Stories From A Rwandan Hospital
These stories are part of an ongoing series by surgeon Matthew Spreadbury exploring the joys and challenges of being a surgeon on mission around the world, serving the hurting and hopeless. You can read his introductory article here.
[Editorial note: All patient identities have been changed for confidentiality reasons. They and their families have given written consent for their stories to be told.]
I’m a young surgeon on a mission, a mission to learn what it means to partner with the Father in his healing work. Now on the surgical ward in Kibogora hospital, Rwanda, I found it starts by stewarding a scalpel and acting in faith. I am aware that I stand on the shoulders of missionary surgeons, who have walked a similar path with Jesus. Like Dr Ronald, the chief of surgery who has selflessly worked at Kibogora for years. Each patient I meet tells a story of pain and hope. By engaging and being present, I learn more about them and something new about God in their situation. The following patient stories demonstrate my dilemma of being present in overwhelming situations where the Holy Spirit brings comfort to all.
Burn surgery is one area where I have limited experience. Effective management is very challenging and it requires specialized plastic surgeons, experienced burn nurses and intensivists to name but a few professions all of which we are lacking here. The nearest burn center is six hour drive away and refuses to take the majority of our patients. This can be due to logistics, or that the patient lacks money to pay for treatment.
Each morning we conduct rounds on the eight bed intensive care unit. One day, I noticed that a young boy, around six years old, had been lying there for a while but nobody had informed me about him. “Oh a burn, not too bad” someone mentioned. Fair enough. Some admissions from the previous night are put in the ICU before moving them to the ward and it’s not uncommon for small burns to be treated like this. However, as I began to take in his situation my concern grew. His urine collection bag was nearly empty and had a very dark color. I thought to myself “Hmmm, low urine output. This could be something BIG, or the nurses may have just emptied it. Don’t jump to conclusions.”
I pulled back his sheet to find sporadic bandages covering half of this poor boy’s body.
That’s not a small burn, that’s a big burn. It turned out to be 40% of his total body surface area. This, coupled with the fact that he wasn’t producing urine, sent me from concerned to fully engaged. This is big, and looks bad.
It turned out, Uway had climbed up an electrical pylon where he unfortunately grabbed the conducting wire with his left hand. The current flowed down his tiny fingers, through his arm to his chest, leaving a lightning-bolt streak across his torso that shot down past his abdomen, to the groin and thighs.
Remember a time when you once burned your hand. That searing irritating pain that didn’t leave for a few days. Times that by 40 and factor in frequent operations to debride the burn. I can’t imagine what little Uway experienced. It is very easy to stand on the other side of the operating table. For me it was at most heart wrenching to see a small child in so much pain and despite having drugs, we can’t remove all pain.
Uway needs aggressive resuscitation and the team of professionals mentioned above. A 10% body surface burn for a child should be referred to a specialist burn center. In our situation I was exasperated when our attempt to transfer was refused, without any explanation.
Administering intravenous fluids is the most important step in the management of big burns. Simply put the better he is resuscitated the better his urine output and the lighter the color. I took it upon myself to take pictures of his urine bag and my watch every time I walked past the ward so I could quantify his urine output and thus the level of resuscitation. Goodness knows what his grandmother thought of me. Surgeons can be odd types. Where are the parents you might ask? A six year old boy all alone but for his grandmother. His mother has left him and works as a prostitute. His father hasn’t shown up.
BUT we haven’t given up on him. The risks for him are great, hypovolemic shock, overwhelming infection, malnutrition, death. But we have this Hope as an anchor. Even for a child with a 40% electrical burn. We declared in prayer things that are not as if they are. We declared he would survive, in Jesus name, he would run and climb again, by the Spirit be fully restored in his body to the original design of the Creator.
Uway became grossly swollen because of the high volume of IV fluids required to keep his kidneys running. A consequence of this is that his IV lines started to pop out as the swelling increased. “Matteau, if a burn doesn’t have IV, they die”. Bernard, my attending surgeon, has a way with words. If one stopped working then he might die within twelve hours. For the next week I was called day and night to replace Uway’s IV lines with an ultrasound machine as and when they stopped working.
The burn ward at Haukeland (my hospital in Norway) is just 20 steps from my own. Why didn’t I spend some time there before coming here? There a child would have had a central line (a big secure cannula entering the chest to give fluids/drugs) which could be kept for weeks. Not small IV’s that fail every day. However we don’t have one. I checked. Optimal doesn’t exist here. But what do we have? Throughout the past few weeks I took stock of the donations the hospital had received and I randomly found some cardiac guidewires gathering dust. These are wires used in a super high tech cardiac catheterisation lab. Who on Earth brought them here of all places? Hmm well that’s something, if only we had a catheter we could place over the wire… then wait a sec i bet neonatology has some umbilical vein catheters! These are thin mobile catheters placed in the umbilical vein after a baby has been born. An idea, hope, a possibility was born. The improvised central line worked and it was a joyous day not too soon afterwards that his urine colour changed from a muddy red to a light straw colour. His kidneys have recovered! Hope.
