The Ballad of Tom

Whoever said beauty is only skin deep has never had Toxic Epidermal Necrolysis.

While I was in Kenya, I actually saw 2 patients with a rare illness called Toxic Epidermal Necrolysis or TEN for short. TEN is basically a very severe allergic reaction causing the physical equivalent of a whole body burn. Skin can just come right off in huge thick sheets. TEN even involves the mucus membranes of the individual-their mouth and eyes ulcerated and bleeding-it is truly a terrible disease. Let's say you are fortunate enough to live in an industrialized nation with access to a burn unit-even then you have a 1 in 3 chance of dying from this disease. We of course had nothing even close to an ICU let alone a burn unit. We had just discharged a patient a few days before with TEN who had managed to hold on for several days. The allergic reaction removes a good portion of what protects your body from infection and keeps your fluids and electrolytes inside you. People that die from TEN often develop overwhelming infection or severe electrolyte imbalances and require a good deal of care to give them the best chance of living.

This is Tom.




Seeing someone like Tom come in with such severe disease I knew would be a death sentence-we couldn't even keep the flies from eating his dead flesh, how would we keep him from getting infected. Tom didn't talk to us, and his family did the talking for us-apparently he had been sick and received some antibiotics (penicillin is notorious for causing TEN) and then 2 weeks later had severe burns all over his body practically overnight. While we were taking care of Tom, I learned that the patient that we had sent home with TEN died in her house within a few days and Tom looked much worse. You would pull back his blanket and his skin flakes would create a cloud of dust in the air so that you were terrified to inhale but you kept Tom covered so he would not develop hypothermia.





Every day I would show up in the morning expecting Tom to be dead-but we did wound care as best as we could and gave antibiotics. I remember one day Dr. Hardison coming in and without gloves pulling napkin sized pieces of skin from his leg-showing everyone he was growing new skin underneath. I couldn't believe it when Dr. Hardison said that Tom was well enough to go home-not going home to die like our last patient with TEN. Even with our limited resources and with a disease that kills >50% of patients when they come to a place with low resources like our hospital we still saved him. Look at the after pictures below




It usually wasn't the patients like Tom that ended up dying right away though. Even with a relatively low patient load, I saw a good share of death that month. There were a few that stand out in particular though. I saw one man in the clinic that was there with his brother who had fallen ill in the last few days. He was febrile and apparently had a seizure earlier that day. When I saw him, he had reduced mental status. I also found out that this young man (around 24 or so) was a heavy Changaa drinker (moonshine) and had stopped drinking a few days ago. I admitted him and gave him scheduled valium for what I thought were withdrawal seizures. Within 2 hours of me admitting him, he had a seizure and died. I remember walking in the ward to see if he made it up ok and the sheet was over his head, his brother that was just there with him at his bedside-I tried to think of something to say but was too overwhelmed myself and figured my words would be useless in this situation-so I said nothing. Another patient later was admitted overnight for seizure disorder which Dr. Hardison believed was pseudoseizures because of the truly bizarre way she was behaving ended up also suddenly seizing and dying on us-these were young kids-early 20s at best. I'm used to death being all around me and I accept it as just a part of life we all must face and embrace at the right time-but the people that were dying in front of me had no past medical problems-it was like the helicopter accident in the Twilight Zone movie that killed the actors, life just snuffed like the candlelight and just the smoke remains close to the cold wick until it gathers itself up toward the heavens.

Hard Lessons in Swahili

I will trade you that black pen for a black eye-that's what girls get for trying to learn!

Alivunja kalamu yake ya wino ("ya wino" is actually part of the translation!)

He crushed her fountain pen