At a little half past eight in the morning on the 25th of November last year I started on the ICU ward round with the team of residents, at the Black Lion Hospital in central Addis Ababa – the capital of Ethiopia. There were sixteen patients to see, with a high proportion of trauma – especially brain injury – and severe life-threatening infections. It looked so different from the unit here in Dumfries. It had big wide windows allowing in daylight, for a start. In a UK hospital, windows at this height would be securely fixed so as to avoid the kind of unfortunate incident that makes the headlines. Here, in Addis, one of the nurses was leaning right out of the window and yelling cheerfully to a colleague in the carpark over a hundred feet below.
As I looked around I took in more differences. The beds were quite close together, with a low wall separating the heads of beds between the divided area. Instead of uniform ranks of identical equipment all bought at the same time, the pumps and ventilators were a mishmash of ancient and relatively modern kit. Huge, head height tanks of oxygen sat beside each ventilator, as there was no built in oxygen supply in the walls. Beside most beds sat a big bottle of caramel liquid – it took me a moment to work out that this was nasogastric feed. Of course! – they don’t have the pumps to delivery a trickle of feed continuously, so they have a supply for the day and administer it at intervals. Each patient’s bedsheets were different, brightly coloured, and obviously donated or brought in from home. Nobody was wearing aprons, or gloves – the bright smurf blue and purple hands of healthcare that are so ubiquitous in UK ICU were nowhere to be seen. I could imagine our own infection control team spontaneously combusting at the sight. Of course, they would likely have already lost consciousness at the sight of an entire team of doctors standing around the bedside in long-sleeved white coats – something which has been verboten in the UK for years.
But then, I looked closer and readjusted. Put into context, they were doing the same stuff we do. Airways were protected. Patients were being rolled, washed, and cleaned every day, with a change of sheets. Physiological parameters were being diligently recorded on big charts in close detail. Because pumps were usually either broken or in very short supply, sedation and analgesia were given by injection at regular intervals. They were being fed – one way or another. Patients were receiving regular chest physiotherapy to try to shift stubborn sputum and prevent pneumonias. Blood tests. The nurses still laughed and joked and teased each other. It’s the same stuff that we do, but in a much simpler, less precise way. And, a lot of the time, it worked. Which, to be brutally honest, is just as true of our own, ‘modern’ intensive care.
I turned my attention to the lady in the bed. Clearly profoundly affected by a severe head injury as a result of trauma, she also had signs of a severe chest infection. Here in the UK, it would be standard practice to send sputum samples off to the lab to identify the offending organism, certain specific blood tests might be done, and a chest x-ray would be a routine investigation in order to see the extent of the infection. I asked if they could do any of those things. Dr. Woubadel looked at me with a wry, slightly sheepish smile. “Well, we can. But we only have two antibiotics and our microbiologists have refused to analyse our sputum samples. And the lifts are out at the moment.”
Right. Wait, what? “You only have two antibiotics?”
“Yes, ceftriaxone and ceftazidime.”
If you don’t speak antibiotic, that’s a little like going to the supermarket and discovering that the only two cleaning products available are napalm and a hydrogen bomb. Given that antibiotic resistance is a real and growing threat, this is a disaster for the future.
And the lifts…. ah. The building of the Black Lion is definitely a little bit past its best, and was undergoing a phase of refurbishment. Almost all of the lifts were removed and in true, relaxed Ethiopian style, there was occasionally a warning sign. I had had a look at one of the lift shafts and it really was an open door onto a seven storey drop. Later that day, I watched a patient being taken urgently to theatre from one of the wards on the floor above the theatre complex. Four orderlies and a nurse were carrying the entire bed – with the patient lying on it – down a flight of stairs. Another nurse was carrying the drip. That morning, if they really wanted a chest x-ray, they’d have to do the same thing if the lift was out as there was no portable facility to take x-rays on the unit. And if need be, they’d have done it.
So why was I there? It’s worth pointing out that the Black Lion is a large teaching hospital in the city centre. It’s one of the lucky ones, as the facilities it has are relatively modern. They can even do cardiac bypass – provided there’s a visiting perfusionist from overseas to work the machinery. This definitely wasn’t one of the small hospitals out in the country. I was there along with Fanus Dreyer, a consultant in General Surgery here in Dumfries, to teach on a critical care course that he organises. The College of Surgeons of East, Central and Southern Africa overseas the training of surgeons in that part of the world, and the critical care course is part of the mandatory requirements of their training. It is a charity – the aim is to make the course (along with the others which deal with surgical skills, and research) self-sustaining in each of the involved countries. The idea behind all of this is to try to improve the healthcare in that part of the world, by standardising surgical training, ensuring basic competencies etc, in an area where healthcare is sporadic and frequently poor or non-existent. Peri-operative and critical care is a vital part of that – being able to competently do an emergency bowel operation is nothing if the patient dies post-operatively from a lack of care.
Being out there and teaching on the course was an extraordinary experience. Having had the chance to spend some time in the actual clinical areas, to see how they worked on a day-to-day basis, helped hugely as it helped give me direction on what the course attendants needed. The junior surgeons on the course had excellent clinical knowledge and ability – the real difference was the approach. They have the same knowledge as our junior surgeons – medicine is universal, fundamentally – but what they needed was guidance on how to organise the approach to sick patients, and how to structure their management. They were highly motivated, and very keen to learn. But as I knew, they would often be working in facilities that had next to zero resources, hundreds of miles from Addis. There’s no value in teaching about the potential uses of dialysis in critical care in that sort of scenario – but there is enormous benefit in teaching about the approach to sepsis. Being able to manage a patient with a critically endangered airway with simple techniques would be life-saving – even in the most rural surgical facilities there will be some sort of scalpel.
And over the two days of the course, in the four days that I spent there, I realised that the simplicity of approach is something that we are still striving to teach here, even with the advanced facilities available to us. Their ICU looked primitive in comparison to the UK, but it was still striving to provide the basics of critical care. I realised I was teaching the same things that I teach here – sort out the basics and communicate well. Recognise illness, recognise dying, and treat each thing in turn, with compassion. These things are universal – and we shouldn’t allow a distraction with technology to cost us our humanity.
Dave Christie is a Consultant Anaesthetist at NHS Dumfries and Galloway
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