At 0430 this morning, my phone rang and dragged me out of sleep. With my mucus-filled, allergy-sleep-voice I had a brief conversation with the on-duty intern about a patient who had just been admitted. It was a twenty year old man who had sustained a high-voltage electrical burn 48 hours earlier. The resident informed me that his right hand and left foot were necrotic (dead), extending up to mid-forearm and mid-lower leg. However, he was alert and had normal vital signs. There was nothing immediately life threatening going on. I groggily told him to get the patient admitted to the ICU, start some IV fluids and control his pain. I would be in to see him at the usual time in two and a half hours.

I hung up and rolled over with selfish musings about why-on-earth people who were days out from injuries always seemed to show up in the middle of the night and why-on-earth the resident couldn’t wait one hour to call me about a totally stable patient. (My wife will corroborate that I suffer from a delusion that the entire world is in collusion to always thwart and irritate me.) An hour later, the hot shower coaxed me back to the remembrance that the real world is a lot bigger and more profound than my dinky little sphere. Over in our ICU there was a poor soul whose life was thoroughly jacked up (well beyond interrupted sleep…) and that resident was seven months into his training and doing exactly what I told him to do; i.e. call me with new admissions. You know, the Bible says that God has promised I will someday be conformed to the image of His Son. I long for that day and confess I’m still a long way out.

I later saw the young man in the ICU. He was alert and fairly comfortable. He had been working on a roof and touched a bar that was touching a power line. From the middle of his right forearm out, it looked awful. The skin of his arm was like hard plastic and looked like dull leather. His hand was clawed and the fingers were black and hard. The current probably entered through his thumb. What flesh remained on the thumb was hanging off the bottom knuckle, black and charred. The bone beyond that was sticking out, exposed. It looked like a little rod of charcoal. There were additional deep burns on his elbow and up his upper arm, but the limb looked salvageable there. His left foot was a similar story. From the middle of his lower leg out, the skin was leather and hard. His foot was blackened and charcoal hard. There was no feeling or function in either the hand or the foot. They were dead. Again, there were additional burns elsewhere, including his right foot and left hand. But his heart seemed clinically OK and he was making urine.

We talked with him about the situation and explained that we needed to amputate the dead extremities. We would do our best to save as much as possible, but we had to remove the dead tissue. What happened over the ensuing hours is a common story here. He was polite and quite, but stated that he needed to talk with his family. We told him we would return later.

Later, one of the residents spoke with the patient and his family. He was told that they were not willing to have surgery. I then returned to the ICU to talk with everyone. As I came in, the nurses rounded up the crew and soon we were all standing around the patient’s bed: me, the on-duty resident, four or so nurses and about twelve family members, including the father. I asked them if they had decided on a plan and the father informed me that they wanted to take the man home. I explained that we were certainly not going to do anything against the patient’s will, but before a decision was made, I wanted to make sure that everyone properly understood the situation. With the resident’s translation, I explained the medical facts of the situation, including the reality that it may be life threatening if he goes home with a dead hand and foot. Again, the father, family and patient listened politely and without interruption. The father then repeated that they were going to take him home without surgery.

In Ethiopia, the shemagalay (old man) is in charge. When the father speaks, the decision is made. He holds the purse strings and he calls the shots. Sometimes, I’m shocked at how open the fathers can be when talking while standing at the bedside of their alert family member. They calming and plainly state their intention to take the patient home to die. And the patient calmly and stoically listens with agreement.

I then pushed further and asked the patient himself for his decision. The young man agreed and said he wanted to be discharged. Both he and his father verbalized back to us their understanding of the medical situation, including the high risk to his life. But they held to their plan. I asked why. The father explained that with a missing hand and foot, he was as good as dead anyway. They would take him home and if he lived or died, it would be up to God. We prayed with him and the family and discharged him from the hospital.

Over the years, I’ve seen this played out many times. There are lots of variations, but it is usually the same theme. This time we had the luxury of an alert adult patient who could clearly articulate his understanding of the situation and his wishes. Often, though, it is a baby, a child, a severely ill person who cannot communicate. I have become aware of an invisible threshold in the care of our patients. My instincts are getting better at sensing its approach. But is it is always evident when we cross it. We are simply informed by the family that it is time to quit and take the patient home.

