Intensive Care

Intensive Care is an interesting concept at UTH. The first time I set foot on there 18 months ago I was shocked by the lack of nurses, lack of sedation for patients (who were tied down lest they remove their breathing tubes), the lack of facilities, the lack of equipment, the lack of resources, the lack of oxygen, the lack of drugs, the lack of peace and quiet with the alarms blaring at every conceivable minute of the day… the list is endless, as were the problems…. My abiding memory is that the first 8 patinets I’d admitted there all died there. It was pretty demoralizing. I don’t think I’d ever had that many patients die in a month before.

  But this is now. The sign remains as a pretty stark reminder of what the general consensus of opinion was about going to ICU. But after 18 months when there has been a considerable increase in the input by anaesthesia – supplying an MMed trainee there on a daily basis in the week, and the institution of a daily consultant ward round. Things, surely, must be better.

Tell it how it is I guess!

Beware the fairy tale ending I guess, it was more like the Brother’s Grimm when I walked through with Dave on my first day back at UTH (Monday) where there were 3 nurses to look after 8 patients – ok, not the usual 1:1 ration, but still maybe a 1:2 ratio. But no, they were rooted in the same spot as they always were to be found – sitting at the desk, chatting and playing on their phones. Not a single nurse next to the patients and the alarms pinging wildly.

A typical example of the ICU - patients in the beds and no nurses to be seen... apart from the one sat by the main desk. But the floor is gleaming due to cobra polish!

Infection control is taken very seriously - see the note above the patient's bed 

One of the regular ICU 'admissions'

When we approached (bearing in mind Dave is a consultant on the ICU) and asked politely if one of them wouldn’t mind attending bed 4 – we were greeted with a brief raise of the eyebrows before normal business was resumed back into the phone screen. We were both astounded. Though it is interesting that when the hospital matron came striding in they got up off their chairs in unison like some sort of African Mexican wave as if they’d been scalded. It added a whole new dimension to ‘jump to it’. It seems that matron still wields some power but it seems that she only wields it as long as she and her starched uniform and hat are in the vicinity. They soon sat down when she left!

So Thursday I thought I would go and spend a whole day there lest that brief snapshot had coloured my experience. Within minutes of starting the ward round however there was a great cuffuffle as a patient was unceremoniously dumped on the bed. No prior warning or consultation. He was struggling to breathe and thrashing around wildly in a confused state.

Malaria life cycle for those interested in seeing how it spreads! 

  We gleaned that he had tested positive for malaria and that we was in his early 30’s . Now there are 4 types of malaria carried by mosquito’s. However in Zambia they only carry Falciparum – which is the worst type to get! So, he had signs of cerebral irritation (essentially the malaria had penetrated the brain) but his lungs were also full of fluid and he couldn’t breathe because the malaria had caused his kidneys to stop working and they were unable to excrete any urine and hence the build up of fluid were filling his lungs and constricting his heart.

  We treated the fluid in the lungs as best we could with a water tablet and some morphine. There wasn’t any nitrates in the hospital in any shape or form (to dilate the blood vessels to reduce the workload for the heart). He was too wild to tolerate a tight fitting mask blowing high pressure air into his lungs to keep them water free, to be honest he was too wild to be left without about four of us by the nedside making sure he didn’t roll off the bed such was his agitated state. So we were left with choice but to put him to sleep and take over his breathing that way. That at least was uneventful after the Mmed managed to clamp an oxygen mask over his face and hang onto it whilst he was lying on his front, naked with his bottom on show to everybody on the unit as he’d managed to completely disrobe himself by then.

 After intubating he seemed to stabilize so we sent blood tests to the laboratory, ordered an xray, wrote up his antimalarials and went back to start the ward round. However as we started back we noticed that the heart tracing (ECG monitor) was getting wider and wider – to the extent that it started to look as wide as my little finger. Uh –oh.

He looked like this when normally he should have a rhythm like the one below

This was likely to be his potassium levels being very high. So we treated those with calcium (an antidote) with insulin (that drives the potassium out of the blood stream into the cells of the body), we couldn’t use a nebulizer as that didn’t fit on the ventilator. At this point we still didn’t have blood results back. In fact we didn’t get them until 2 hours after we had sent them – pretty standard. They confirmed indeed that his potassium was high when we took them – 6.8 mmol/l (who knows what it was when we treated it 120 minutes later!), however his sodium was low at 106, chloride too and his creatinine was circa 2150. The reagent for urea was not working, but to be honest we didn’t really need that as it was likely to be high also! So imagine my surprise amongst the non-availability of key drugs like nitrates that Dave picked up the phone and spoke to the kidney doctor (who is also one of the co-opted ICU bosses now) and arranged for him to have kidney dialysis! Bonkers!

  HOWEVER, this is not as easy as it sounds…. Usually it means putting in a special line and then the machine is wheeled to the bedside and the patient is hooked up and away we go. Oh no, not here! There is a dialysis unit. It is however up a flight of stairs and the furthest end of the corridor away from the ICU. So cue ‘operation take patient to the dialysis unit’.

