Trigger warning

I don’t know if it’s interesting to others, or more just a sort of morbid fascination on my end, but – in the same vein as my recent post re: how hard life can be w/o modern medicine - I’ve been thinking about the incredibly weird (for a Westerner), sad, and frankly gross stuff you see, sometimes, here. This post is going to discuss a couple of them, and, at the very bottom, there are some photographs. So – if you don’t want to read about gross medical things, and especially if you don’t want to see them, either skip this post, or stop scrolling when you get to the end of the text. I’ll leave some space between there and the pictures so you won’t be taken by surprise.

So, the first – um - interesting malady I wanted to mention is not something I have actually seen, though one of my colleagues has. It’s called bot fly, and it is truly worthy of a horror movie. (In fact, I actually saw a movie once where this happened, and it freaked me right out – the memory is still powerful.) What happens is this: The fly lays eggs in some way as to bring them in contact with your skin. I have heard that one of the things it likes to do is lay the eggs on clothes hanging on a line at night, which is why they iron all our laundry here, and why you’re supposed to take anything you’ve hung up inside before it gets dark. Anyway, when they contact your skin, the eggs are able, on their own, to burrow into it. And, once there, they hatch. So that a little while later, you develop what looks like a pimple. Except if/when you squeeze it, AN INSECT COMES OUT! Well, a larva comes out. But, from the point of view of grossness, that seems to me a distinction without a difference.

I guess I’m being a little light about that particular parasite because – well, I’ve never actually seen it, and I don’t have the impression it is rampant, in any case. Plus, though it sounds repellent, presumably the damage done is relatively superficial. (Also it’s so weird and nefarious, what can you do but laugh?) I can’t joke about the next one, though. I see it regularly, and I still don’t know WHAT is going to happen to the kids afflicted by it. It could very well end up costing them legs and feet.

I’m talking about snakebite.

It’s interesting to me how many things we sort of think we know about, but, in fact, really have no idea. Reminds me of what European explorers in the Arctic found when they asked local people to describe/map out the local geography. Apparently, people were able to give remarkably precise and accurate maps of any area where they actually lived/worked/hunted, but when they started talking about areas they didn’t usually go to, their accounts became fanciful. There are a lot of “hinterlands” in my mental landscape – places I’ll happily describe to an interlocutor which turn out, upon investigation, to be figments of my imagination. (Doctors may be particularly good at this. I remember my first college friend who went to medical school telling me, during his residency, how most of what a doctor can tell you is what you DON’T have. He said when he saw a doctor venturing beyond this while talking to a patient, he could tell when the doc “just started to make stuff up.”)

Anyway – to the extent I’ve ever thought about snake bite, I guess my image has been “Snake bites you – something bad happens – you die.” As if what snake venom does is strike directly at some central body system, and it is all over quickly. And, of course, there are snakes like that – mambas, as well as little tiny coral snakes, have a venom that paralyses your respiratory muscles, and that’s it. Can’t breathe – die.

But a great many snakes have more insidious venom, that does things like thin your blood, or break down your cell membranes so that what was once differentiated, functional tissue becomes a kind of egg-scramble of inactive organic molecules.

We frankly don’t know which snakes are biting the kids we see – I don’t even know what snakes live in South Sudan. But bite them they do. One of my OR colleagues said that you especially see it around this time of year, the rainy season. The rains fall, the grass gets tall, the kids go out and play, as kids do, and the unseen snake feels molested and strikes.

In theory, if the kids could be treated immediately with antivenin, they might have only minor problems (although that isn’t actually certain…). But often, we don’t see them for days – over a week in some cases. The problem may be distance from the hospital; in addition, the OR staff tell me, people may go first to traditional healers, which also costs time. Giving the poison – here, it seems to be primarily that cytotoxic (cell-killing), egg-scrambling venom I mentioned above – lots of time to work.

By the time we see them, large areas of skin around the bite have either blistered up or fallen off, and underneath, there are expanses of dead, liquefied, pussy tissue. (Since I’ve already given you the trigger warning, I guess I can say that, sometimes, you can smell these wounds all the way down the hall.)

When they come to the OR and the technicians begin to debride the wound, whole areas just dissolve and fall off. And what is scarier to me – often the entire layer of tissue above the tendons and muscles – the skin, the subcutaneous fat, the connective tissue; half an inch of the stuff that makes your leg rounded rather than wiry – is dead, over a large part of the leg. One girl we are treating now had a kind of fissure that went from her lower leg up past her knee to her thigh; over the past few days, the fissure has opened up, revealing dead areas halfway up to her groin. And about half the cutaneous tissue of her lower leg has already fallen or been cut away, allowing everything – muscles, tendons, ligaments – to be plainly visible. It is like looking at an anatomy textbook, or even something bionic.

But isn’t it nice that they made it to us eventually? Well – yes. In the sense that they now probably will not go septic (get a blood infection) and die. But the fact is, we do not have the means to treat these kids. I don’t think they would be cured by skin grafts – for those to work (and we don’t do them here, and they are very iffy, in any case, in any situation where you can’t maintain absolute sterility), there has to be something to graft the skin to, and I don’t think muscles and tendons qualify. My sense is that, in the West, these would be cases where the survivor, or his/her family, would regale the curious years later with stories of how it took “12 surgeries to repair!” Grafts of muscle and fat, watched over scrupulously for days to ensure they maintain their blood flow and don’t choke off and die; skin grafted, and possibly grafted again. We can’t even do the first operation, let alone all 12.

At this point, I simply do not know what our plan is for these kids. I’ve asked my Medical Director if we can clarify what we are doing, and I think we may send the photos to a “surgical referent” in Paris who can give us some idea of what the options are (remember – none of us on this project is a surgeon!). But in the absence of any suggestions from higher up, I can only see two possibilities: Keep cleaning the wounds and changing the dressings every couple of days, which is not in any way a solution – merely a holding action that, hopefully, if we’re lucky, will prevent new infections, but without actual healing. Or amputation.

I saw a young woman with one leg the other day, making good time on crutches in the market. Maybe, in the scheme of things, it wouldn’t be so bad. But what disability (and what, I don’t know, devaluation in the marriage market, leading to “spinsterhood,” dependency, and maybe abandonment in old age – as I say, I don’t know).

You can see the other shore, of cure and safety and wholeness. But the river is flooding, and there is no bridge, and you can’t get there.

Here are the promised pictures, of the sequelae of three different bites. Scroll down a bit; as I say, I wanted to separate them for anyone who doesn’t want to see.