My thoughts on this, especially from a Western viewpoint, have gone through several changes. I often get reminded of how much I am changing when I hear comments from our visitors. The usual tendencies are to explain such behavior in one of two broad camps, or a combination of both: cold-hearted callousness or ignorance. Because we’re Western, we tend to gravitate away from then mean and toward the warm and fuzzy. Therefore, we prefer to focus on ignorance. It’s nicer and the remedy seems so much easier. (Of course, though we won’t verbalize it, we still note the cold-hearted callousness.) We once had a medical student visit us and observe how patients tended to wait until their condition was far advanced before coming in for care. And when they did come in, they tended to bail when the care would be long and drawn out. Our med student explained this in terms of ignorance. He felt they didn’t know enough to come in early and receive effective care when it was simple. Shoot, even I fall prey to that. My explanation of the medical facts of this man’s dead hand and foot were certainly to assure informed consent was taking place. But there was also a concern that they really understand, “Hey, his foot and hand are dead… they’re not coming back.”

But let’s show some common sense. They’re not stupid. You don’t need much schooling to know when a disease is bad. When a woman shows up with a twenty pound tumor in her breast, she didn’t finally come to the hospital only when a PhD on the street told her she needed care. This man’s family knew perfectly well his hand and foot were dead. I once had a patient on my medical school inpatient psychiatry rotation that, true to form, was crazy as a loon. Her foot was dead but, thankfully, her body had walled it off so that she wasn’t systemically ill. But her foot was just sitting there; black, shriveled and stinking, waiting to rot off. But she insisted that her foot was fine and adamantly refused amputation. Everyday my job was to round on her, sprinkle some more peppermint oil on her dead foot which was stinking up the whole ward, and ask her if we could amputate her foot. She would then yell at me that her foot was perfectly fine and tell me to get the h-ll out. (Delightful rotation…) But this man, and his family, knew perfectly well that his hand and foot were dead.

So we’re back to cold-hearted callousness? Well, I don’t think so. I do think the real answer relates to some open-eyed decision making. But I don’t think it is cold-hearted or calloused. By the way, I’m too realistic to idealize anyone; Ethiopians included. While I recognize some bad decisions do happen for the wrong reasons, I will also assert that most of the time people are just doing their level best to play their cards well out of the lousy hand that was dealt to them. Many of my patients face a starkness of reality that the average American cannot understand. They are forced to do some hard math in which there are no easy answers. And, frankly, I think most of them do it with honor and courage.

Real poverty is a horrible situation. I do not know what it is like to choose between two loved ones. What do you do when you literally only have the resources to either care for the sick and dying one or feed the healthy ones at home? There is no safety net here. There are no bank loans, no WIC coupons, no food stamps, no welfare, no government lunch. Yes, there is a societal back up where neighbors help neighbors (this is usually how Africa works). But we usually hear about the dilemma once those resources have been used up.

No, far from ignorance, I think the ugliness of poverty generates some very aware but difficult decision-making. When your back is against the ledge you have to play your cards with discipline. So you put your buck where it will deliver the best bang. So sometimes you say no to the sick and dying so that you can maintain the living and productive.

I look at my patient from this morning and recognize that he and his family are in a horrible situation. He is from a poor farming family. As a young man in rural Ethiopia, labor is the most realistic chance he has at living a life. Living here, in this situation, with one hand and one leg is a daunting thought. It’s so difficult.

This is very foreign to our average Western minds. We haven’t been in that situation and it’s hard to grasp it. But it really gets ugly when we start rendering judgments based on our assumptions. It is so tempting to get outraged at a father or mother who would take their baby home to die when care was available. What kind of parent are they!? Don’t they care!? The shocking and humbling truth is obvious. Of course they care. But they’ve been forced to do the math. In one hand, they look at a sick child for whom they have a choice of gambling most or all of their meager resources for a chance (no guarantee) of improvement. In the other hand, they look at the healthy remaining family who will likely do well should those resources be sent their way. With all the aching, agonizing pain you can rightly imagine, they make the call. They play their cards the best they can. That is the deep, deep evil of poverty.

And that is also where we can really jack it up. At the time where they are making one of the most heart rending decisions we can imagine, we call them ignorant, cold-hearted jerks. Our Western sensitivities are simply sizzling and righteous anger spews forth! Sigh. God help us all.

It is humbling to be brought face-to-face with the raw world, to see how small you are and how little you really know. I wonder how much of our generosity (and the pride that goes with it) flows from our surplus. It is so much easier to champion the causes of the weak and downtrodden, to say we’ll do everything for the least of these, when it only threatens our luxuries. I’m reminded of the story from the Bible where Jesus goes into the temple and observes a rich man give a large offering from his surplus and then a poor widow give her meager gift, yet her all. It seems Jesus was more interested in what each person held back than what was given. It’s an awfully complicated and overwhelming world out there. I certainly haven’t found any pat answers. There is no easy formula. God calls us out in different ways and in different flavors. But I’m confident that all of them involve sacrifice, dying to self. Day’s like this encourage me to reevaluate and look for what I’m holding back. I pray that He would give me His grace and mercy and generosity.

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