As the world grappled with the COVID-19 pandemic, intensive care units (ICUs) and hospitals in high-income countries were faced with the potential for limited access to lifesaving equipment, trained staff, and essential supplies. Hospitals and ethics committees set up plans to allocate ‘scarce resources’ such as ventilators, dialysis, and extra-corporeal life support. As the pandemic has eased and ICU censuses have returned to near-normal, it's easy to forget that healthcare providers in low-resource settings face daily challenges that go far beyond the pandemic-related limitations encountered in higher-income countries. My experience at Adama Hospital Medical College (AHMC) at the beginning of 2023 in Ethiopia highlights healthcare providers' difficulties in delivering critical care every day.

Walking into the ICU at AHMC, I felt like I had been transported back to the worst height of the COVID-19 pandemic. It was chaos, to say the least. Patients were crowded into every corner of the room, mechanical ventilator alarms and patient monitors were going off left and right, and Healthcare providers were running around frantically, trying to keep up with the demand. When asked what the greatest barriers were to caring for critically ill patients, they cited strain not just due to the volume of patients but also due to a lack of trained healthcare providers, functioning equipment, and medications.

It was a far cry from the organized health system I was used to in the US. In the US, the healthcare system is like a well-oiled machine. Barring the peak of the pandemic, lack of bed availability is rarely a barrier to accessing critical care. In the US, there are about 34 ICU beds per 100,000 people. In Ethiopia, there is 0.3. Even within those few ICU beds, there are significant limitations to providing high-quality critical care. In the US, equipment is standardized and frequently updated or replaced as newer models become available. Clinicians are rigorously proctored and trained through in-services and competencies when taking on a new role or adopting a new piece of equipment. Healthcare providers utilize evidence-based order sets to support the delivery of best practices. Equipment is maintained and repaired by biomedical engineering departments and company representatives to ensure it functions appropriately. But not so much in AHMC.

Though lifesaving, the mechanical ventilator was the bane of the ICU. Each ventilator was from a different manufacturer and had its own user manual (if the manual could be found). The ventilators were constantly malfunctioning but could not be replaced. One day we would be fighting with a Philips ventilator that would decide to stop working right after we intubated a patient, and the next day we would be wrestling with a VG 70 that alarmed continuously for no identifiable reason. It was a constant battle to keep those machines running. The ICU staff had to rely on their ingenuity and quick thinking to keep patients alive without adequate biomedical engineering support. Ventilators are expected to undergo preventive maintenance every six months or approximately 2,000 patient hours to function optimally. These ventilators were assessed only when they ceased to function. Other advanced respiratory support equipment known to decrease the need for intubation, such as bilevel ventilation and high-flow nasal cannula, was simply unavailable.

Even when the equipment was functioning, another significant barrier was a lack of trained staff to manage the ventilators. Over 130,000 certified respiratory therapists (RTs) in the US provide expert care to ventilated patients. Most will manage about 2-8 ventilators at a time outside of the peak pandemic. At AHMC, there are no RTs; in fact, there is only one RT program in Ethiopia, which was started only recently. About six RTs work in the capital city with a population of over 5 million. Without a respiratory therapist to assist, nurses and physicians, many of whom are insufficiently trained as there are few intensivists in the country, must manage all aspects of mechanical ventilation. A pervasive need for adequate diagnostic equipment further hampers them. Most US-based physicians would only think of adjusting mechanical ventilation guided by readily available diagnostic tools (e.g., blood gas analysis, end-tidal CO2 monitoring, pulse-oximetry, and measures of respiratory compliance). These measures were only sometimes available. It was almost impossible to implement mechanical ventilation in patients without worrying about complications and the safety of patients. Indeed, the ICU mortality in Ethiopia likely exceeds 50%.

However, despite the challenges, the staff persevered. The AHMC ICU staff has become experts at troubleshooting and repairing those machines, sometimes even using spare parts scavenged from other equipment. It was like being on an episode of “Survivor: Medical Edition.” Looking back, some situations I found myself in feel almost laughably absurd if the stakes weren’t so high. Like that time, we tried to use tape to prevent an ETCO2 sensor from leaking while working to adjust the ventilator settings of an 11-year-old child. This was the only way to obtain information regarding the child’s CO2 level, as the arterial blood gas machine had not been functional for years. Unfortunately, the tape did not make the ETCO2 sensor work. In addition to a call to a US-based RT for help, we had to rely on other clinical and objective data to make decisions.

As the US grapples with unprecedented shortages in the healthcare labor market and RTs are being offered sign-on bonuses of $10,000 or more to ensure adequate ICU staffing, it is heartbreaking to compare the deployment of resources, watching patients die or linger in the hospital from highly treatable respiratory conditions due to the accident of geography. It serves as a stark reminder of the unequal access to healthcare in the world.

Despite the frustrations and occasional comedic moments, the ICU staff at AHMC never lost sight of their ultimate goal: saving lives. In that sense, for me, every day felt like we were in the midst of an ongoing pandemic of resource limitations. As critical care outcomes in high-resource countries continue to improve, the global health community must support high standards for ICU care worldwide. Establishing programs for training RTs is one critical intervention, as are efforts to expand the training of respiratory and critical care physicians. However, this will be of little use without the provision of adequate equipment, both diagnostic and therapeutic, and the means to maintain, repair, and replace that equipment, not to mention the disposable equipment (e.g., ventilator circuits, personal protective equipment, etc) necessary to support it. With attention to the careful allocation of resources, the benefits of critical care can finally be equitably available across the globe.