Meeting Uway everyday I had no choice but to face the question of suffering day after day. The tragedy of the accident happening. The injustice that his mother had abandoned him. “Where are you in this situation God?” I wrestled with Him. That a child could endure so much pain. “Where are you in this?” I felt the weight of personal responsibility for Uway’s life and wellbeing.
I learned that when faced with a situation that goes against the desire of God, my role is to pray until I see the Fathers heart for the situation. To pray the question: “How will you redeem this?”
The revelation came “I am in you, and you are present right now.” I can’t change the fact that an accident happened or what other people have decided. My response bears witness to Jesus’s love for him, right now.
“I learned that when faced with a situation that goes against the desire of God, my role is to pray until I see the Fathers heart for the situation. To pray the question: ‘How will you redeem this?’”
Uway’s strength in spite of suffering had captured the hearts and minds of the staff at Kibogora hospital. The team and I fulfilled our part in the Kingdom not just by operating on his burn. We got to pour out our love for him in other ways. As we rounded on the intensive care unit Uway had started to close his eyes as we prayed. I realized he is praying with us! Christ’s hope in us, shone out to others and created hope in them. Later on, when he had more strength I gently tossed a tennis ball on his bed. He knew what to do and threw it back with his good arm. Play helps to ease pain.
This was a process. Not a one time event.
A few days later we took him to theaters to examine, debride and dress the burn. He was still physiologically unstable and needed regular blood transfusions, so we had to be quick, he wouldn’t tolerate much surgery and could potentially die if we operated too much.
His left palm was dusky and cool but his right was a warm pink. Could this be compartment syndrome? The swelling was not only due to us giving him fluids but also because of damaged muscle from the electrical burn. When the swelling in a compartment exceeds the blood pressure in a compartment the blood supply is diminished causing ischemia and ultimately loss of the limb. We decided to open, this means a rather morbid procedure called an escharotomy when one cuts through a burn to relieve the pressure below.
With a scalpel we opened from hand to shoulder and his left hand turned pinkish and warm again. Hope.
Matthew 7:7 says “seek and you will find” and one evening as I passed through the ICU I heard Uway say repeatedly “I need you Jesus and his Father”. He’s calling on Jesus to be comforted, to not be alone, to give him strength to endure. It’s enough to make you cry and I indeed have on occasion. I would completely understand if Uway and I were not friends. Children take pain very personally. He could associate the tall white guy with bringing pain in the form of a dressing change or a needle prick. However earlier today as I sat by his bed he said “I’m happy to be with you”.
It is with great happiness that after a month I can say that Uway has not only survived his burn but is thriving. Hallelujah!
Eric, a hospital chaplain and I visited Uway regularly and one time he said he wanted a picture. We took one, printed it out and I wrote a message on the back. About a week later Eric gave him the picture and Uway started talking frantically whilst pointing up. Oh my word I realized, he is telling his testimony of the last couple of months. Eric translated for me:
“One time when you took him to the operating room, you put him to sleep and suddenly he was in a beautiful place, a place he had never been before. He saw a man walking towards him and gave him a gift. He took the gift up to his mouth and ate it. It tasted sweet. Delicious.” He could now connect his dream with the photograph he had received.
On the back of the picture I had written “Uway, Jesus has healed you during your time in hospital, aided by the nurses and the doctors’ hands. He came that you may have life, and life to the full John 10:10”.
That’s the gift he received. It’s the word. It’s sweet like honey, it’s the sword of the spirit. It’s the anchor to the soul. It’s the peace beyond all understanding. It heals. It comforts. It’s hope where there is no hope. It speaks forth life itself.
Later on in reflection a verse from Luke came to me “Heal the sick and tell them the kingdom of God has come near.” It’s just that I didn’t have to tell Uway that the Kingdom of God was near, Jesus did it himself.
“The worry was spread across his face, he cared more about his family’s welfare than even his current pain.”
Sometimes we are living our lives blissfully in the day to day when our world gets turned upside down.
Zaustin is 28 years old, the breadwinner for his family of six. During the day he carries rocks or does manual labor to provide for his loved ones. He earns around a dollar a day. He has a wife and a newly born daughter. One evening after payday he had a drink with a group of guys, he paid for the drinks and they assumed he had money. They beat him up, stole his money and left him for dead. The trauma call came eleven days later, which is very odd. As I saw Zaustin laying on the OR table I placed an ultrasound probe on his abdomen and saw a lot of free fluid. This could be blood or something else, either way he needs an operation.
