who heals the fallen

this is not really my story. but in a sense this story belongs to all south africans. it is our shame and may be part of our downfall.

we are a people at war. we war against ourselves and we war against peace. each fights for himself and bugger the rest. but who heals the fallen? it seems in south africa, quite soon maybe no one.

recently a story made the news. it was shocking, but it actually gives an inclination of how morally decayed south african society has become. an ambulance was despatched to some informal settlement after a household fire burned a child. the caretakers of the child brought the child to an intersection that the ambulance would actually be able to find. quite soon the paramedics were hard at work stabilising the screaming child. at about this stage two armed thugs turned up. they threatened the child's caretakers with their lives and forced them to flee. then, while the child continued to scream in pain, they raped the female paramedics. they were not caught.

yes it is shocking and now the ambulance personnel need to wait for police escort before they respond to calls in certain areas, greatly increasing their reaction time. we would like to believe this sort of thing is isolated but is it? just the other day i heard on the news about another case where a crowd assaulted the ambulance crew because they wanted to help the victim of a stabbing. as i said we are at war with each other and the victim was their enemy for whatever trivial reason.

but the question i end up asking has little to do with the morality of what's going on. that, it seems to me, is obvious. to discuss morality with the people involved in these stories is a waste of time and effort. i wonder when at war, which we clearly are, how is it in your interest to antagonise the medics? yes you may have won today's battle and not actually need a medic, but what about tomorrow? who will help you when you find yourself on the business end of a knife or panga? also the people who give their lives to help the injured and downtrodden are not quite as involved in their petty squabbles as they may imagine. to drag them in and try to kill them for helping the wrong person is both small minded and short sighted. we didn't really need evidence to know the people that engage in this sort of activity fit nicely into this category, but there it is if you want.

a number of years ago a paramedic friend of mine responded to a gunshot case in mamelodi outside pretoria. what he didn't know was that the mob around the patient had little interest in the survival of the patient. they actually wanted him dead. the paramedic therefore in their narrow view of events was the opposition. as far as they were concerned anyone from the opposition should also be dispatched.


he drove into the thick of things in all oblivion. when he arrived he opened the car door to find out how he could help. the crowd immediately tried to drag him out of the car, beating him with fists and the weapons they had at hand as they did so. he quickly realised he was going to share the same fate as the patient, which was, by that time, sealed. by pure accident the paramedic's safety belt was not loose and they could not pull him out. he slammed the car into gear and throttled out of there with his torso leaning out of the open door in true hollywood style.

thereafter the ambulance service refused to respond to calls from mamelodi except with a police escort. bearing in mind our police are stretched thinly on a good day, the whole situation became ludicrous. i would love to believe in some sort of karma where the people that suffered because no help was forthcoming were the people who were responsible for the problem in the first place, but, like all wars, the actual people who suffer will be the old and the weak, the vulnerable and the children. but that is the african way.

ruthless kindness

in my line of work there is sometimes a fine line between cruelty and kindness. sometimes the line can seem to blur. hang around me long enough and you will probably be shocked at some stage.

the guy had apparently fallen asleep next to his fire. when he rolled over into it his alcohol levels ensured that he only woke up once his legs were well done. someone found him and brought him in late that night.

when i walked into casualties i could smell him. you can almost always smell the burns patients. i took a look. the one leg actually wasn't too bad. it had an area of third degree wounds but they weren't circumferential. i could deal with that later. the other leg, however, had the appearance of old parchment from about mid thigh to ankle right the way around. this could not wait for later.

in third degree circumferential burns, the damaged skin becomes very tight. constricting is actually a better description because unless it is released the taught skin will so constrict the leg's bloodflow that if left untreated the patient's leg will die. it is like a compartment syndrome only the entire leg is the compartment. interestingly enough in third degree wounds all the nerves have been destroyed so in these areas the patient has no feeling whatsoever. that means when we do the release (an escharotomy which is cutting the dead skin along the length of the leg in order to release the pressure and thereby return the bloodflow) no anaesthetic is needed. you just cut the skin and as soon as you hit an area that the patient feels you've gone too far. if you do it right they will feel nothing. the longer you wait the higher the chance that he will lose his leg. i knew what i needed to do. i also knew my students might never get to see this again before they might have to do it themselves in some outback hospital in their community service year.

i asked for a blade and gathered my students around me. i sunk the knife through the dead skin and ran it down the length of the leg. the wound burst open as the pressure was released. the patient didn't flinch. quite a number of the students did. one excused herself and ran out. i think she might have been crying. despite me telling them that it wasn't painful and it was in the best interests of the patient to actually see it was more than most normal people could take.

when i wrote my last post and expressed a form of traumatic stress i found the contrast within myself compared to this incident quite interesting. everything seems to be relative and during the job there will be things that leave scars and many things that traumatise/desensitise us. i was ok doing what that one student obviously thought was gruesome and bizarre because i was convinced it was in the best interests of the patient. when i did this procedure which, on the face of it, is so much more brutal than taking someone to shower, i was ok, but the shower incident was terrible for me. i ended up hoping the student didn't see me as quite that monsterous. i also hoped she would get over the trauma i had inadvertently caused her.

the patient kept his leg.

leaking

people are basically sacks full of water. the skin keeps the water inside. trust me when i say you want to keep your water inside.

the second post i ever wrote had to do with watching someone with burn wounds fade slowly away. in the end it had more to do with my own mortality. when i read it recently i was reminded of quite a few poignant stories. this is one.

usually things happen in groups and, it seems, burn wounds are no exception. on two successive nights two severely burned patients came in. i got the first. my colleague got the second. my patient had 98% burn wounds (usual story of being doused in petrol and being set on fire. someone didn't seem to like him). only where his hair had been was he not burned. that means that 98% of the sack that is supposed to keep the water in was leaking.

let me take this moment to say that it is not possible to survive 98% burn wounds in any setting. this patient was as good as dead, so whatever we were going to do would only partly help. the outcome could not be changed.

the immediate treatment for burns is to replace the fluid that is leaking out through the wounds where the skin used to be. the amount of fluid one gives is proportional to the surface area burned or the surface area leaking. in 98% that turns out to be quite an amazing amount of fluid. and that is what we did. i worked out the fluid needed, put up a good central line and started running it in. the next day he was still alive.

the next day was when the second burn wound patient came in. he had 95% burns and therefore was leaking pretty much the same amount as my patient. my colleague admitted him, but he treated him differently. my colleague knew that the end of the road was predetermined and didn't see the point in prolonging the inevitable. he only gave him normal maintenance fluid which a normal person would require. he considered more as treatment and didn't see the point in treating something that could not be treated. i considered that he may have a point. i went to see his patient.

his patient was not doing well. the loss of fluid had pushed him into a stuporous state. he didn't seem to have long to go. i left. he died soon after.

my patient remained alive through that day too. because of his wounds he could not lie in bed without extreme discomfort. but the soles of his feet had no skin so he could not stand either. the skin of his hands had all peeled off and they had swollen into useless immoveable paws.

the head of the firm then decided we should take him into a shower and remove all remaining loose skin. i got the feeling he was trying to teach us some sort of lesson. the only thing i learned is that it is brutal to try to remove loose skin, even gently from such a patient. the patient was not having fun at all. i kept thinking why are we making the last days of his life any more miserable than they already are? the head then decreed that we would repeat this process in two days time. i felt sick at the thought. the wisdom of my colleague not treating his patient seemed much clearer to me then.

the next day when i arrived at work i was relieved to discover my patient had finally succumbed to the inevitable. it would not befall us to have to torture him the next day in order that we learned some mysteriouis lesson.