| Features | Autumn 2008 |
The Still Small Voice All residents dreaded the burn service. The adult ward was bad, but the pediatric ward, known as the Shrine, was far, far worse. The Shriners Hospital in Boston served as the major center for most pediatric burn victims along the eastern seaboard. Its burn service, which the surgical residents had grimly nicknamed Crispy Critters, was the closest thing we could imagine to hell on earth. There, dozens of mutilated, suffering children huddled in one somber, sorrowful building. On my first day, the head nurse led me to the intensive care unit to see the big burns—“the eighty-percenters or higher.” Before going onto the unit, we had to don masks and sterile scrub suits with hoods. As the translucent glass doors hissed apart, we entered into an alien world—an encampment. The room was bathed in the purple glow of ultraviolet lights. Each child was surrounded by huge plastic drapes designed to wall out bacteria. Devices made whining, sucking, and bubbling sounds, a robotic chorus that rose up around each swaddled form. Each child resembled a mummy; only the shape outlined beneath layers of dressings hinted that a child might lie buried within. Had it not been for the frenzied activity of the machines, there would have been nothing to suggest the larval forms were even alive. I had never seen so much suffering concentrated in one place. How would I get through the rotation? It seemed unendurable. The nurse led me out of the ICU, known affectionately as Mummy World, and into Camp Chronic, the ward where survivors eventually arrived for endless rounds of reconstructive surgery. Here the children became living clay as surgeons practiced the dreadful artistry of reconstructive surgery. And here the children began to emerge. Like geologic formations, they became sedimentary, surgical layers, recording each new technical era, one upheaval to the next. It took me weeks to settle in. At first I felt relief whenever I could leave the building and breathe lungfuls of antiseptic-free air. I would gaze at people walking down the street, with bodies like supple saplings and hands as smooth and perfect as porcelain. It amazed me how utterly normal the physical world was outside. Entering Crispy Critters each day felt like being condemned, with my heart drowning as soon as I passed through its doors. After some time, I began to view things differently. Every child became a small, brave experiment in courage, endurance, and improvisation. Gradually, Crispy Critters seemed less like a bleak prison and more like a hybrid of laboratory and chapel. Life had been rendered to molten form. Child after child was recast into an angel and then sent to test the world’s compassion. And we—the outside, unmarred world—repeatedly failed the test. Fallen Angel One angel–child stood out for me. His name was Thomas. His story, like those of so many in the institute, had a grim beginning. When he was about ten years old, he and a friend were playing in the rolling farm country outside Lancaster, Pennsylvania. They walked across fields that were pushing up the green promise of the season’s first corn. From there, they passed through the edge of a family farm. As they hiked, they came across a footpath to the crest of a large hill, upon which sat a tower carrying a high-voltage line. They scaled the tower, which commanded a view of the whole countryside. From its heights, the boys could see not only their own houses but horizons far beyond. What a view it must have been! For a moment, they must have felt like eagles. But Thomas slipped. He fell about a dozen feet and came to an abrupt halt. His clothes had caught on one of the arms of the tower. As he reached up to pull himself off, he touched the power line. Thousands of volts arced through his small body, shaking it convulsively. His body tore loose from its snag, but not before his clothing had ignited. He plummeted more than a hundred feet to the ground, a flaming meteorite. His companion clung to the electric tower, too terrified to move. Smoke rising over the horizon alerted firefighters. They lowered Thomas’s friend safely to the ground. Of Thomas, there remained little that was not burned. Small patches of skin remained intact only in his armpits, his groin, and the folds of certain joints. It seemed as if every bone had been broken. Nearly all his soft organs were damaged and bleeding. No one held much hope the boy could survive. Mercy suggested that dying might have been gentler. Thomas’s life, though, continued to flicker. The paramedics stabilized the boy and rushed him to a trauma center in Philadelphia. There he underwent three operations to stem the internal bleeding. Then a special medical turboprop aircraft flew him to Boston, where an ambulance sped him to the Shrine. He arrived ready to enter Mummy World, swaddled from head to toe in gauze. Intravenous lines poked through his dressings like unruly vines. That was when he became my patient. A Fresh Start In the initial phases of critical burn care, the patient must be covered with new skin. This is accomplished first with grafts taken from fresh cadavers. Although the skin is dead, the thin strips of dermis and epithelium work beautifully as temporary skin. Soon the patient’s immune system will reject the foreign tissue, but, with luck, the cadaver grafts will buy the time needed for harvesting the patient’s skin—the autologous skin—and using it to resurface the body. Thomas’s body had an unusually potent proclivity for rejecting cadaver grafts. While most patients rejected a graft in ten to fourteen days, Thomas