Inshala

It was my first day in the Iraqi pediatric burn clinic, and the experience had been exhausting. The medics called me over to the newly burned 12-year-old girl who was in respiratory distress. She was burned from head to toe, and the smell was overpowering. While I repositioned her head, she stopped breathing. I didn't have a crash cart, suction, or even a bag valve mask. Her carotid pulse was gone when I checked it. Her fixed and dilated pupils regarded me in glassy peace. I reassured myself that a person with a burn over 40% of the body surface area is likely to die.

I am an internal medicine physician in the U.S. Army completing a 15-month rotation in Iraq. I have no training in burn treatment, and I have never treated a child. Along with the health of my soldiers, I am the officer in charge of the local pediatric burn clinic. We see approximately 35 patients per day with burns ranging from mild to very severe. The makeshift treatment area consists of 2 welded shipping containers. This provides a 20 × 16–foot area out of the elements to treat patients with more serious conditions. Those with less-extensive injuries are treated in the shaded, outdoor waiting area. We are an all-volunteer, all-donation clinic that does the best it can with what it has to help local children. Iraqi hospitals admit and retain patients on the basis of their ability to pay. Parents come to me in desperation from halfway across the country.

On my first day, I also meet Haseed. He is an 8-year-old boy with burns over 85% of his body. He is lying in the litter next to the 12-year-old dead child. His face is a mass of burn, puffy and grotesque. His penis has a first-degree burn from the tip to the base. His body is covered in leather-like, dead skin. Most of his pelvis and the back of his left leg are all that remain unscathed. He is passive, lethargic on his cot. The burned flesh causes a nauseating reek around his entire body. I feel completely unprepared and unable to properly care for this child. Although painful and difficult, I dutifully tell his parents that he is going to die just like his neighbor. You can see the desperation in their eyes, but they say, “Inshala”—if it is God's will. They have faith in my ability to heal their child.

Our time and supplies are limited, but we need to manage his pain. Acetaminophen, NSAIDs, and toradol are the only pain relief at my disposal, and I use them all. I emotionally compartmentalize him as already dead and move on to 1 of the other 32 people treated that day. Much to my surprise, he returns the next clinic day and we treat him, although we expected him to die of renal failure or infection. He returns again, and again. Despite my better judgment, I start debriding his dead tissue and using our precious medication, medical-grade honey, over his entire body. His mood and activity slowly improve; his ability to cry out from our second-rate pain management is a good sign. His parents are ecstatic about the slow change in their son. Three times a week for many months, we spend countless hours and limited resources on his treatment. In many ways, he reminds me of my own sons. He asks me if I have children, and then he asks for my family picture to put on the wall of his bedroom. Against my better judgment, I start to hope.

As of today, his face and chest no longer require treatment. His arms are 80% better, but his legs are still badly burned. He continues to have a poor prognosis, but his improvement is remarkable. Sometimes when we are tasked with the impossible, faith and hope are all we have.

I have recently seen another 15-year-old girl with burns over 80% of her body. She has just recovered from having blood in her vomit, feces, and urine. She has started eating and drinking well. Inshala.