In the Line of Fire (Oh Brother)

What drugs will not cure, the knife will; what the knife will not cure, the cautery will; what the cautery will not cure must be considered incurable.

– Hippocrates

A call from the surgical residence in the outpatient clinic informing us of a new admission to the ward. “It is a burn case,” he warns, “Najwa Abdul Hadi, female, in her early 30s, transferred from a local hospital with burn injuries covering nearly 90% of her body following the explosion of a cooking gas container at her home.” Mohammed and I, the two junior doctors on the floor, rushed to the other side of the ward, impatiently waiting at the service elevators to receive our new admission. Only days into our surgery rotation on the second floor of Baghdad Teaching Hospital—Iraq’s largest referral hospital and medical complex—we had finished medical school a month earlier, in May 1997. This was our first job as “real” doctors. Unlike Mohammed who had studied medicine at another med school, I had spent the past 6 years of my training in this teaching medical complex, and was familiar with the ins and outs of the hospital. Still, this was a new terrain for me. No longer a student, this night was my first time “on call”, and I was getting a bit anxious.

For many of us who lived through the first Gulf war, the sight of a burnt body became a doppelgänger of that war. One such doppelgänger was the charred body of one Iraqi soldier in the carnage of tanks which littered what became known as the “Highway of Death”—where the retreating convoys of thousands of Iraqi soldiers from Kuwait were attacked by the US military with Depleted Uranium (DU) weaponry. DU was developed in the US during the Cold War era and experimented with for the first time in real combat during the 1991 Iraq War. It was designed to burn through thick metal surfaces, namely tanks and fortified armored vehicles. The artillery tips burn through the thick alloy, incinerating them inside and out upon impact.

Another image of that war, which I witnessed for myself, was the silhouette of two skeletal remains fossilized into the concrete walls inside the famous Amiriya Shelter, where 408 people were killed with so-called bunker busting, “smart bombs.” US pilots nicknamed them “the hammer” for their massively destructive capabilities and wide-ranging blast radii. I visited the Amiriya shelter in 1991 after the cessation of the bombing campaign. I remember thinking that it was a blessing that those in the bunker did not suffer for long. It was more merciful and dignified to die on the spot than to endure the effects of surviving such brutalization.  

Medicine’s relationship with burnt flesh is multifaceted. Burning is both a pathology and a technology of healing. Doctors care for burn wounds and have developed specializations around its therapeutics. On the other hand, as a technology, the use of cauterization is an ancient therapeutic technique that dates to the Greeks and is widely used in local healing traditions like Galenic and Arabic Medicines. In modern surgery, high electric currents are regularly applied to bleeding vessels during operations to control and stop hemorrhages. Heat cauterization technologies are also used in cancer treatment, alongside radiotherapy, applied to tissues to kill cancer cells and allow the organs to regenerate themselves. Today, doctors can insert a very thin catheter through the body’s vascular system and guide it to the site of localized malignancies. Then, the radiologist will release small nano pallets through the tiny vessels to “burn” the localized cancer tissue with utmost precision. An intervention radiologists described to me as applying a small “nuke” to the affected tissue.

Burn victims need special care and management. The skin is the largest organ of the body. It is responsible for regulating the body’s temperature and protecting it from external factors like chemicals and bacteria. A burn is like a wound, a precarious openness to the outside world. Burn victims are at risk of dehydration as the body begins to lose more fluids through the compromised skin. Infections may ensue as the body becomes exposed. Burn units are designed with the highest sanitation measures to maintain a protective environment, supply the patient with intravenous fluids, and apply different techniques of burn care to keep the affected parts moist and clean. Burns could scar into contractures, a shortening of skin and muscles that lead to deformities and rigidity of joint mobility. Doctors opt to surgically release the scarred tissue and transplant muscles and skin from other parts of the body to facilitate restoring functionality and cosmetics.

It was an unusually hot June day in Baghdad. We were still weeks aways from Iraq’s hottest month of the year, which residents call Aab el lahhab, or flaming August. With such extreme heat and no proper ventilation, the ward would become increasingly stuffy come the midday sun. The air-conditioning system had been turned off for almost seven years, a casualty of America’s 1991 “Desert Storm” and subsequent sanctions.