would slough his off within five. We’d have to find more skin in the hospital’s tissue bank, then resurface his body again. Each time the procedure required six to eight hours of tedious work to suture the new skin grafts into place. The surgery was painstaking and wearying. Skinning a human corpse and sewing new skin into place like upholstery fabric are gruesome tasks. But we could do little else to save Thomas’s life. He rejected the second series of grafts in just four days. We undertook a third set, and a fourth set. The latter lasted less than 48 hours. It seemed unlikely that Thomas would survive. We simply couldn’t harvest enough native grafts to cover his entire body quickly enough. We were ready to give up on him, more out of exhaustion perhaps than pity. But fate intervened. The boy’s parents had been devastated by what had happened to their son. To be isolated in Pennsylvania, while their son’s life slipped away in Boston, proved to be too much. Thomas’s father, only 42 years old, collapsed from a heart attack and died. Thomas’s mother called to let the surgeons and nurses know her husband had passed away. It seemed just too much tragedy for anyone to bear. But his mother calmly asked whether we would be interested in harvesting skin grafts from her husband’s body. The idea had merit. Thomas’s condition had continued to worsen, and he was slipping deeper into his coma with each bout of graft rejection. His body was already becoming peppered with small abscesses and sites of local infection, signs that the latest cadaveric grafts would soon be shed. But skin from Thomas’s father might not be rejected. It would not be autologous tissue, but it would be close. It was worth a shot. A Kindred Spirit Our surgical team flew to Philadelphia with crates of instruments. It was difficult to imagine any relationship between the gray, cold body of Thomas’s father and the other, near-lifeless body in Boston. Yet we sliced the skin as thinly as we could, packed the translucent strips in sterile plastic bags, and placed the bags inside a refrigerated cooler for the return trip. At the Shrine, more bad news awaited us. During the night, Thomas had worsened significantly. Bacteria were growing in his bloodstream. He was slipping into a terminal, septic coma. We felt like fools, stranded on the beach with our picnic cooler full of skin. It seemed a grim, futile joke. In the coffee-break room at Crispy Critters, we debated endlessly. Should we just freeze the father’s skin and keep it in the unlikely event that Thomas survived? Finally, hope prevailed. The senior surgical attendings made the decision: We would cover Thomas with his father’s skin. That morning we removed all the dead graft tissue covering Thomas. Painstakingly, over the next eight hours, we quilted his father’s skin onto him. The grafts looked lifeless and gray. I had little confidence. By dinnertime, we had finished. Fresh bandages in place, Thomas’s comatose body was wheeled back into its slot in Mummy World. His vital signs seemed stable enough. We knew he had survived considerable surgery, but we had doubts about his physiologic reserves. I went into the call room and fell asleep instantly. I had been on the move for more than 48 hours. Only seconds seemed to have passed before I woke up, angry and disoriented. A nurse was pounding on the call-room door. I looked at my watch. I’d been asleep for only two hours. Thomas was probably dying. Maybe his heart had already stopped. I steeled myself. We’d done everything possible. It was time to let go. I opened the door. “It’s, it’s Thomas,” the nurse stammered. “He’s, he’s trying to talk!” That simply wasn’t possible. Thomas must be having problems with his ventilator. She’d misinterpreted his respiratory efforts as an attempt to talk. Hadn’t he been in a coma for nearly a month? I ran to the ICU. Not only was Thomas trying to speak, but he was also moving all his limbs—something he’d never done before. He was fighting his bandages and constraints. It must have been extremely painful, as many of his fractures hadn’t yet healed. But the efforts were unmistakable. He was trying to pull out his endotracheal tube. I slipped my hands inside the plastic-encased arm ports, reached around his throat to undo the knot, and deflated the small balloon at the end of the tube. Then, daring more than hoping, I pulled the tube out of his mouth. He coughed violently a couple of times. Suddenly, he spoke. His voice was perfectly clear. “What happened to my father?” No one had uttered a word to Thomas about his father; he’d been unconscious the entire time. The nurses looked at me. It was my responsibility to answer. After all, I’d been the one who’d removed the boy’s endotracheal tube. I decided to lie. “Nothing has happened to your father, Thomas. He’s just fine,” I said. Thomas looked at me in confusion. “Are you sure?” The boy was completely lucid. “Yes. I’m sure. He’s fine. He’ll be glad to hear you’re getting better.” Today, I deeply regret that lie. I should have told him the truth right away. I was a young resident, though, and I didn’t know better. I thought I was being kind. But Thomas knew something was wrong. “My dad’s just standing there at the end of my bed. Why doesn’t he say something?” There was the hammer blow. For a crazy instant, I blanked out what had actually happened. The father’s death. The harvest of skin. Then reality returned. Thomas must be seeing someone through the plastic, a distorted silhouette that reminded him of his dad. I looked around. No one was there. Just the drapes and the lights beyond. “Thomas,” I asked, choking