His Name is Legion

A thin, dirty, bloodied 15-year-old was brought to the hospital by his parents last evening, just after the Outpatient Department had closed and just as the Pharmacy was wrapping up. The clinical officer on duty was leaving, and the night call officer was not immediately available. Fortunately, Jordan, a friend and visiting paramedic from the U.S., was up to the challenge.

The young man had been running from a group of older kids when he fell into a ditch and suffered a gaping compound tib/fib fracture. In acute pain, he was nonetheless stoic. So were the subdued and anxious parents who stood quietly by their son.

Jordan expertly assessed the situation, established IV access and administered fluids, pethidine (the only thing we have for pain besides aspirin and ibuprofen) and tetanus toxoid. We irrigated the wound with normal saline, gently wrapped it in sterile gauze and carefully immobilized the limb. Although a pedal pulse was miraculously still intact, time was of the essence to save the boy's right foot.

But TIA: This is Africa. Time is not often of the essence here. That is a disconcerting but reasonable reality in a country where death has become sadly commonplace. The few remaining staff members on duty at 5 PM were shaking their heads at the wazungu racing around to find the requisite supplies from four different buildings on the hospital campus. One of them said, "All this commotion for 'just' a broken bone?"

What Jordan and I were thinking, however, was, "We have to save his foot. No, traction is not appropriate in this case. We have to save his foot. PLEASE don't move anything. We have to save his foot. He can't sever any more vessels. We have to save his foot. He needs surgery. We have to save his foot. He is just 15, dear God..."

He could be my grandson, my own heart added, when I finally had time to look into his frightened eyes. We had to save his foot.

Although a qualified surgeon happened, surprisingly, to be on site (to supervise this week's public circumcision program), his professional fees for performing the "private" service far exceeded what the boy's family could pay. We knew we needed to transfer our patient to Kisumu's Provincial General Hospital, about 40 minutes away. There surgery and hospitalization would cost only 5000 KES (about $63) total, still an exorbitant sum to a family that earns less than $1/day.

We requested the hospital ambulance and were told that it had just left the grounds -- without a patient and for an errand. "Get it back," Jordan and I simultaneously urged. At that point, the dickering began. "The family has no money. We can't take the boy to Kisumu tonight. Just admit him and talk to Administration tomorrow to see about adjusting the fees."

"No," we insisted. "He must go tonight." "Surgery needs to happen sooner than later."

In fact, the boy's parents could not even afford the 500 KES ($6.25) for the emergency services just performed, much less the 2000 KES ($25) for the ambulance. They had no time to beg for money from relatives, and we had no time to be polite. The boy's right foot and entire future were at stake. "Please bring the ambulance NOW. We need to get this kid to Kisumu."

"They must pay first," we were again told by people who understandably had no choice.

And for that we would have further risked the loss of a young man's foot and future? OK. You know what we did. It was undoubtedly culturally inappropriate and fostered dependency, besides. But what would you have done? And, yes, I should have worn latex gloves, but the Outpatient door was locked when I arrived at the scene, and I got lucky. Again, what would you have done? (See miniscule video clip: click on Picasa link at left.)

We don't even know the boy's name. But we do know "his name is Legion..."