Patients, their escorts, and the hospital staff, desperately sought any breeze from the floor’s open windows to no avail. Abu Ali’s family, in room 5 brought their own punka, electric fan. Suad’s sister in room 7 used hospital folders to move the hot air, and flies, away from her face. On days like this, I want to tear away my medical gown and do my rounds shirtless. On my break, I would use some of that Iraqi perverse innovation, a response to our chronic scarcity under sanctions, and buy a huge block of ice, throw it in the hospital’s roof water tanks, and dip in it for hours. The joke went, “With such heat, no wonder Iraqis are not afraid of God’s hell.”

The door slid open. I saw Farhan, the manual operator of the hospital’s crumbling elevator system, struggling with Adnan, the ER nurse, to move the stretcher out of the elevator’s door without hitting its edges. The staff at the emergency room had made a makeshift tent over her body to protect her frail skin. The fading white color, yellow stains on the sheet, made it appear unclean. This sheet was obviously past its glory days, the smell of cheap cleaning detergent from the laundry room lingering.

At the time, this hospital did not have a specialized burn unit. Given the situation of the collapsed infrastructure, the entire hospital had become an ecology of major risk for patients as infections ran amok. Most of the quarantine, sanitization and sterilization equipment were compromised or had ceased to work. Doctors were reusing disposable gloves and needles and we had no clean water. As an alternative, the admitting physician opted to isolate Najwa on our “regular” floor. While each room on the floor would usually host 6 patients, Najwa was lucky enough to be put in a room on her own.

It took me some time to adjust to the overwhelming sight of the scalded body. From head to toe, Najwa’s brown complexion was scraped, leaving red and black patches of burnt skin the color of a rotting pomegranate. Her face was disfigured beyond recognition and most of her hair, including eyebrows, was consumed in the fire.

For close to a week, and to little avail, Mohammed and I tried to manage the burns and ease her pain. Najwa rarely spoke to us in conversational terms. She was restless and in constant agony; moaning and screaming in pain and anger, sometimes expressing herself through seemingly incoherent words. she was trying to tell us a story that none of us understood, or maybe cared to listen to. We were too concerned with keeping her alive, sedated and hydrated. Mohammed and I alternated on caring for her body daily, washing it with soap and water, changing dressings, and replacing the IV line when the skin around the needle showed signs of infection. We used every antibiotic we were able to get hold of to boost her body’s ability to fight back.

Najwa had no visitors, except for her brother Ahmed. I learned that she had three children, though I never saw them, nor did I ever meet her husband. Ahmed was a pharmacist and was in and out of the floor daily. He was devastated and spent hours next to his sister. He would leave to bring her medication and come back. With the scarcity of medical supplies at the hospital, Ahmed maintained the daily stock. He showed up every morning with a plastic bag full of medical provisions that he either brought from his private pharmacy or purchased on the black market.

I arrived at the hospital in the morning to take over from Mohammed. He was on call the night before. I found him finishing up his morning rounds. We walked together as he started filling me in with patient updates. “Najwa died last night” he said as his voice struck a sad note. I felt the weight of the news. It was not a shock, we both expected this outcome; she had been running an uncontrollable fever for the last seventy-two hours. We both had put so much effort to take care of her. This ephemeral relationship with patients was something we were becoming accustomed to both as doctors, but more so as caretakers working in such a depleted setting.

A week later, I saw Mohammed in the floor’s corridor. He brought up Najwa for the last time, “Did you know that Najwa’s burns were not due to an accident?” He stared at me inquisitively. “They were self-inflicted,” he continued, “she tried to kill herself.” Suddenly everything made sense. Self-immolation was a very common method of suicide in Iraq, especially among younger women. Mohammed went on, “Had I known this, I would not have put so much effort in taking care of her. This is against God’s will, it is haram.” I knew Mohammed was a religious person, but his words fell on me like those merciless bunker busters. We had a heated argument about his sentiments and mine, but were unable to reach any kind of understanding.

That night, I was on call. I did my rounds, went to have a bite, and returned to my room on the floor. That night, I slept like a baby. 

*Excerpts from Forthcoming book manuscript, “When Wounds Travel: Ecologies of War and Healthcare East of the Mediterranean”