back tears in disbelief, “where do you see your father?” “He’s standing right there,” he answered, staring at the empty foot of the bed. “Hi, Dad!” he called out, and he feebly attempted to wave. One of the nurses choked back a sob. “Thomas, your dad passed away,” I said. “He died three days ago. He had a heart attack.” I could see the shock registering within, even beneath so many layers of bandages. Then I heard him whisper something. I leaned over. “That must be his ghost then that’s waving back at me,” he said softly. I knew then that what Thomas saw at the foot of his bed was his father’s spirit. Here was my own fragile moment of awakening. It left me tingling, as if sparks were dancing off my skin. Body and Soul Thomas improved. He didn’t reject his father’s grafts. And over the next month, a researcher at the Massachusetts Institute of Technology announced a new research method to harvest epidermal cells. The patches of skin required for this experimental technique were exactly like those Thomas still had intact. Harvested cells from these patches were taken to the laboratory, induced to grow, and spread atop a layer of denatured collagen. Eventually, the cells would coalesce on the collagen sheet, which could then be grafted directly onto the patient. Since the original cells were all derived from the patient, there was no risk of immunologic rejection. Thomas was among the first patients to undergo this procedure. His survival was, in effect, the culmination of a long sequence of miracles. As the months passed, Thomas grew strong enough to graduate to Camp Chronic. There he endured the usual series of surgical revisions. His fingers were gone, and his reconstructed hands looked like something akin to lobster claws. His new nose—constructed of fat and muscle from his scalp, then covered with a graft patch of skin—was more a piece of fleshy caulking than elegant reconstruction. It covered a terrible gap, irreconcilable with our usual notion of facial symmetry and composition. But Thomas was alive, against all odds. And his spirit was clear and bright. If anything, Thomas’s spirit shone brighter than those of others. He became indomitable. Where hundreds of kids had faltered, he would not. He was adamant about returning to public school outside Philadelphia. Then the prosthetic shoes on his feet failed. Both legs became infected, and he needed to have bilateral amputations below the knee. It took four more months to learn to walk again. But he did, and then he asked to return home, back to school. It took seven more years to complete my neurosurgical training. I didn’t see Thomas again until the last day of my final year as resident. I was on the elevator. In the corner stood a horribly disfigured, diminutive person. I suddenly recognized the attractive woman standing alongside him. It was Thomas’s mother. Thomas didn’t remember me at all, but his mother did. She bragged that he was an honor student now. And she wept as we departed, telling me how grateful she was for what we had done for him. Thomas waved goodbye to me with a misshapen hand I had probably helped build. But as he waved, he smiled at me. A big smile! A real smile! The smile of someone genuinely happy to be alive. Then I realized I had received a great gift on this last day of my surgical training. I had been brought into a great, full circle. I had seen the hell of Crispy Critters. I had learned to see beyond the burns and the deformities to the real children who lived and thrived there. I had been permitted to experience the transformational moment when the spirit of Thomas’s father had come from beyond the realm of the flesh to intervene, to protect, and maybe even to guide us as we took care of his son. Now I had been permitted to grasp the miracle from beginning to end, its entire sweep across time and space. As I saw Thomas smile and wave, I reminded myself that I had been permitted to watch the mortal threads of my life interweave with the strands of the spiritual powers in Thomas’s life. The trip had lasted precisely the span of my eight-year surgical training. That could not have been mere coincidence. I understood, for the first time, that the filaments of my own existence were inextricably interwoven with Thomas’s, his father’s, his mother’s, and those of a host of other individuals. An idea began to take shape: I could see thousands of orbits, mortal and spiritual, all spun from the luminous fabric of creation. My eight-year-long adventure was not just the story of a surgical residency. It was a message: We’re never solitary mortal beings. Supernatural comfort is all around us—like the spirit of Thomas’s father—and never leaves us alone without divine strength and protection. But without the certainty of our link to the supernatural, the burden of our individual existence can make us crazy. Thomas’s experience made me realize that suffering is the background, the context, against which we discover love’s power over death, over illness. Suffering is what lends love its supremacy over death. Allan J. Hamilton ’82 is a professor of neurosurgery and a clinical professor in the radiation oncology, psychology, and computer and electrical engineering departments at the Arizona Health Sciences Center in Tucson. This essay was excerpted and adapted from Hamilton’s most recent book, The Scalpel and the Soul: Encounters with Surgery, the Supernatural, and the Healing Power of Hope, by arrangement with Jeremy P. Tarcher, a member of Penguin Group (USA) Inc., copyright©2008. Photo: Mr. Means/Stone/Getty Images |
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