Venuste, a Rwandan surgery resident and I opened the abdomen and 2.5 liters of dark blood were sucked out. The bleeding had stopped, we palpated the entire bowel to check for injury and satisfied we washed and closed, but i didn’t have a good feeling. Two days later he had a fever, abdominal distension, low urine output and tachycardia. We operated again and discovered that his entire pancreas was necrotic. His spleen and pancreas were injured in the same forceful kick to the abdomen. This condition -traumatic necrotising pancreatitis- carries with it a 50% mortality rate. After two laparotomies Zaustin was in agony.
Since Zaustin wasn’t working, he didn’t know how his family could afford to pay for his treatment. They might have to sell their land, bankrupting the family. The worry was spread across his face, he cared more about his family’s welfare than even his current pain.
“5 billion people do not have access to safe & affordable surgical care” (The lancet commission on global surgery 2015).
Patients undergoing surgery shouldn’t face bankruptcy to pay for it. Such is human injustice that exists today, while there is enough wealth in the world so that nobody has to be hungry. It’s a heart issue.
Once again I joined Eric, a young hospital chaplain, on pastor rounds. The hospital chaplains have a unique role of not only ministering to patients but also can lobby to cover patient expenses. As we prayed for Faustin, Eric and I felt moved to tell him not to worry. We will somehow find a way to cover his hospital stay. You can’t help everyone, but here is a patient who I can help. I thought of James 4:17 where we are blessed to bless others. To know the good we can do and then do it. That comes with a moral responsibility. Zaustins relief of hearing this was visible on his face. From the western point of view we are not talking a lot of money either, 15-50 dollars perhaps.
The next day he was in agony. He sat upright in bed, rigid, avoiding even the slightest movement and refusing morphine. Morphine is expensive.
His breathing was fast and shallow between a moan of pain. The oxygen concentration in his blood kept falling and the hospital had run out of standard intravenous painkillers. I don’t think you could imagine his pain after two operations and necrotising pancreatitis. His pain meant that he wouldn’t breath deeply, thus his lungs won’t expand fully. This isn’t the whole story, he had a condition called acute respiratory distress syndrome. Simply put his lungs were leaking fluid and he was drowning in his own secretions. He needed two weeks in a fully equipped intensive care ward but even then the mortality rate is still 50%.
In an attempt to help someone started performing lung physiotherapy. This means brisk pounding on the lungs and Zaustin screamed uncontrollably as he coughed up fluid and sputum. I had to do something.
“When there is no worldly hope, all it takes is a step of faith, to change everything.”
I paced to anesthesia to get drugs and rigged up an infusion myself. At least he was more comfortable and relaxed now. That was the limit of what I could do in the system I am working in with the resources available. You know that burn you get in your legs when you run? That’s due to oxygen debt and lactic acid being produced. As Zaustin’s oxygen level was so low he would have felt the same burning pain in his entire body. He was scared and with beads of sweat covering his exhausted face. Our team gathered together and pondered what to do. The truth was there was very little in our toolbox. We only had the box, a now empty one. Our only hope now was to try and transfer him again. The larger hospital would not accept this transfer unless he was intubated. That means having to give general anesthetic, placing a tube into his trachea and using a machine to breathe for him. This in itself could kill him. Then he might die on the journey as someone had to hand ventilate him on the 6 hour car journey.
I took in his situation again. The oxygen monitor, the anguish on his face, his wide eyes imploring me. “Lets pray”. I lay my hand on Zaustins shoulder, he nodded and closed his eyes. “Comfort oh God, be with him, cast out the fear, we need you now…” as I started I heard a voice to my left, Gilbert, the anesthetist joined me with a softly spoken voice “Jesus hold him, never let go, bring your peace Father..”
When there is no worldly hope, all it takes is a step of faith, to change everything.
On the other side of the bed our two voices became three as Zaustins nurse lifted her voice to heaven. The ebb and flow of prayer changed as a family member and even the patient in the next bed felt moved to join. My prayer blended into a melody of others where there is all hope and we declare things as if they are.
Not too long afterwards, Zaustin passed away in the embrace of the Father. His body was failing, but his soul was abiding and secure. He is now at peace and in a final moment of divine healing. He is in a place where he can breathe deeply again, where there is no pain and is at rest.
Two steps away, in the next bed lay our little boy with burns, Uway. He had been trying to wave at me the whole time I was with Zaustin. I smiled, held his hand and gave him a bottle of juice. He had been asking for juice the last few days. Here in the space of two physical steps I have mounting sorrow and overflowing joy. I know God is present in both.
We are not machines that operate on other machines but humans; body, mind and spirit. In being with my Rwandan friends, I share the burden of the long hard days and also the highs of humbled relief when a child pulls through against all odds. Then we give thanks to our Father in heaven who does His healing work through this small family at Kibogora and we teach each other something about humanity, hope and how to live a life worthy of our calling.