When I was in medical school, I got a summer research scholarship to join a lab at the University of Toronto. I worked under a seasoned and clinically retired surgeon with a long research career on sepsis. My research project, compiling publications to generate a database on resistant organisms from hospital acquired infections in ICUs around the world, subjected me to months of mouse-clicking and sore eyes that never found publication. Despite that, I got intimately close with the data on antibiotic resistance in a class of bacteria called gram negatives. One of their key characteristics: the ability to form a self-sustaining matrix (goo, essentially), that protects the bacteria and allows it to stick to organic and inorganic surfaces. The most notable trends I uncovered were the rate at which these organisms were becoming more resistant to antibiotics, especially in low and middle income countries. For reasons that are multifactorial, likely tied to prescription practices and sterility gaps, the low income world has become a breeding groundl for resistant bugs the likes of which we simply can’t understand in the West.

I didn’t either until I worked in Botswana. In Princess Marina ICU it became nearly everything I saw.

One after another, all in the same week, I saw drug-resistant, hospital-acquired infections land patients in our unit. The first was the lady I saw getting silent chest compressions from Misael as I walked in that first morning. That same day, I picked up the patient next to her, a gentleman in his sixties deeply sedated on a ventilator in septic shock after a bladder infection. His blood cultures were growing a bacteria called Acinetobacter, which was resistant to nearly all of the antibiotics we had available except for the mac daddy Colistin, well known for its ability not only to eradicate infection but also destroy kidneys in the process. After fighting for some time, he died of worsening sepsis and renal failure. Then there was the lady in the next bed over, sent to us from the wards after she developed low blood pressure and was found to have an infected catheter with a multi-resistant strain of E. Coli. She was put on a drug called Amikacin, also highly toxic to kidneys. Every day I watched her renal function worsen, readjusting the medicine every morning until she produced no urine at all. We had no choice but to stop the antibiotics and hope for a miracle. We didn’t get one. In the other bed across from her was a patient who came in for a stroke and was doing okay before she aspirated and developed pneumonia. She was growing another gram negative, Klebsiella, also only sensitive to Colistin. She died of renal failure and sepsis. There was another in the room next to her who was intubated for meningitis that suffered the same fate; I’ll spare the details, you get the point. We were fighting a losing battle

It was terrifying. It made me understand Misael’s cataclysmic reservation at admitting a patient with full blown immune deficiency from HIV. Once it settled in, I realised I would walk through the general wards and look at patients differently, like they were all an infection waiting to happen. I would scrutinise more closely how difficult it was to find alcohol for hands, how many sinks were covered with trash bags out of service, how the paper charts were stacked on top of each other on this table and then that table. I thought about how if my father were visiting and had to come to hospital for something simple, a gallbladder, a broken leg, an uncomplicated skin infection, I would tell him to turn around and run 100 yards in any other direction.

Still, they were trying. We had an infection control nurse who rounded and inspected the units at regular intervals. When we grew a resistant bug, the bed was decommissioned and out of use for x amount of days while everything was sterilised. There was an awareness of the problem and attempts made to investigate and help improve the situation, but it felt like a drop in the bucket.

It all sent me back to that summer in the research lab in Toronto, where I sat in the hospital conference room compiling ones and zeroes. Here I was, now five years later, fighting the same beast in a different way, calling families and telling them to rush in to see their loved one before they died from multi-drug resistant sepsis.

One of the ways our team tried to mitigate hospital associated infections was through regular replacement of devices such as lines or catheters. Every week we replaced the central lines regardless of the context or situation. I had placed loads of central lines in Philly, but in the US they were always placed with ultrasound guidance; this was considered best practice. At Marina, the ultrasound wasn’t always available, sometimes taken by the surgeons, so the residents placed the lines the old school way, guided by landmarks. I remember Nthibo showing me her approach on one of our patients. The whole area was blanketed in green blankets and gowns, and I held the needle in my hand as she stood off to the right of the bed.

