Monday, December 1, 2008


Nearly a year and a half have passed since we met, but I can still remember the terrified tenor of his screams. I looked him the eyes and caught a glimpse of a once vibrant spirit, now teetering on the edge of extinguishment. He returned my gaze with the precursor of a nascent smile for a short moment before recognizing the familiar sights and smells of his surroundings. A look of horror obliterated the smile, and in a brief nanosecond his expression changed from one of mischievousness to sheer terror at what he was about to experience. His slight three-year-old body writhed violently against the iron grip of the nurse as she attempted to calm him. "Tranquilo, Yason, tranquilo. Shhhhh. Tranquilo."

At this point in my trip to Guatemala, I had been working mornings in the operating room for about two weeks. A small stroke of luck brought me to this moment. I had traveled to Guatemala intending to learn Spanish at a Guatemalan school, with the hope that I would have the opportunity to spend some time observing and possibly helping local doctors at one of the many clinics sponsored by international aid organizations. My first few days of volunteering were spent in one of these clinics, where I encountered a total of three patients in twelve hours. After making a connection with one of the local doctors, I asked for a transfer to a hospital, and found myself on the bus to a small city in the highlands the next morning at 6:00 AM. Upon arrival, the physician in charge asked where I would prefer to work. He was pleased when I chose surgery and sent me down the hallway to the surgical wing of the hospital, which consisted of two small operating suites that had clearly--even to my untrained eye--been built sometime in the late 70s. Seafoam green tile covered the walls, and the operating lights lacked the occasional bulb or two. I changed into a pair of borrowed scrubs, conversed with an anesthesiologist for a few minutes in broken Spanish, and was then asked if I knew how to scrub. My first operation was a cholecystectomy on a thirty-five year old woman--a standard operation in the land of little access to birth control and 5+ parturitions--and I never looked back. I learned how to snip suture, hold retractors, and operate the bovie as I went along, finding the work simultaneously fascinating and immensely enjoyable.

Yason was different. He was three, and, as far as I could tell, had once been the archetypal healthy young Guatemalan. I had scrubbed on a few pediatric cases in the preceding two weeks--hernias and such--but this one was bore no resemblance to the others. Severe burns covered roughly fifty percent of his body. According to the doctors, he had pulled a pot of boiling water onto himself, and had been in the hospital for the past two weeks. New skin was slowly displacing the dead tissue, but pus and scabs were forming over the burns, necessitating disinfection and debridement. This was his fourth trip for debridement since the injury, hence the writhing and screaming. I stood at the scrub sink and attempted to fortify my emotions for what I knew would be a tough case.

Fast forward a year and half. I am sitting in a lecture on child and elder abuse for a class on human behavior. A slide flashes across the screen depicting patterns of injury that indicate abuse, and the moment comes rushing back. Suddenly, I am standing in the OR, gloved and gowned, with the surgeon and a medical student. Weilding sterile brushes with plastic bristles, we scrub--back, buttocks, back of the thighs, parts of the foot, the palms of the hand. Yason whimpers despite the anesthetic, his face flinching now and then, screams and contortions numbed by unconsciousness. Rich carmine blood oozes from the burns, as if protesting our assault on the skin's healing processes. We finish after forty-five minutes of scrubbing, our white gloves stained bright red, bristles glistening. Yason whimpers more as the anesthesia begins to wear off and we apply bandages to the burns. A nurse wraps him in a blanket and spirits him off to recovery.

After Yason was gone, I stepped back from the OR table and removed my gloves and gown, finally permitted the chance to contemplate the event in which I had just participated. My eyes welled up with tears for the young boy, a few dripping onto my mask and darkening its baby blue fibers. I marveled at the seeming lack of fairness. It made me want to scream.

But now--with nearly a semester of medical school behind me--I think my reaction to the case would be changed. If I encounter something similar on the wards as a medical student, the case will hopefully have been referred long ago to child protective services. American burn care is also much more advanced than that available in Guatemala. But I would still want to scream. I hope I never lose that impulse.

(image via Wikipedia)

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