Hope & Healing

Strangely, some of my favourite and most challenging conditions to treat are severe burns. What makes them challenging are a number of factors. Take for example my current patient a young man named Gerard (name changed to preserve his identity). He fell in a cooking fire backwards in his home likely the result of an undiagnosed seizure. When he came to our hospital several months ago, his entire upper back, neck, shoulders, side of face, arm, eye and skull were severely burned. His skull specifically was burned right down to bone. In most developed countries, patients like this would be transferred to a high volume burn care unit where there would be treated by a multidisciplinary team of plastic surgeons, nutritionists, physiotherapists and nurses. 

In developing countries, there often aren’t high volume burn centres and frequently patients are so poor that they lack the means to get there, let alone afford the care (if available). Care can be sporadic and interrupted due to lack of finances or resources.

For patients like Gerard, it’s really is a matter of life or severe suffering and eventually death.

His first major challenge is nutrition. Severe burns basically destroy the skin and the capacity to retain fluid and protein. In fact, severe burns are the highest demanding injury for nutrition - even higher than trauma and severe infection. You can imagine the need for the body to reconstruct skin, soft-tissue and the cells required to resist infection while at the same time losing the ingredients to do so through extensive open wounds. 

Protein is key! 

But in Madagascar, many people do not regularly eat protein. Some people only eat meat once a month because it is expensive (or a luxury food). You can understand the challenge! 

Gerard is on strict doctor's orders not to share his protein meals with anyone! Sometime he eats duck and we joke with him that we are jealous of what he is eating…but he has been told not to share with us. This makes him smile. 

Burns need regular dressing changes with clean sterile dressings. This takes a team when a larger percentage of the body is burned. Dressings need to be regularly removed as bacterial and infection begins to multiply in them. Replacing them, keeps the wounds clean. Recently we ran out of vaseline gauze. You can imagine pulling dry gauze off an open wound after it is kinda stuck. Thankfully, we have been able to start making and sterilizing our own gauze (which actually works better in my opinion) than the pre-packaged stuff. 

Another challenge is timing surgeries. Because of the massive metabolic needs and limited nutritional resources, it is critical to get his wounds clean so they can be grafted in a hurry before he loses the nutritional race. For Gerard, I grafted as much of his wound surface early as possible, leaving more complicated areas for later. This reduced his metabolic demands quickly allowing his body to “catch up” and gain ground resisting infection and beginning to heal.

Then there is the issue of the skull. With desiccated dead bone on the outside and brain not far below the challenge is how to create a surface that can be grafted to. You can’t graft onto dead bone. The only option in Gerard was to try to stimulate granulation tissue by drilling partially through his skull. This would allow any viable tissue within the thin skull to slowly grow out and hopefully cover some of the exposed bone. Additionally, an outer layer of his dead skull bone would separate from the live bone below it and slough off with granulation tissue below that can be eventually be grafted. Waiting for this takes patiences, nutrition and lots of wound care. 

Then there is the challenge of protecting the delicate grafts. Each graft is harvested from a part of his body, legs, back, arms or buttox. Using a “glorified cheese cutter” knife, skin is shaved from each donor site and sutured over the burn wounds. Vaseline gauze is placed over both sites and everything is wrapped to keep infection out. Having worked in Africa, I have seen grafts infested with maggots after several days and all my graft patients are under strict orders to rest 24 hours a day in a mosquito netted bed to keep away insects. They also are instructed not move their grafted body parts for up to 7 days. For large burns like Gerard’s, there are not endless body parts to get skin so making each graft count requires strict measures.  

Then there are the challenges of patient resources. Many people in developing countries suffer significant financial loss from health care bills and burns are famous for this. As a surgeon, I am always trying to think of ways to save patient’s money without compromising their care. To save Gerard and other patients money, we sterilize T-shirts to them as re-usable bandages. This also helps because covering the torso is challenging.

Over the last four months, our tireless team of nurses and OR staff have performed dressing changes 3-5 times per week for Gerard. He has undergone multiple operations. Miraculously he continues to heal. In fact, up until his more recent surgery, he was coming to the hospital as an outpatient.

The reason I love treating burns is being able to witness hope and healing. Walking these patients through each dressing change. Encouraging them to stay strong. Giving them realistic goals. Finding ways to make them laugh and experience joy among the suffering. It’s the reason I love my work as a surgeon in Africa. Giving dignity to those who would likely otherwise have little or no hope. 

Gerard is frequently told that he is a walking miracle. And in many ways given the context we are working in... he is! I think as we work to get the last of his wounds covered...he might be starting to feel like one! 

I am extremely grateful for the advice of two plastic surgery colleagues who have both worked in challenging African contexts and who have helped me treat Gerard using Whatsapp! (you know who  you are)

Jesh