Fieldset
“Collateral Beauty”: Emergency and emerging humanity in the COVID ICU

When a COVID-19 patient’s oxygen levels start dropping rapidly in Baghdad, Dr Ibie Mohammed and the team have to think fast to save a life…

It was 9:00am in Baghdad, the temperature was already 28 C! 

Thanks to Omer, our Médecins Sans Frontières / Doctors Without Borders (MSF) driver, our team arrived in Al-Kindy teaching hospital (currently a COVID-19 treatment centre) after a one-hour commute from the MSF guest house.

I got off the minibus and collected my personal protective equipment (known as PPE). The gloves, gowns, masks and goggles are vital for medical workers in these times of COVID-19.

Friendly curiosity

At the gate, I fitted my mask before heading through the dusty passage into the busy hospital yard.

The hospital is run by the Iraqi Ministry of Health (MoH). At the time I was working there, MSF has been providing clinical management and training as part of the COVID-19 response project.

MSF has now started operating a whole ward for COVID-19 patients, donating equipment and resources to improve clinical care and what we call "infection prevention and control".

My first stop was the management office, where I dropped off my proposal for the hospital to implement these measures.

Then I stopped to put on my full PPE. Nearby was a lady in a traditional black gown and a younger girl wearing her hair in a bun, then three men and a cleaner sweeping floor. As I put on all my kit, they took turns gazing with friendly curiosity at my curly hair, MSF vest and the unusual activity of equipping PPE.

I smiled back behind my mask. These kinds of silent interactions are a special part of helping me unwind before a shift, so I always took my time putting on PPE unless the team needed to rush!

In the ICU

At the entrance of the ICU, I greeted the guard, “Salam, Abu Mohammed”.  

”Welcome Doctor,” he replied cheerfully, holding the doors open.

Inside, I wiped the sweat off my forehead and nose for last time before fixing the sides of my goggles to the top of my N95 mask.

The busy ICU has 24 beds, all occupied by COVID-19 patients. It used to be seven, but when the Ministry of Health converted this hospital to a COVID-19 centre, the hospital had to stretch to find the extra capacity.   

It was easy to spot the MSF team in their blue PPE gowns. With his turquoise trousers and MSF t-shirt, my nurse colleague was hard at work across the ICU.

And Pedro, MSF’s ICU doctor, with his neat black hood and his green scrubs under a majestic PPE gown. I smiled to myself as I thought that despite the stresses of the job, my team somehow had their own PPE style.

A sudden emergency

The MSF senior ICU staff and I started our ward rounds. Our role was to help to define the plan for the deteriorating patients and inform the Ministry of Health doctor. We also provided bedside training for staff and help manage stable patients to optimise ventilators, all done competently by MSF’s Iraqi doctor and nurses who transferred knowledge and skills impressively among themselves.

I followed Pedro and our team’s Iraqi doctor straight to the left corner bed to review a patient he was particularly concerned about.

She was being treated with continuous positive airway pressure (CPAP), a non-invasive form of ventilation that makes it easier to breathe.  Behind the mask her skin had the bluish tinge that can come with low levels of oxygen in the blood.

In this project, MSF training and medical orders were in progress to upgrade the ICU care level, but at that particular point, there was no capacity to intubate any of the 23 in-patients for more advanced mechanical ventilation.

The woman’s blood sugar was high. And, right as we reviewed her case, her respiratory function suddenly deteriorated.

"She became disoriented today, although I gave her 10 units of insulin after I checked in the morning,” her son explained, worried.

As he was speaking, the numbers on the oxygen monitor kept dropping.

50%

45%

35%

Normal blood saturation levels are 95-100%. Pedro had a listen to the patient’s chest while I rushed to check her airways.

“She’s very obstructed,” he said, starting to work his magic on the ventilator settings.

Working fast to save a life

I adjusted the CPAP mask and tilted the patient’s head.  The figures on the oxygen monitor began to climb again, and quickly reverted to 70%.

Meanwhile, I asked her family to help move her up the bed while the MSF nurse held her neck extended to keep her obstructed airways open.

We needed to reposition her. If we could get her lying so that her head was slightly raised at 30 degrees, it could improve her circulation and help resolve her breathlessness and low blood oxygenation.

But on its own, repositioning might not be enough.

A steroid nebuliser helps deliver anti-inflammatory drugs that help breathing disorders. One of the ICU nurses went to find this immediately!

“We need to prop her up more,” I said, and in a heartbeat, someone was offering two pillows from the next bed over.

I grabbed them and added them to the folded blanket her son had put behind her.

Inflamed and obstructed

Everyone in the bay rushed to help us move her, including the family members of the other patients. Here, patients in the ICU usually have two family members with them, who do all the nursing for their kin except for giving injections etc

However, we asked everyone to keep to a safe physical distance, and explained the situation both to the family and the Ministry of Health nurse who joined us.

Meanwhile, the other nurse returned with only a bronchodilator nebuliser - not quite what the patient needed. In apologetic tone, they explained that a steroid nebuliser was not available!

I explained the urgency of a steroid nebuliser for managing the inflamed and obstructed airways of a diabetic patient going into a coma.

However, the nurse explained that the only way we could get the nebuliser is if the family bought it themselves.

The protocol used by the Iraqi Ministry of Health included providing COVID-19 medications free to patients in ICU. Yet, overstretched resources, the struggle became getting hold of other essential drugs – like the ones needed by this lady.

The kindness of strangers

Pedro and I agreed that an emergency dose of injected steroids (hydrocortisone) could work as a substitute for the nebuliser. But before the Ministry of Health doctor could prescribe it, a lady came over, with an ampule of “PulmiCort” – the exact medication we needed!

“Do you need this?” she said. “It belongs to my dad, but he’s stable right now” and she pointed to the patient in the far corner.

As a person, I was touched by such collateral beauties and humanity in the middle of the COVID-19 crisis, another level of solidarity and care between strangers who met in the worst of circumstances.

In the ICU, family members seemed exhausted and sad, watching their sick and vulnerable relatives. Yet instead of sorrow or anger, when I spoke with them I mostly encountered appreciation for us and selflessness among themselves.

The top image shows the COVID ICU at Al-Kindy Hospital. Please note that it does not depict the patient described in this post.

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