I kept my usual pep as I sauntered into the ICU the next morning. I had spent some time reflecting on my circumstances and how I could help. In truth, I was never going to change anything here. That was never my role. My role was to learn, soak up as much information as I could, and take mental notes on everything so that someday, in the right position with the right instruments, I can understand the inner workings of these networks to bring about meaningful change. Still, even if I wasn’t going to be instilling sweeping reforms as one agent, I could do my best to inspire others through action. So really all I had to do was be myself and care for my patients: a task I was up for. The opportunity to do so came gift wrapped shortly after I walked in.

‘There is a patient on the wards for us to evaluate,’ Nthibo told me. ‘She is a patient who has been here rehabbing after a recent seizure last week, and now she’s having worsening respiratory status and appearing sicker. The medicine team feels she is developing sepsis and may need intubation.’

‘Sounds good. Shall I go and see her?’ I asked.

‘We can go together if you wish,’ she said.

‘Let’s roll.’

Donning our hairnets, we walked outside to the medicine wards. Turning into one of them, we found the intern who had paged us. She was from the Indian subcontinent and spoke with a quiver in her voice, clearly worried about the patient. The patient was in her late sixties, admitted initially for a fairly large stroke one week prior. She was making some progress, now was able to sit up and follow simple commands, but still unable to communicate or ambulate due to the effects of the stroke. Over the last two days she was noted to have become a bit more lethargic and her breathing more demanding. They felt like she was likely developing a pneumonia based on her exam and lab work. After starting her on antibiotics, she continued to worsen with heavier breathing. Her vital signs were okay, oxygen was holding and her blood pressure on the low end of normal, but she looked rotten: sweaty with her eyes glazed over. Even from a few metres away, gurgled secretions rattled in her airway. She had coarse lung sounds on the right side of her chest with absent sounds near the bottom. I wasn’t able to elicit much when asking her to squeeze my hand or give me thumbs up. She was in a bad way.

Examining her case, I tried to think neutrally about her position and prognosis. She had just suffered a severe stroke. Her best baseline several days after the stroke was non-communicative. Her path to meaningful recovery was littered with obstacles even before developing sepsis. Her kidney and heart function were okay, but her lungs and brain were failing. She likely needed a breathing tube, and trying to even get her extubated with a post-stroke brain was going to be a challenge, one that I didn’t think she’d come back from. I asked myself if it would bring more harm to have her plugged into a million things when her chance of recovery was razor thin. Here in Princess Marina, I would not take this patient to the ICU.

Nthibo and I discussed the case and then called Misael. He was already on his way and met us at the bedside. We looked at everything together. Misael surprised me.

‘Let’s take her,’ he said. ‘For now she is stable, we can open one of the beds and intubate her when she comes over.’

I was not expecting that. When and how he decided certain patients should come and others shouldn’t was something I was still figuring out. I got the feeling that his criteria shifted as a function of how much pressure he was getting from up above. Maybe on some days he got more lip about our mortality numbers than others. Maybe there were other silent criteria contributing to his decision making that he couldn’t articulate specifically enough. Either way, we spoke again with the covering intern and agreed to take the patient later in the day once we had a bed available.

Returning to the ICU I stopped by the lab to pick up all the results from our patients from the day before. The front of the lab has two clerks who sat in a windowed admin office resembling a government building where one would file paperwork. The staff would receive and intake blood work inside a cooler designated for each team. If the bloods were not in a cooler they were not accepted, which I found puzzling given none of the coolers had ice packs. I was here to collect results, which meant I was skipping the drop-off line and went to a handwritten logbook adjacent to the clerks. The book had all received labs documented, which was how I could guarantee that the labs I drew yesterday had actually been received and run. With my handwritten list of all the ICU patients, I looked for their names and found most of them with an associated record number. Writing down the record number, I would go through double doors directly into either the chemistry, hematology, or micro labs to ruffle through a stack of papers in a dated box looking for the same forms I filled out the previous day. Of course one or two were somehow always missing, and I had to ask the lab staff for loose records still processing to find them lost in the ether. Collecting a stack of papers across the three rooms, I took them back to the unit and dropped them on the nurses station. By now a daily occurrence, the novelty of the chore had worn off and it was frustrating to have it take up thirty minutes of my morning every day. Still, I did the job with gusto. It was the only way to stay sane. A far cry from the simple click on the computer in Pennsylvania it took to see any lab test I wanted.