‘We like the posterior approach here,’ she said pointing. ‘You enter in the neck, just behind the sternocleidomastoid muscle at the level of the cricoid cartilage, and then you angle your needle towards the sternal notch here, feel with your finger.’

I did.

‘Right, now go ahead, I sometimes find you don’t get blood return until you start retracting the needle. Sometimes it takes a while, but you can do it.’

I nodded, and pushed the needle into the skin along the track she had shown me. Following her course, I tried to find the angle, pushing the needle forward, adjusting and re-adjusting as I went. No luck. I tried again, and still had no luck. I looked up towards Nthibo and saw that she had gone.

K, I thought. Just me I guess. Taking a breath I tried again, advancing the needle while pulling backwards on the syringe to create negative pressure. I fished and fished and just couldn’t seem to get it. Then I felt the syringe give and watched it fill with air.

‘Fuck,’ I said.

The syringe is not supposed to fill with air. As a matter of fact, that is the last thing you want it to fill with. If it fills with air there is a good chance you punctured lung.

I pulled the syringe out and set it down. Ok, procedure aborted, I thought. Frazzled, I stood there for a moment. I watched the vitals on the monitor intensely, all stable. I collected my thoughts and thought about the next move. First, I took off my gown and walked over to the ventilator. I took a mental note of the parameters, she was on minimal oxygen, unchanged from when she was intubated. Any increase in her oxygen needs could spell a pneumothorax. Next, I called Misael. He heard panic in my voice

‘Tranquilo,’ he said. ‘Calm down. It is hard to cause a pneumothorax with the jugular lines, the much higher risk is the subclavian site at the collarbone. Keep an eye on the ventilator and if nothing changes I would do no further. More likely is that you poked into the trachea and got some air. This is okay, it happens. You are learning.’

 He made me feel much better. Still, I felt like a Jackass. I was doing a procedure that I didn’t have loads of experience doing and could have seriously harmed the patient. My first oath is to do no harm, and any time something bad happens in my hands I feel responsible. I took my ruminations to Nthibo and she echoed Misael.

‘How are you going to learn?’ she said.

Hard to argue. It’s not like I was out here being reckless. This is Africa after all, the rules of engagement are different. I tried not to beat myself up too much and kept busy with other things.

‘Lopez,’ I heard Illunga boom from the other end of the unit not too long after. ‘Can you assist me with this central line?’

Great, I thought to myself. Another chance to fuck something up or a shot at redemption?.

I came by and gowned up, watching closely at his technique, I was surprised to see that he zigged and zagged far more aggressively than I did. It was uncomfortable for me to even watch. He was at it for nearly five minutes with no luck.

‘Would you like to try?’ he asked.

‘Uhh… There’s no reason why I should have any more luck than you, but sure let me have a go,’ I said.

Again, I found my landmarks, pointing towards the notch and slid the needle in. Again I fished for a while, more nervously this time, and then the syringe filled with dark blood.

‘Ah, excellent!’ said Illunga. His voice shook the whole unit.

With his help I dilated the line and sutured it in place. Glad to get that one back, I thought.

I got to do a bunch more lines while I was there. I did jugular, femoral, and was even asked by the pediatrics team to assist with the help of my trusty ultrasound to place one on a 6 month old after they failed several attempts. Using my usual tools, I got it without much difficulty. Praise went all around. For a day I got to be the hero. Dr. Bozo the superstar.

Still, even with exchanging the lines once a week, we hardly made a dent in the infection rate. So many moving parts that contribute to that set of problems makes it seem nearly impossible to change the outcome. Like I have said so many times, the issues run so much deeper than just alcohol at bedside, or lines getting placed and replaced. It’s an issue to do with staffing, equipment, facilities, and frameworks that are effortful to establish and require motivated buy-in. Where to start, I couldn’t tell you; that’s something I would have to figure out later with a view from higher up. I just felt after a time that with one train-wreck infection after another, it would be impossible to keep faith. The team was desperate for a win, and I was motivated to try and bring one.         The next day I would get my chance.