The ICU

I just finished two days of call in the ICU. AIC Kijabe Hospital's ICU has five beds. It is reserved for the sickest five people (adults, children, or babies) in the hospital. Many other patients would qualify for ICU care, especially by American standards, but since there are only five beds the five most ill that have a reasonable chance of surviving get the beds. During my two days in the ICU all five beds were continually used.

Miriam was brought to our hospital Friday night from the Somali refugee camp in northern Kenya. Somalia has no government and it is anarchy there right now. The UN has a camp at the Kenyan-Somali border for refugees from the violence. Miriam, 38 years old, started noticing her foot hurting and changing colors a several days before coming. Over the last 3 days the gangrene that started in her foot rapidly advanced up her right leg. She was evacuated for emergent care. On arrival Friday night she could only talk a little due to the sepsis that had set in. By Saturday morning she was completely obtunded. On examination, her right leg was completely dead. The black skin was peeling off leaving only mildly pink and dying black tissue exposed underneath. This process extended from her foot all the way to her groin.

Miriam was taken emergently to the "Theater" (operating room in Kenya) where the orthopedic surgeons did a complete disarticulation with the amputation extending up to her right pelvis. She barely survived the surgery. She was returned to the ICU under my care late that afternoon. Despite all anesthetic being worn off she was completely comatose. We left her on the ventilator. During the evening her blood pressure plummeted despite IV fluid resuscitation and four different antibiotics to fight the systemic infection that was throughout her body that started in her leg. Extremely high doses of vasopressors were required to maintain a safe blood pressure. When I left the ICU about 11:00 pm things were tentatively stable.

At 3:00 am I received a call that she had no heart rate. I ran to the hospital from my apartment and performed CPR with the nurses for a half hour. Despite the CPR and multiple medications, she never regained a heart beat. At 3:35 we stopped CPR and pronounced Miriam dead.

We called her gentle, Muslim family over to the ICU from the guest house. As they entered the ICU I informed first her brother then her husband that she expired. They made a quick visit with her then started to inform her sisters and other family of her passing as they made their way to the ICU.

Quickly, in the midst of their grief, I could see they were pressed by another priority. In Muslim law, all deceased people need to be buried before sundown. They started making calls to figure out a way to transport her to northern Kenya or Somalia for proper Islamic burial. In their gracious and kind way they had two questions for me: first; could they pay the hospital bill later because they couldn't afford it right now and in Kenya bodies are not released until the account is settled. Second, could they get her right leg which must be buried with her according to Islamic custom.

I made a call to the medical director of the hospital and these issues were quickly resolved. They were the most patient, kind and gracious family I have seen in a long time in such trying circumstances.

Unfortunately my two days in the ICU had many other difficult stories. I hope to share them when time allows.

Mitch