Getting burned. Moving forward. Finding a name.

The babe didn't have a name yet. His face, most of his torso, and his entire left 

arm and hand were badly burned though. He was 18 days old when the mosquito net 

around his parents bed caught fire. At 21 days old, he developed a secondary infection. By day 23, he had been transferred to us at CHUK ED in septic shock. We put IV lines in his burnt neck and gave him fluid and antibiotics, a nasogastric tube for expressed breast milk, an anesthetic dose of ketamine, debrided the dead tissue, dressed the newly exposed pink skin with honey, wrapped him in clean sheets, tucked him in a rusty stretcher with his 

mother, and hoped for the best....but we all expected the worse.  

Why wouldn’t we? More kids die than survive in our ED setting who present with complications from burns. I used to remember all of the cases of childhood deaths, but now their faces blur in my mind like fragments of half-remembered dreams.

The care-delivery matrix is grossly under-developed and under-funded in this busy public hospital. It is not even just the hospital- it is the entire health system. It has improved so much over the last 5 years, but there are still so so many challenges to overcome and systems to bolster. Some days, it feels unattainable. 

But it can't be, or else we are all wasting our time. I have to remember that Rwanda is a G167 country, not a G7 one like where I am from. One has to be patient, one has to know when to push, when to pull, and when to stand still.  One has to accept that despite best efforts and intentions, time is needed for these big system improvements to filter through the bedrock of positive developmental change. 

This is a candid assessment, but it is also a brutal truth for those who have to deliver, or don't have the means to deliver, emergency medical care in Rwanda. 

All to often, patients die unnecessarily. As emergency care providers in this  resource-limited place, we sit at an uncomfortable interface. We see and understand where and how the national system needs to develop, but we also see and feel the patients dying literally in our hands for want of that positive change. 

This juxtaposition rattles me. 

The families look on hopelessly, I subconsciously withdraw my emotional patient investment. I detach. I callous. I inadequately process the daily death around me. I catch myself doing it. I then try to reconnect.  To stretch back out to the human connection of the patient-doctor relationship. I speak to the families who lose their children or spouses. I sit patiently and try and answer their questions. I speak frankly about grave prognoses, I try to empathise and comfort. 
I am a teacher here, I try to mentor appropriate behaviours. I engage the patient, I discuss death and dying. I try to be honest, respectful and caring….but some days I can't. 

Some days, I just try and wall myself off. Some days, caring seems hopeless. Caring can’t seem to improve the system.  It is maddening. Instead, I  want to curse and shout my frustrations. I want to throw broken resuscitation equipment across the room.  I want to blame someone for the system failure.  But I don’t. I can’t. In this immediate context, such a rampage will only make the system more dysfunctional. I simply try to resign myself to the approaching poor patient outcome.

So it was this day with this young babe. Burned, volume-depleted, hypoglycemic, and now in septic shock , he was going to die. I was resigned to this fact.  I went through the motions of care and went home for the night. 

The next morning he was still alive. Same too the following day. He remained nameless, but he began to breast feed. We called him Buddy. Bernard, the EM resident of room 8, became invested in Buddy. I saw it happen. He fed Buddy's mother chapatis he would buy on the way into the hospital. He scrounged bandages and honey to offset her medical costs, he lent her his phone to call back to Buddy's father still in the village. In the true spirit of the word, he cared for them. 

Children are the future everywhere. Children are certainly the hope of this small and crowed country.  Almost half the population of Rwanda, over 5 million people, are less than 18 years of age. They are the ones who will move this country beyond it's genocidal past.




Though already 20 years old, the genocide is still so young.

http://www.rwandanstories.org/origins/real_differences.html

  There are laws defining what and how to speak of the genocide and reconciliation and reunification rhetoric pervades the social fabric.

“All Rwandans are Rwandan” is the official doctrine. 

The country develops rapidly and strides steadily forward towards remarkable improvements in health, education, industry and infrastructure.      

But how can there not be some tension? Some distrust?  How do neighbours who killed each other with machetes re-become 

being neighbours? Being villagers? Working at the market, in the fields, and attending church together? Beneath the controlled surface of social interaction, there is a tension. 

The process of healing for one individual, one family, one village, and one country is far beyond my comprehension.  Amazingly, some have claimed recovery -  http://www.kwibuka.rw/  - but most will need a generational buffer. A generational gap between being hunted, being a killer and being killed. 

The Rwandan children now and the Rwandan children to come are key to Rwanda’s peaceful and prosperous future. 

Other room 8 patients came and went. Some died, others went to the ward and a few 

returned to their district hospitals. Buddy remained- day 7, day 11, day 15 - he required less and less bandaging. IV lines were removed, antibiotics stopped. Then one day, he was no longer Buddy.  He was no longer nameless. His Mom stood happily during rounds and announced his name - “Graceadieu Dieudonne Fabrice”.  Bernard already knew.  We on the emergency staff always feel hope during such times as these. I think it is a large part of what drives us. It has to. 

The next day they left the hospital. Back to their village, their community and their future.  

Thanks for reading.