After three weeks on the inpatient wards, I felt a longing for my biggest passion in medicine. So, after some strategic phone calls and well-placed visits to the intensive care unit during my time on the wards, I changed colours to join the Department of Anesthesia as one of their critical care doctors in the Marina ICU.

As instructed, I showed up around 9AM on Monday. Compared to what I was used to, 9AM seemed oddly late. On my arrival I was greeted by Illunga, a medical officer of many years’ experience probably around age 50. He was always dressed in a button-down shirt and had a deep voice, and Nthibo, the young surgical resident I met earlier when my patient went into kidney failure; she was chatty, small, and full of spunk. Quickly, they showed me the ropes.

Princess Marina ICU is an eight-bed open ICU, meaning they take patients of any disease process needing intensive level care: medical, surgical, neurologic, or pediatric cases. They are the only government hospital ICU in the whole country. That means eight ICU beds for a population of 2.6 million people.

Talk about limited resources.

The unit was clean and appeared fairly well equipped. Every bed had a ventilator, medicine pumps, and active monitors including blood pressure, oxygen levels, and telemetry of the heart. At the base of every bed was a small table with the chart, and nurses were assigned two patients at a time. The medical officer and the resident split up the list and pre-rounded on their patients before rounds started at 11AM. Pre-rounding meant going to the lab to collect the previous day’s test results, drawing new labs for today and filling out the associated paperwork, assessing vital sign trends as documented in the chart, or making note of clinical events that would change the plan before rounds. Both the house staff (resident and MO) would stay as long as needed until tasks were done, and then one would go home and assign the whole list to the other doctor who would be staying until 8PM to handle issues or see consults. Outside of those hours, there was no dedicated ICU physician in house overnight, but the attending was on call to come in 24 hours a day while the night nurses ran the show.

Nthibo showed me how everything was documented and assigned me one patient for that morning as I got a feel for the unit. I was familiarising myself with everything when I noticed the attending, Dr. Misael, closely studying one of the patients in the corner. He was the Cuban intensivist I met earlier: lanky, with wire glasses, who spoke in broken English. Subtly, almost as if being mindful that nobody was watching, he placed both hands on the patient’s chest and started doing chest compressions. I came over to him. As he saw me come close, he gestured for me to stay quiet and not make a scene.

He continued compressions for close to a minute before he stopped to check her pulse, and then again subtly resumed chest compressions with eyes fixed on the monitor. He stopped after about a minute and checked her pulse again.

‘Ya esta.’ he said. ‘That’s it’

‘Que paso?’ I asked. ‘What just happened?’

‘You see here?’ he asked, pointing to the ventilator. He was pointing to a CO2 tracing. It was low, almost non-existent. ‘This tells me the patient, despite being on the ventilator, has no carbon dioxide clearance; her tissues are not using oxygen. Despite the heart tracings capturing a signal, she had no pulse. I found this when I came in just now. She’s gone.’          

I understood what he was saying. Patients can lose a pulse despite having a relatively normal heart tracing on the leads, we call that pulseless electrical activity or PEA arrest. Unless you have a real time blood pressure or a finger on the pulse, you could miss it, especially if the ventilator keeps going without a hitch. If the blood pressure cuff cycles once an hour, it’s possible she had been pulseless for any amount of time between checks. I can’t say I knew anything about the patient, why she was that sick in the first place, but this is a story I knew well already. Some patients are just too sick.

So throughout the rest of the morning I became acclimated to the rounding structure and how the team operated. We had five patients that required little active management: three brain injuries waiting to wake up, one TB meningitis who was stable and also on a ventilator waiting to respond to therapies, and an eight-month-old with multi-organ failure being managed by the pediatric team. This meant that despite having eight beds in total, we only had 3 ‘active’ patients, one of which just died as I arrived that morning. Rounds were relatively quick.

After rounding, we’d typically get called away to evaluate patients on the wards or in the emergency room to determine if they needed ICU level of care. What I learned quickly, to no surprise, was that our thresholds for action were far different here than in the US. On my first day we got a call to evaluate a woman in her nineties who was developing sepsis after a recent orthopedic surgery. She was in shock with a blood pressure of 70s/50s. When we saw her, she was obese, obtunded and toxic appearing. To give one of our limited beds to a patient with such a poor prognosis was considered an improper use of resources, so the team signed their note saying that the patient did not meet criteria for ICU admission and moved on. This happened time and time again.