Morning rounds were relatively smooth, more things had to be done and they got done. By the early afternoon, the nurses had prepared to receive the new admission. I saw the patient’s medical officer and intern wheel the bed in with our ICU nurses. She looked worse than before, significantly so. Her diaphragm shook the bed with every breath and now she was only hardly pulling away when I tried to stimulate her with pain.

‘What’s the last set of vitals?’ I asked the medical team.

‘We haven’t collected any,’ the intern said.

‘What do you mean?’ I asked. ‘Just give me the most recent vitals you have.’

‘We have the ones from when you saw her this morning,’ the intern said.

‘This morning?’ I asked. Exasperation rang from my voice inadvertently. ‘It’s almost four in the afternoon.’

They didn’t respond.

‘Has anything been done since we saw her this morning? Labs, fluids, imaging?’ I asked, neutralising my tone and setting aside judgement. ‘I am just asking.’

‘No doctor,’ the intern answered.

‘Right then,’ I said, turning to Nthibo. ‘Let’s get her on the monitors. I feel like we should intubate now, do you agree? Do you want to do it?’

‘Yes doc I agree,’ she said. ‘I can do it with Julius assisting.’

Julius, who was in earshot, started getting the materials together. As we prepared to get things happening, the first set of vitals came up on the monitor. Blood pressure was tanking at 60/40, she was going into shock. Her oxygen levels were also low. This was now a peri-code situation.

‘We need hands here please,’ I said to the nurses across the unit and everyone came together around the patient.

We rushed to get her on a breathing mask and the nurses hung two bags of fluids wide open. Nthibo did calculations and asked the nurse to mix a bag of adrenaline to start an infusion. We were going to need a central line for the infusion, and some of the nursing students ran off to get a kit and brought it to the bedside. Feeling for landmarks in the leg, I set up the materials and put on sterile gloves and attempted to get a line. I stuck her twice, following the landmarks just medial to the femoral artery trying to thread into the femoral vein. No luck. Nthibo tried the same on the other side, also with no luck. Our patient was still looking like shit.

I turned to the student nurses.

‘Intubating her in florid shock like this was a good way to make her have a cardiac arrest. Intubation often drops blood pressure since it reduces preload to the heart by increasing thoracic pressure in the chest, so our priority is to stabilise her blood pressure first,’ I explained. ‘Is one of you able to grab the ultrasound from the supply room?’

They nodded.

They brought one over and I tried again, this time with the help of the Wall-E, and was able to thread into the femoral vein sitting directly underneath the artery. We started the patient on vasopressors and her blood pressure responded. Shortly after, we intubated her. We had stabilised her through the worst of it and she was now breathing comfortably on moderate levels of oxygen.

‘Nice work doctors,’ Julius said.

‘Team effort,’ we answered.

I was determined to force a positive outcome with this case, so I volunteered to take the patient as mine. I had seen how they handled these patients here, deep sedation with full assist ventilation. Progress is slow, nobody seems keen to make adjustments except for once a day. I wanted to show how things could be done differently. I pulled the nurse and Nthibo aside to explain the plan after I had written a detailed note in the chart.

‘We have a small window to get her extubated,’ I said. ‘I want us to try a different approach here. I am going to be aggressive. We should keep her on as light sedation as possible, and I want us to use fentanyl instead of midazolam. She should still be awake if possible. Right now she is only minimally sedated, taking her own breaths, and on medium levels of oxygen. I will be looking at the ventilator and the blood pressure every few hours. We are going to keep her blood pressure at target and no higher so we can wean off the medicine. I am hopeful that within 48 hours, if we correct the sepsis, her shock improves, and she is on minimal oxygen, maybe we can remove the breathing tube. Every day that tube stays in, her chance of recovery goes down. Does the plan make sense to you?’

‘All the sense in the world,’ Nthibo said. ‘I understand. I think it’s a good idea.’

