They teach us in medical school not to get emotionally involved with our patients. We are taught to stay professional and objective so that we can best care for them. There is certainly wisdom in this. If we were devastated every time we cared for someone really sick we would never be able to keep going. Having said that, it's impossible to stay completely unattached, and there are some patients who really get into your heart. Sonu is one of them. For privacy reasons I won't post a photo of her.
She is a beautiful 16-year-old young woman, newly married (yes, girls, especially poor girls, marry early in Nepal). Her husband can't be more than about 18, but I don't know his age for sure. She comes from a family of 8 children - 6 girls and 2 boys. The youngest girl is 1 year old, a spunky, very cute, curly-headed little girl, who is staying here at the moment while her mom cares for her sister. About 2 months ago, Sonu was holding some kind of metal rod in both hands, when it touched a live electrical wire. The current went in through both hands, travelled through her abdomen, down out both her legs, exiting, I suspect, around both knees, though also affecting her below the knee. When she came to us, both hands were completely black and shriveled. She had a huge, gaping abdominal wound, with some bowel exposed. Her legs weren't charred, but they were also badly burned, and bone was exposed and infected around her knees.
When she came in, we could see immediately that she needed both hands amputated. She knew this, as well. We couldn't see the rest of the damage because she was covered with blankets and dressings. I took her to the minor procedure room, sedated her, and took a look. When I took the dressings down, all I could do is stare for about 10 minutes. We usually measure burn severity in terms of percentage of body surface area burned. Her total percentage was only about 35%, but it had so badly affected her arms and legs that the injury was devastating. I stared, prayed, and wondered what I could do for her...or more to the point...what I should do for her.
Looking at it all I realized that full treatment would involve amputating both arms and both legs above her knees, a tragic circumstance, even in the west, but here in Nepal, coming from a very poor family with lots of mouths to feed and lots to do, is it even a survivable circumstance? We have funds here to pay for the medical care of poor patients, but even if she survived the care (which was unlikely), what would happen to her after she left hospital? And so I stared, and prayed, and wondered, and eventually decided that the best option would be to stick to comfort measures, knowing that she would die, but at least giving her the chance to die without (hopefully) too much pain and suffering, and hopefully being cared for in a compassionate way. As I made this decision, and for several hours afterwards, it weighed so heavily upon me that I found myself weeping, both for her situation, and for the weight of responsibility that I felt for making that decision. Then we spoke with both Sonu and her husband, and they pleaded with us to try. They said they knew her hands needed amputation. They didn't want her legs amputated - they were adamant about that. They knew she had a severe abdominal wound, but they were hoping that it might heal. They asked us to try and give it some time and see if her abdominal wound would heal, and see what happens.
This took pressure off me in terms of the decision-making. We still thought she was likely to succumb to her injuries pretty early on. She had raging fevers for the first several weeks. But she remained spunky and spirited, and it really seemed like she was fighting. After long discussions with them, we amputated her hands (which obviously needed it), and performed a skin graft on her abdominal wound, which actually was starting to heal on its own. Amazingly, the skin graft took better than almost any other skin graft I've seen! Instead of dying, she seemed to be actually thriving. She was maintaining her weight (i.e. nutrition), and was still energetic and holding on. But she still remained in a lot of pain, and there was still the question of her legs.
About 2 weeks into her hospital stay, her husband disappeared, and nobody has seen him since. I suppose you can't blame him...what a circumstance to find yourself in when you're just a kid, newly married, with your whole life ahead of you. But it added to Sonu's woes and to the tragedy of the situation. Her father came to stay with her, bringing with him a notebook in which people from his village had written their names and pledges for how much they would give to help pay for Sonu's care. The pledges were generally in the 10-20 rupee range (15-25 cents maybe), and amounted to about 5000 rupees (maybe $60) - a fraction of what her care would cost...but it was really touching to see.
Now, about 2 months later, Sonu is still with us. But she isn't herself anymore. She sleeps a lot and she's refusing to eat. We keep on putting feeding tubes through her nose into her stomach to feed her, and she cries and cries and begs us to pull the tube out. But she is losing weight, and is now looking more like a skeleton than a girl. She cries in pain whenever we touch her legs, so we have to sedate her for any kind of dressing change or wound care. She hasn't had a fever in about a week now. We don't know if that's a good thing or a bad thing...good thing because the infection is more under control, or bad thing because her immune system is so compromised that she can't even mount a fever anymore. We're not sure which.
I spoke with her and her mother the other day about how things are going. It really seems like she is going to die. But she's surprised us before. I talked with them once more about amputation of her legs, which may put more stress on her body than she can handle at this point, or it may be what is needed to save her life. But for what? They haven't made a decision yet, which means that the decision may end up being made for them soon. The other option is comfort care and letting her die. She's almost past the point of us being able to do anything more for her, and delaying this much more may put her past that point. We'll see. When I said to her mother that her daughter might die, she began to cry, and said, "My daughter is going to die?" I said - with tears in my own eyes - that yes, that was very likely. There really is no easy answer in this situation. And with my still limited Nepali, having an indepth conversation about all of this is impossible. All we can really do is pray for wisdom and compassion as we continue to care for Sonu and her family as best we can.
It has been an emotional roller coaster for me and for the other doctors caring for Sonu for the past few months. But it sure is a reminder of why we are here. She was sent away from 3 other hospitals because of both the severity of her injuries, and their poverty. At least here we have funds that we can use to pay for her care, we have compassionate staff, and a wonderful Pastoral care team who has been very much involved in caring for her. Whether she survives this or not, we do know that she has had the opportunity to hear about the God who loves her, created her, and died for her, and who will gladly welcome her into His arms if she'll put her trust in Him. We pray that she does.