In essence, we were gatekeepers. Many of our consults were to say goodluck and not much more. ‘Recommend palliative care, prognosis too poor and ICU admission unlikely to change outcome.’ It’s ironic, because in other writings I have talked about how we offer too much in the US even when we know it’s futile. I had gotten used to taking on extremely poor odds with a never say die attitude, and even though I knew there was a middle ground somewhere, this nearly felt like we had gone too far the other way. There were a few patients at Marina where I remember thinking yes, there’s a slim chance, but maybe we can give them a shot?

‘Our mortality is too high,’ I heard Misael say over and over. ‘Find me a patient we can actually help.’

The next day I did.

I got called to evaluate a patient in the emergency room. It was a patient I had heard about in the outpatient clinic a week prior, a young guy in late twenties with poorly controlled HIV. Not only that, but he had chronically worsening kidney function over several years that his outpatient doctors encouraged him over and over to get treated and he declined every time. I remember hearing one of the medical officers presenting the case to the attending in the clinic.

‘I begged him every which way to go to hospital and he just won’t go. He is swelling everywhere. He can barely breathe. I don’t know how else to tell him that if he keeps this up he is going to die,’ he said.

Unfortunately, on this day it all caught up to him. Either of his own accord or forced by family, he wound up in the Marina ED. Not too shortly after arriving, the ICU team got a call to come evaluate him. Misael was doing a procedure with Nthibo, which left Illunga and I healing to the emergency room together.

Arriving in the ED, it was immediately clear who we were called for. I saw curtains drawn on one of the beds, and personnel bulging from inside. When I poked around the curtains, I saw a young guy sweating profusely, like he was dunked in a pool. His eyes were burning in exhaustion, with arms dangling from the bedrails too tired to move, a non-rebreather was sealed around his mouth and his entire thorax protruded with every breath.

He was sick.

Quickly, the emergency department resident found me, chart in hand, and started telling me about the case. I recognised the story from the clinic. Uncontrolled HIV/AIDS, worsening kidney failure for some time, with new complaints of shortness of breath, sweats, profound weakness, and ambulatory difficulties. Initial labs were notable for low cell counts across the board—common in the context of HIV—and nearly off-the-charts kidney protein elevations. A chest X-ray done on the portable machine in the emergency room showed diffuse infiltrates in both lungs, something which could be from fluid building (not urinating in kidney failure), or an infection.

‘His blood gas is showing a significant metabolic acidosis,’ the resident told me. She was short, with hair braided with colourful beads. ‘We think this is likely mediated by both worsening kidney function and possibly infection. We have called the medicine team and reached out to nephrology to likely initiate dialysis given his poor status, however nephrology would likely only dialyze this patient in the intensive care unit under close monitoring given his clinical status.’

When people go into kidney failure, one of the main toxins cleared by the kidneys is urea, a derivative of ammonia that is generated by the breakdown of nitrogen chains when cells recycle proteins. Urea is highly acidic, and so when it builds up in the bloodstream it can cause the blood pH to decrease, which can cause dysregulation of electrolytes and enzyme dysfunction. One of the ways the body can regulate the pH of the blood when this happens is by attempting to reduce carbon dioxide, which is also acidic. So now, not only was the fluid in his lungs causing him to have poor breathing mechanics, but the respiratory centres of his brain were triggering hyperventilation to help him blow off more carbon dioxide in an attempt to normalise the pH of his blood. The emergency department had already done all the work figuring out what was happening and putting together the plan, now they only needed our help to put it into practice.

‘That all sounds reasonable,’ I said. ‘What was the carbon dioxide and lactic acid on his blood gas?’ I was trying to find out if sepsis was also playing a role given his HIV/AIDS. A high lactate here could have been a hint that an infection may have tipped off the whole process in a previously stable but sick guy. Also, as his diaphragm fatigued, I would expect carbon dioxide levels to start going up, compounding the problem.

‘Our blood gases here don’t measure lactic acid,’ she said. ‘His carbon dioxide was low, I don’t remember exactly what number.

‘Oh okay,’ I said. ‘We can just presume the lactate is high in that case.’

Examining the patient more closely, his breathing was tremendously laboured, and his eyes were nearly rolling back. Both his lungs sounded junky everywhere, with no dullness. His legs had swelling that left a big pit when I pressed my thumb down all the way up to his thighs. Listening to his heart valves was a moot point; there was too much noise from his breathing. His belly was soft. His blood pressure and oxygen readings were okay, but who knew for how long.

‘I agree with everything you’re telling me. I will discuss this with Dr. Misael and also speak to nephrology about coordinating dialysis. Another thing I would consider is intubating him sooner rather than later.’

‘You think he should be intubated?’ she asked. ‘He is still awake and his oxygen levels are okay on the rebreather.’