The next morning, I came in to find her oxygen levels were at 100%. I went to the ventilator and adjusted the settings. Her blood pressure was above target, so I turned down the medications. I revisited her bed once an hour and kept at it. By the end of day we were flirting with potentially extubating; her pneumonia and sepsis were improving.

As an aside, when it comes to considering a patient for extubation (removal of the breathing tube), broadly speaking three things need to work well, with a fourth caveat. Your lungs need to work, meaning you should be on minimal oxygen, your brain needs to work, meaning to need to be able to follow commands or lift your head up from the bed (this demonstrates you have enough muscle tone to hold your airway open once the tube is out), and your airway needs to work, meaning if you have a lot of secretions or airway swelling, that needs to be corrected. Lastly, the added fourth, your patient needs to have a stable enough blood pressure to tolerate the shifts in cardiac mechanics that will come from removing the breathing tube. If a patient ticks all the boxes but is on rocket fuel to maintain their blood pressure, I don’t want to risk a cardiac arrest.

I repeated the evaluation process the next morning and we were good to go from a respiratory and blood pressure standpoint. I shut off her fentanyl and let her wake up, and she was able to give me thumbs up intermittently when asked. I worried most about her stroke. Yes her pneumonia was resolving, but she aspirated because her brain was goosed and she was a sitting duck to aspirate again. She looked like far less than a million dollars, but this was probably the best we were going to get. In the distance, Misael gave his nod of approval to extubate

Again, I pulled Nthibo and the team aside.

‘If we want to give this lady a shot, we have to extubate,’ I said. ‘She is losing muscle mass and conditioning by the hour, and this is the most fit she will look for us. If she looks okay, we let her ride. If she starts okay and then tires, or aspirates again and gets worse, we’re committed to intubating again and considering if she needs tracheostomy going forward, which for her likely spells the beginning of the end. Being aggressive gets us to this point. We may fail, but we have given her a chance. Dr. Nthibo, do you agree?’

‘I agree,’ she said.

‘Illunga, Julius, Dr Misael?’ I said. I was desperate to deliver us a win after so many losses over the last two weeks.

They all nodded.

‘Every patient is a race against time,’ Misael added. ‘We can try.’

‘Okay let’s do it.’

We all got in position. Julius and Nthibo at the head of the bed with Misael alongside, Illunga and I near the foot of the bed, and one nurse with a suction tube—we went for it. She was extubated successfully around 11AM. We suctioned her mouth and sat her upright. Her head was supported by two pillows and she looked at us taking deep breaths. Her breathing rate was in the high teens and her oxygen levels were fine on a nose piece alone. She looked okay.

‘Now we wait,’ Misael said.

So wait we did. I stayed nearby as we tended to other patients. Slowly, her breathing rate picked up. Within a few hours she was breathing with a rate in the twenties. A thin gurgle was kept at bay with frequent suctioning by the nurse. I didn’t like the look of her to be honest. Still, we weren’t yet in panic mode, and had to give her more time.

I came back around again sometime later and she was looking no better. Julius, Nthibo, and I looked at each other knowing but not wanting to say it out loud. Still, I wanted to delay. I wanted her to make it for the team as much as I wanted it for her. This is the unfortunate nature of work in the critical care setting, sometimes you are desperate for a win and it doesn’t come your way. Especially here in Princess Marina, the wins were so few and far between it felt unfair. In the end we re-intubated her that evening, knowing it would be either in daylight and controlled or at two in the morning when the situation became unstable. We tried our best and gave her every chance, but sometimes people are just too sick.

So as for what my role here really was: despite my patients faring worse than I would have liked, the nurses and my colleagues commented on seeing the value in this more proactive approach. Nthibo told me how it made more sense to her than what was previously being done, and she was going to consider using fentanyl more instead of midazolam because it can be weaned more aggressively. The nurses told me they appreciated the learning of hearing my rationale and being updated regularly on changes in the plan. I had been so onerous with many of them, at times straddling the line between demanding and difficult. The next day was my last in the ICU, and I was flattered at the personal thanks I got from them, some of which I thought just didn’t like me. Thank you for your contribution and education, they said. I still have the letter hanging in my kitchen.

I’d call that a win.