Illustration by Tallulah Fontaine
It’s been said that God comes to West Africa to learn how to wait, a cultural difference that can surprise even the most hardened, cynical American physician.
Yet something about the line of patients seated in the early morning heat outside Margret Marquart Catholic Hospital in Kpando, Ghana, looked different that day. We were walking from breakfast to the operating theater, expecting a string of hernia repair surgeries that would last until nightfall. A crowd had gathered around a thin boy who lay still on the concrete walkway. He moaned quietly, his eyes widening with fear as we approached. The boy’s teacher, a diminutive, middle-aged man, stood nearby, distraught but able to tell us what had happened. The boy was bright and had offered to help with the repair of electrical wiring in the school. He had suffered an electric shock. The boy’s name was Joshua. He was 13.
Joshua had a severe electrical burn. Most burn injuries are confined to the skin. The worst burns, known as full-thickness injuries, burn all the way to the fatty tissues underneath. Lethality depends on the depth and extent of the damage. A full-thickness burn involving over 50 percent of the body’s surface area is often fatal.
Electrical burns like Joshua’s are particularly virulent. The current enters the body part that touches the live wire, then exits the body far away from that point, leaving a path of destruction. The injury is no longer skin deep; tissues such as muscle and internal organs are damaged. At modern burn centers, patients placed in trained hands armed with the latest technology may survive these injuries. But in Ghana, the only burn center — a rudimentary facility at best — was nearly four hours away. At our small hospital, Joshua’s chances of survival were slim.
As I absorbed the scene by the first aid room that morning, I wondered where exactly to begin. Our medical team at Margret Marquart consists of doctors, nurses, therapists and social workers. We tend to focus on hernia repairs and may perform the occasional thyroidectomy or mastectomy. The facility has little more than old gurneys, faded curtains and rickety carts of sterile instruments, gauze and sutures. But surgeons are trained to be decisive. In my hospital in Ohio, I would be spouting orders. Here I stood mute.
Cara, one of the nurses who assisted me in surgery, tapped on my shoulder and motioned at Nicole. “You know,” she said, “back home we’re burn-unit nurses.” In a moment, they transformed the small first aid room into a trauma bay, and the resuscitation began.
By now Joshua was shocky and delirious. The initial threat from a burn injury is fluid loss. The burned skin weeps vital fluids, and the need for IV fluid replacement can exceed 10 liters per day. In an electrical burn, breakdown products of the burned muscle can attack the kidneys; even more fluid is needed to prevent their failure.
Formulas help caregivers calculate the rate and volume of fluid replacement. Somewhere in my temporal lobes resides the Parkland formula, a standard measure for the needed fluids. I scratched my head, took out pen and paper, and began the calculations. Before I had arrived at an even remotely correct figure, Cara and Nicole had not only calculated the numbers but had begun the rapid fluid instillation. They functioned as they would in Ohio, for they knew that it is precisely in times of emergency that routines are most important. My surgical hubris dropped a few notches as I saw them at work.
Once the initial shock was corrected, we turned our attention to the wounds. Now infection posed the greatest danger to Joshua. One usually coats burned areas with a potent antibiotic ointment and applies dry, sterile dressings. The small hospital pharmacy actually had a few jars of Silvadene, an ointment commonly used in the States. We had just enough for the initial application.
Prior to dressing the wounds we removed necrotic skin, a process known as debridement. The work is surgical in nature and can be quite painful. Joshua would need anesthesia, a risky prospect in such a young, fragile patient. “We can use ketamine,” said Daniel, our Ghanaian anesthetist. “It’s safe — we use it in children all the time.” It was an excellent suggestion, and one often used in American burn centers.
We moved Joshua into the one-room operating theatre. Slanted rays from the morning sun shone on the lone table, where Joshua lay. Daniel injected ketamine into the IV line, and the debridement began. Dead skin covered Joshua’s hands and legs and part of his torso. Eventually we turned to his fingers and toes. He had apparently grasped the wire with his right hand. Dead flesh hung from his shiny, red, swollen thumb and forefinger. The acrid aroma of ash rose from his hand. His left big toe, the current’s apparent exit site, looked and smelled the same.