‘Not exactly,’ I backtracked. ‘This is your patient, and so ultimately the decision is yours, but let me tell you what concerns me. Look at his breathing. Look at his eyes. Sooner or later he is going to fatigue. His oxygen is fine yes, his carbon dioxide is also compensated now, yes, but he is in extremus. Once he starts to tire, that carbon dioxide will climb, and what is now a significant acidosis will rapidly turn to a profound acidosis, and we risk serious trouble. It would be a reasonable decision to take control of the situation early and not late. That is all I am saying, does that make sense?’

‘Yes yes I understand,’ she said. ‘I will discuss this with my attending.’

‘The only thing I would add is that if you do intubate, make sure to turn the ventilator up as high as you feel comfortable. We want to match his carbon dioxide clearance. If you put the tube in and set it to 12 breaths per minute, that’s not going to be nearly enough.’

‘Right, makes sense,’ she said.

‘As of right now I think you have everything covered, you have given antibiotics to cover for possible sepsis. I will discuss the case with Misael and come back. Is that alright?’

‘Yes of course’ she said. ‘Thank you.’

‘No, thank you.’

I went back and presented the case to Misael, who was still involved in the unit, and he agreed to evaluate the patient once he was finished.

‘Hold on any movement for now,’ he said. ‘Just support the Emergency Department if they need help.’

I hopped back over, finding the patient was intubated. He was fully sedated, and with permission from the covering resident I tweaked the settings on the ventilator. This was another thing I had gotten used to doing here for the first time. In the US, it’s nearly considered blasphemy to encroach on the territory of the respiratory therapist and change settings on the ventilator. Here, there were no respiratory therapists, and the nurses weren’t coming close to touching them. All my vents were mine alone, and so I learned a lot about flow mechanics and how to play around with settings. Once I was happy with the ventilator, I turned around to see the nephrologist standing behind me. She was also Cuban.

Never thought I would come across so many Cubans in Africa.

‘I agree this patient needs dialysis,’ she told me. ‘We just need a bed and support from the ICU to get started. I also worry about his blood pressure and wonder if he will even tolerate it, so it would be good to have ICU backup for vasopressors if needed.’

She was referring to vasopressors which are special medicines used to constrict the arteries to increase blood pressure. Those medicines carry a lot of risk and can only be administered in the ICU setting.

‘Of course, we are working on it,’ I answered.

As I finished with her, I noticed Misael had arrived. He was standing straight and steely-eyed. The look on his face was serious. More serious than I had seen before.

‘Where is the chart?’ he asked.

I got it for him.

Not disturbing him, I watched as he combed over the numbers. He had a few questions along the way, but not many. Most of them were about his HIV status and immune function. Then he drifted to the bedside to lay hands on the patient, and listened intensely with his stethoscope. Like an adult to a child, he signalled with one finger for me to come close.

‘We cannot take this patient,’ he said.

My heart sank.

‘I feel like his primary issue here is acute renal failure,’ I answered. ‘Which is a reversible disease process with dialysis…’

‘I’m sorry, Juan,’ he said. ‘This patient has a very poor prognosis.’ Again he raised a hand, counting finger by finger. ‘Renal failure. Respiratory failure. AIDS. Sepsis. Intubated. He will die here. Maybe not everywhere, but here, in Princess Marina ICU, he will die. He will get an infection. He will have an event with dialysis. I know it’s hard, but we have to accept it. This is not a patient for us.’

‘Okay,’ I said. He could tell I didn’t like it.

In all likelihood, Misael was right. His likelihood of death in our unit was sky high. Still, I felt he deserved a shot. I dealt with it and nodded. This is why I was here, to learn.

He was 27.

Misael then pulled the emergency department resident aside and gave his recommendations. Palliative care. Not for ICU. I felt bad, we essentially gave them no direction to go. Now the patient just stays in the emergency room and they wait for him to die? Didn’t seem right.

Still, this was Africa, the rules of engagement here are different. Everything here was limited. Our antibiotics were out of stock half the time, our beds were precious, the lab ran out of reagents for standard tests on a regular basis, and the scanners were always broken. At Pennsylvania Hospital we would have thrown a million dollars at him just to see that one percent chance fail to manifest. This is the fundamental reality of work in low resource settings. Some people die when they shouldn’t, and many of them never even get a chance.

I thought about this on my walk home that day. The sun searing my neck didn’t seem to bother me as much this time. Misael’s comments sat with me. ‘Maybe not everywhere, but here, in Princess Marina ICU, he will die.’ At first, I thought I understood what he meant, but I didn’t. It was only after spending more time in the unit that I did.

This was only the beginning.