell is putrid, and the discolored and destroyed skin is hard to see. The hardest fact to process is knowing that most of the patients will die.

What were the burn patients doing to get eleven people catastrophically burned?  They were getting ready to distribute gasoline.  In West Africa, gasoline is purchased in bulk, divided, and sold in smaller quantities.  They store it in whiskey bottles and sell it to motorcyclists along the roadside.  In this case, someone inadvertently ignited either the fumes or the gas, and it burned everyone in proximity.  Given the air temperature and the volatility of gasoline, it was unsurprising but still devastating.  Eleven burn patients are a lot for any hospital.  The fire burned all their exposed flesh which was their faces, arms, and feet, at a minimum.  Even those with low percentage burns were burned in complicated places across joints and essential structures. 

In situations where outcomes will be catastrophic, the medical and surgical providers must refine their goals.  There has to be more than one goal.  The plan cannot be survival because it is unlikely to happen for all patients.  Instead, a provider thinks about making attainable goals like pain control, giving the family time to arrive, letting people know they are cared for, improving the system, etc.  By making achievable, reasonable goals in the face of solemn consequences, we can still do good.  A few did live.