The ketamine had sedated Joshua, but it did not get him to sleep. While the drug served our purposes, it is known to cause hallucinations. As we worked, Joshua rolled his eyes upward and started chanting, “Jesus, Jesus, Jesus!” in a repetitive monotone. We checked Joshua’s blood pressure and pulse to reassure ourselves he wasn’t about to die. Then we followed his eyes. John, a neonatologist who had accompanied us on the trip, was observing our work from the head of the table. John has dark hair and a brown beard. All he lacked was the halo.
Joshua finally drifted into sleep, and the room grew quiet. The nurses and I worked without a word. Sometimes the most significant moments in our lives pass in silence. The operation focused us and drew us out of ourselves. We had no need for speech.
The debridement complete, we painted the burns with Silvadene and wrapped them in cotton gauze. Joshua would need to be transported to the distant burn center at the teaching hospital in Accra, Ghana’s capital city. All agreed he would need to be stable for the trip. He needed an ambulance, but such trips are expensive. The cost would run the equivalent of $300. The money would need to be found somehow.
By then Emilia, Joshua’s mother, had arrived. We learned he was the youngest of five children. His father was an itinerant farmer who earned $1 a day. Emilia sold beverages on the street to provide food for the family. She walked between cars with bottles in a large basket on her head. Their home was on the outskirts of town. It had neither electricity nor running water. Most importantly, they had no money for an ambulance.
Most health care in Ghana is meted out on a cash-and-carry basis. The patient pays before care is rendered. Recent reforms have delivered medical insurance coverage for most of the country’s 30 million people, but at the time of Joshua’s injury, less than 10 percent of Ghanaians were insured. When a true emergency occurred, doctors provided the care first and billed the patient later. Then, in an unusual departure from American protocol, the patient would often not be discharged until the bill was paid. We began to wonder if we would ever get Joshua to the burn center.
Noon arrived under a sweltering sun, and we finally turned to our surgical schedule. We checked on Joshua between cases. Afternoon brought a cooling tropical cloudburst and a much-needed breeze to Joshua’s stuffy ward room.
As evening shadows lengthened, a new problem arose. Joshua was in pain, and the nurses could not give him the narcotic injections I had ordered. The pharmacy had demanded payment up front, and neither Joshua’s mother nor his teacher had any cash. Donations from the medical team solved the problem.
Darkness falls early in Kpando. It was late when we finished our last hernia repair. After supper, we sat outside under the brilliant African stars. The flush of shared effort yielded to a discussion of ways to get Joshua to the burn center. One of the nurses stopped by on his way home and gave us the disturbing news that the center was demanding a $500 payment upon arrival. It was again time to pass the collection plate. After all, one can only spend so much on souvenir beads and sculptures.
The ambulance arrived early the next morning, and payment for service was rendered. Joshua had passed a quiet night and appeared stable. We lifted his stretcher into the patient bay. His mother followed. John the neonatologist, armed with the additional burn center payment, scampered aboard as well. As the ambulance pulled away, we couldn’t help but notice the words painted on the side panel: “Donated by the Islamic Republic of Iran.” The irony wasn’t lost on us.
We learned a few days later that Joshua’s condition was improving. Upon arrival in Accra, Joshua had been transferred to the plastic surgery center at the large teaching hospital. A small wing houses the burn center. There had been much ado about getting Joshua through its doors. The admitting clerk coldly demanded, “Pay first,” by now a familiar refrain.
On our way to the airport, we stopped to see Joshua. He was quartered in a large ward and was surrounded by dozens of patients with wounds of all types. Burn patients were part of the mix and not separated in any way. The sickly smell of bacterial infection filled the room. A surgeon told us that Joshua would lose fingers and toes but would most likely survive.
Several years later, during a return visit to Margret Marquart, I was examining hernia patients when a young couple entered the clinic. The man smiled and raised his right hand. Two fingers were missing, the wounds long since healed. Joshua had come to thank us and introduce us to his girlfriend, to show his gratitude by his very presence among us.
Over the years, I’ve learned not to expect gratitude from my patients. Like most older doctors, I’ve donned the armor of cynicism. Even so, thousands of Joshuas are recuperating in hundreds of hospitals around the world, grateful for their care. Some true servants of God have written that the only path to happiness is through service to people like Joshua. But doing something, even a charitable act, in search of my own happiness, seems selfish. I like to think that something deeper, something redemptive, was afoot on that day in Ghana, an unbidden joy I found not in the gratitude of others but in the work itself.
Dean Mayors M.D. is a general surgeon from Akron, Ohio.