Scalpel's Edge

A surgeon's notes

Three lives

Fire

Grandmother wise

In Nepal it is getting colder.  Winter here is sunny in the day, warm enough in the sun to dry clothes, but icy cold overnight. Now it is Autumn, for want of a better word, and the nights have become colder.  Many village houses have open windows for ventilation, and people rely on being close to a fire for warmth.  Imagine how you would be in a house with no electricity, and no fireplace, living in the icy cold.

Grandmother Wise came to us with flame burns along the both sides of her legs, over her perineum, and across both the front and back of her trunk.  She had been standing with her back to the fire, warming her legs.  Many older women in this region  wear saris – loose flowing garments wrapped multiple times around the body, made of cotton or silk.  If you have your back to a fire and your sari catches fire, I imagine you don’t immediately realize.  There is time for the fire to flicker and strengthen before you feel the burn.  And, as I know from surgical outpatients, it takes a long time and effort to put on or off a sari – most ladies insist on examination around, under and through.  

This pattern of burn is quite common over winter in our hospital.  We often have three or four by the end of winter.  When I look after them, I can’t help imagining the frail grandmothers, struggling in fear to remove a garment that is burning them.

There is an index in burn care that describes the risk of mortality as a function of both age and percentage of burned body surface.  This means that the older a patient is, the less likely they are to survive.  Tertiary burn units achieve higher survival, but in our world, likelihood of survival is 100% minus the sum of age and percentage of burn.  

Many of our patients with this burn pattern end up with around 20% burns – deep burns to the back of both legs and perineum (the area around the bottom and genitalia) and usually both hands.  They are penalized by their age and stay much longer than we hope in hospital.  Many give up and hibernate under blankets, seeming to hope that death will take them.  Often it does.  They may even survive for a few weeks or a month, only to succumb to pneumonia, or something as simple as a urine infection.  We had one patient who hibernated for a month before realising her burns, at 12%, were not severe enough to kill her.  She came close, but was discharged to our cheers.

Our Grandmother Wise had 65% burns and was over 65 herself.  My resident when he described her spoke uncertainly – no one wants to say the high percentages out loud.  It is as if, by saying it, we give the burn more power. We knew she couldn’t survive.  She died fairly quickly, within a day.  Her family were with her, and we did our best to save her from pain.  But she never went home again to the place she had lived.

Strong young man

On one of the biggest religious festival days in the Hindu calendar, the Strong Young Man chose to end his own life.  He poured petrol over his head and body and lit himself on fire.  This is not an uncommon way to attempt suicide in Nepal, along with other violent means like hanging, and sometimes cutting one’s own throat.  Poisioning is also common, with organophosphide fertilizer ingestion being a common method.  Usually in these cases, there are social stresses often mixed with alcohol.  Mental illness is badly treated in Nepal, particularly diseases like depression not marked by bizarre behaviour and psychosis.  I mean, they don’t have enough surgeons to provide adequate surgical care. Mental health care is struggling more.  However, alcoholism is rife, and I suspect many are self medicating, like they did in Australia fifty or sixty years ago.

Given the timing, I couldn’t help think of Christmas Day at home, when everyone wants to leave hospital except for the isolated and lonely.  Our Strong Young Man burnt his head, his chest and trunk and both upper arms.  He also had burns on part of his legs.  He was in pain and his body was struggling.

Self-inflicted petrol burns are brutal.  They are usually very hot fires, causing severe injury.  If the person has enough petrol, they are extensive.  And they affect areas of the body that scar in a very public way.  Anterior neck burns are very common, and when they heal are very prone to contractures – bands of scar tissue that bend the neck forward, making the person look perpetually cowed.  I often worry about our self-inflicted burns patients.  Their burns keep them in hospital such a long time, that the treatment of the depression or alcoholism or whatever underlying cause becomes secondary.  By the time they are discharged they are scarred, marked forever as a burns victim, and are much less a person who attempted suicide.  Many seem much less depressed, more determined, as if to say, they may have wanted to die, but they didn’t want this. 

Our Strong Young Man was not strong enough.  We gave him compassion, and analgesia.  We worked hard to keep his kidneys working and his thirst at bay.  But he did not survive.  In medical euphemism we often talk about a patient’s “will to live.”  I have no doubt that it requires strength and bravery to bathe in petrol and then light a match, but it must also take a desperate will not to live.

Bonnie Babe

The baby was just seven months old, but had crawled into the cooking fire, and burnt both legs badly.  These cases are not exceeding rare. For an Australian, the accident seems unbelievable, but here, there are open cooking fires in many houses, very close to the living areas.  Can I remember a time ever when I fell asleep or was distracted and my baby ended up somewhere I didn’t expect them to be? Yes.  But in Australia that place is much less likely to be an open fire.

Bonny Babe had been admitted to a secondary hospital and had been discharged with antiseptic dressings and minimal pain relief, which is pretty typical.  For babies, outpatient management of pain is quite difficult.  Not coping at home, the family brought him to us to look after.

We discussed his injuries for some time – deep full thickness burns extending above both knees.  On the left the skin was lost almost to the hip crease.  We finally agreed with each other that amputation would be required and he had bilateral above knee amputations.  He also lost almost all the skin above the knee on the left, his stump just muscle.  While in hospital, his family fought and battled.  They blamed the mother, for her carelessness.  They couldn’t find a way to support each other.

He was with us for more than a month, maybe two months.  Although feeding and eating, and not complicated by stump infection, he ran out of steam.  Babe developed a pneumonia, and the staff held their breath with him.  In HDU he was given the best care we have – oxygen, ventilatory support, super-antibiotics, and prayers.  I lay in bed at night, hearing the medical air system decompressing in whooshing bursts, and imagined him breathing, breathing.  But he stopped breathing in the end, and was gone.

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