First you have to call the oxygen guy who turns up with a small bottle of oxygen for transport – one of only three little bottles in the hospital. Then ideally you wait until everything else – i.e. drugs and equipment is ready before you disconnect him straight from the ventilator on to a hand ventilating bag system…. Ideally. Here is seems you turn off the ventilator, then realize that the essential bit of kit i.e. the hand ventilation bag isn’t there, but now as you’ve turned off the ventilator and the oxygen cylinder there is a bit of a wait to get that turned back on again, meanwhile a nurse is slowly (I’m not sure she even reached first gear) walking to see if she can find the hand ventilating bag whilst the patient becomes bluer and bluer. You get the message! Anyway, eventually the bag is found and he is hooked up and all the normal parameters are restored.

MMed transferring patient using Lifebox monitoring en route (yellow box on patient's abdomen)

  I was curious to see the process of the transfer so went along to see. Firstly you have to travel down the concrete corridor using only the Lifebox pulseoximeter as your monitoring. A great, portable device that gives oxygen saturations and also the pulse and a reassuringly loud beeping tone which is saving thousands of lives throughout the world, but its not so great when its in the direct sunlight of the corridor when you can’t actually read the screen – so we were very thankful for the beeping noises. However I discovered another useful purpose of the pulseoximeter when we eventually got to the only working lift in the hospital – it provides a sliver of light – which is a darn sight more than the total pitch darkness that we were plunged into as the lift doors shut and we ascended up a floor. Thankfully we made it to the top and weren’t stuck in a total blackout!

Getting into the lift

 Anyway the next step was a bit of a workout, pushing the bed up a slope was about to commence with some repetitive stops to lift the trolley over the gaping holes in the concrete joins. It was like circuit training just with higher stakes.

Uphill pushing

 But then lo and behold we arrive at the dialysis unit! We are directed to bed number 10. It seems you are not allowed to come to the unit unless you have been tested for hepatitis B or RVD (retroviral disease/HIV). It seems that we were positive for Hep B but negative for RVD so we had to go to the specific machine. They keep this system to prevent any miniscule chance of contamination and spread- it seems to work well. I was amazed to look around and counted at least 8 people there on dialysis. Three of which were children. Apparently they can dialyse up to 14 people in the morning and another 14 in the afternoon. This is great and I’m sure life saving/prolonging to many people.

Plugged into the dialysis machine

  And it looked like it would be plain sailing once we got there. The staff seemed to be very competent and were busy sorting the machine out… except of course it takes time to get the machines set up during which of course his potassium level had started to climb again as was evident from the changing ECG pattern again. To the extent that the ECG was now so incredibly wide and he was having runs of VT (specific heart rhythms that can well pre-date cardiac arrest).  

Thankfully another dose of Calcium slowed them down. My very bright MMed trainee enquired politely where the defibrillator was – in case we did have a cardiac arrest – good thinking. I mean most people with failing kidneys i.e. all of the people that were in the unit have a high likelihood of having high potassium and also potentially heart disease and a defibrillator is often handy in these settings. However we got quizzical looks until we explained it was the heart machine that delivers electric shock – you know like on the telly? It was eventually the obligatory actions of somebody holding two charged paddles and giving an electric shock. That made the penny drop. “Ahhhh, yes..”At last I thought, we are getting somewhere, “yes, we don’t have one”. Oh, said I – do you know where I can get one then please. “Oh yes – main ICU”! Where we had come from! There seems to be only one there and one or two in theatres and that is that. If you have a cardiac arrest on the ward and need an electrical shock I can only presume you either don’t get one at all and you die or your relatives have to be quick at unwiring a nearby plug and trying their hand at DIY defibrillation. 

Anyway we were saved the trouble of fetching it as we got him on the machine and the potassium clearly came down as the heart rhythm went back to normal. He was there for 2 hours before the journey back was commenced – thankfully without a glitch.

  Which is just as well as there were another 7 patients on the ward too. One of which was incredibly sad - he was known as Unknown male. 

He had been in the hospital for 10 days total, 5 of these in intensive care after being found by the police by the side of the road - presumed road traffic accident. Imagine being in hospital for 10 days and nobody knowing your name or who you are. And no family or friends visiting, or maybe even knowing he's in hospital - very sad and sobering.

Anyway after having recurrent fits on the ward they eventually transferred him to ICU who then got a CT head done (this involved transferring him across town to the military hospital as none of the scanners in UTH or in the cancer disease hospital across the carpark that we used to use, function anymore). The CT showed catastrophic brain injuries which cannot be operated on, but as we have him on a ventilator there seems to be a real reluctance to stop ventilating people here. So he remains on the ventilator - a futile exercise for him, nurses and staff. No wonder the nurses have low morale if they care for dead or dying patients all the time. There is a move to try and rationalise these head injury admissions because if there is really nothing we can do then it seems a waste of resources to populate the unit with people who are ventilated until they catch a pneumonia and die. But I'm not holding my breath that this will happen soon.