She is a beautiful 16-year-old young woman, newly married (yes, girls, especially poor girls, marry early in Nepal). Her husband can't be more than about 18, but I don't know his age for sure. She comes from a family of 8 children - 6 girls and 2 boys. The youngest girl is 1 year old, a spunky, very cute, curly-headed little girl, who is staying here at the moment while her mom cares for her sister. About 2 months ago, Sonu was holding some kind of metal rod in both hands, when it touched a live electrical wire. The current went in through both hands, travelled through her abdomen, down out both her legs, exiting, I suspect, around both knees, though also affecting her below the knee. When she came to us, both hands were completely black and shriveled. She had a huge, gaping abdominal wound, with some bowel exposed. Her legs weren't charred, but they were also badly burned, and bone was exposed and infected around her knees.
When she came in, we could see immediately that she needed both hands amputated. She knew this, as well. We couldn't see the rest of the damage because she was covered with blankets and dressings. I took her to the minor procedure room, sedated her, and took a look. When I took the dressings down, all I could do is stare for about 10 minutes. We usually measure burn severity in terms of percentage of body surface area burned. Her total percentage was only about 35%, but it had so badly affected her arms and legs that the injury was devastating. I stared, prayed, and wondered what I could do for her...or more to the point...what I should do for her.
Looking at it all I realized that full treatment would involve amputating both arms and both legs above her knees, a tragic circumstance, even in the west, but here in Nepal, coming from a very poor family with lots of mouths to feed and lots to do, is it even a survivable circumstance? We have funds here to pay for the medical care of poor patients, but even if she survived the care (which was unlikely), what would happen to her after she left hospital? And so I stared, and prayed, and wondered, and eventually decided that the best option would be to stick to comfort measures, knowing that she would die, but at least giving her the chance to die without (hopefully) too much pain and suffering, and hopefully being cared for in a compassionate way. As I made this decision, and for several hours afterwards, it weighed so heavily upon me that I found myself weeping, both for her situation, and for the weight of responsibility that I felt for making that decision. Then we spoke with both Sonu and her husband, and they pleaded with us to try. They said they knew her hands needed amputation. They didn't want her legs amputated - they were adamant about that. They knew she had a severe abdominal wound, but they were hoping that it might heal. They asked us to try and give it some time and see if her abdominal wound would heal, and see what happens.
This took pressure off me in terms of the decision-making. We still thought she was likely to succumb to her injuries pretty early on. She had raging fevers for the first several weeks. But she remained spunky and spirited, and it really seemed like she was fighting. After long discussions with them, we amputated her hands (which obviously needed it), and performed a skin graft on her abdominal wound, which actually was starting to heal on its own. Amazingly, the skin graft took better than almost any other skin graft I've seen! Instead of dying, she seemed to be actually thriving. She was maintaining her weight (i.e. nutrition), and was still energetic and holding on. But she still remained in a lot of pain, and there was still the question of her legs.
About 2 weeks into her hospital stay, her husband disappeared, and nobody has seen him since. I suppose you can't blame him...what a circumstance to find yourself in when you're just a kid, newly married, with your whole life ahead of you. But it added to Sonu's woes and to the tragedy of the situation. Her father came to stay with her, bringing with him a notebook in which people from his village had written their names and pledges for how much they would give to help pay for Sonu's care. The pledges were generally in the 10-20 rupee range (15-25 cents maybe), and amounted to about 5000 rupees (maybe $60) - a fraction of what her care would cost...but it was really touching to see.
Now, about 2 months later, Sonu is still with us. But she isn't herself anymore. She sleeps a lot and she's refusing to eat. We keep on putting feeding tubes through her nose into her stomach to feed her, and she cries and cries and begs us to pull the tube out. But she is losing weight, and is now looking more like a skeleton than a girl. She cries in pain whenever we touch her legs, so we have to sedate her for any kind of dressing change or wound care. She hasn't had a fever in about a week now. We don't know if that's a good thing or a bad thing...good thing because the infection is more under control, or bad thing because her immune system is so compromised that she can't even mount a fever anymore. We're not sure which.
I spoke with her and her mother the other day about how things are going. It really seems like she is going to die. But she's surprised us before. I talked with them once more about amputation of her legs, which may put more stress on her body than she can handle at this point, or it may be what is needed to save her life. But for what? They haven't made a decision yet, which means that the decision may end up being made for them soon. The other option is comfort care and letting her die. She's almost past the point of us being able to do anything more for her, and delaying this much more may put her past that point. We'll see. When I said to her mother that her daughter might die, she began to cry, and said, "My daughter is going to die?" I said - with tears in my own eyes - that yes, that was very likely. There really is no easy answer in this situation. And with my still limited Nepali, having an indepth conversation about all of this is impossible. All we can really do is pray for wisdom and compassion as we continue to care for Sonu and her family as best we can.
It has been an emotional roller coaster for me and for the other doctors caring for Sonu for the past few months. But it sure is a reminder of why we are here. She was sent away from 3 other hospitals because of both the severity of her injuries, and their poverty. At least here we have funds that we can use to pay for her care, we have compassionate staff, and a wonderful Pastoral care team who has been very much involved in caring for her. Whether she survives this or not, we do know that she has had the opportunity to hear about the God who loves her, created her, and died for her, and who will gladly welcome her into His arms if she'll put her trust in Him. We pray that she does.
Jessica thanks for sharing and being such an excellent and caring physician. Praying for your strength and compassion,
ReplyDeleteCheers Heather Brien