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.

balance

i have often given a very critical opinion of our sangomas. to tell the truth i try not to write about them too much because if i were to write all the stories i'd probably not write too much else. but there is another side to the whole thing. so for balance, the following...

some time ago i went on a sort of tour around the lowveld to introduce myself to the doctors as a new surgeon. in one of the neighbouring little communities i met a gp. he told me a story that i actually believe. he said that a growing portion of his practice is made of hiv patients. some he keeps controlled on antiretrovirals. some present too late, basically in terminal aids. he usually tries to bustle them off to some or other hospital. (if you've been following my blog lately you'll know this is not too easy at the moment). these people, in their desparate state often ask for a drip, possibly thinking it some sort of powerful western medicine. he complies, reasoning it may not do much but a vitamine boost isn't the worst thing for them. he then told me he struggles to charge them for this. sometimes he doesn't charge. sometimes he works it out that the equipment costs about r40. he puts a small profit margin on and charges about r60. (this is probably around $5). but then he said some of his patients complained because he wasn't giving them the good drip. when he asked what they were on about he was told that other doctors in the area (medunsa graduates according to him) were charging r1000 for putting up a drip for these terminal hiv patients!

interesting. if you are charging that much you are selling the idea of a cure. even if you don't say it the fact that poor people pay that much means they believe it will cure them. the target audience is also a group that is particularly desparate for a cure. especially now that the state hospitals are basically not working. this is intensely shocking to me. they are willing to fleece poor people for their lasts cents just before they die.

now i wonder. who is worse? the sangoma who kills someone by giving him a cow horn enema that he truly believes will help or the doctor who knowingly charges more than the patient can afford for the promise of a cure he knows won't work. yes the modern sangomas are now amongst us.