Every year, around 1,000 patients are admitted to the Intensive Care Unit at Mater Dei Hospital which caters for those requiring urgent medical attention.

83% of those admitted live through their ordeal and make it out alive, the rest die, according to Dr Zarb Adami, who occupies multiple roles in the hospital.

Since critical illness is a sudden traumatising lived experience that affects the sufferer and the family, this in itself may present a situation where one may feel powerless and helpless.

Families unfamiliar with critical illnesses do not know what to expect prior to entering an intensive care unit.

On a personal note, when I entered the unit in my early 20s, around 18 years ago, to visit a relative at St Luke’s Hospital, I got a dolly zoom sensation. Although I cannot actually describe the setting, I likened the surreal feeling to another level I never experienced before. The glowing and radiant white light that shone throughout the unit might have been why I was engulfed with this semblance.

The only thing that gives the dream-like feeling away is the signalling sounds emitted by the machines, which track breathing, blood pressure and heart rates, among other indicators and which keep the dedicated team of specially trained nurses and doctors attending to patients on their toes.

After having interviewed Dr Zarb Adami, I paid a visit to the unit at Mater Dei, this time the only difference was that the signalling sounds of machines weren’t so prominent.

And one cannot help noticing the team of nurses and doctors attending to the critically ill.

Dr Zarb Adami’s career spans a good 35 years but during the last 12 years he has hardly got his hands ‘dirty’ opposed to before when “I occupied the role of an intensivist”. He now is a consultant to the intensive care unit’s team, overseeing the department while also administering anaesthesia to patients. He also chairs all the meetings related to the hospital’s departments.

Basically, he’s got his fingers in many pies.

Asked if he had welcomed the change in roles, he said that the nature of the job, that of an intensivist, “makes people burn out”.

Dr Zarb Adami points out: “Physicians who operate within the intensive care unit have dual roles, fully capable of dealing with the needs of patients requiring such care and that of anaesthesists.”

Asked if children are admitted to the ITU, since the Neonatal Paediatric Intensive Care Unit (NPICU) caters for children requiring urgent medical care, he says: “Normally we admit children over three years old but at times we are forced to bend the rules and admit younger patients, depending on the nature of the trauma, mainly children involved in serious accidents.”

He says that the harshest of cases admitted to the unit are those who sustain extensive burns.

“Unfortunately, overwhelming injuries such as burns produce poor results in terms of survival since the percentage of damaged skin affects the chances, despite our efforts to save such patients.

“It is a heart-rending situation for the ITU team when faced with such cases,” he says.

Dr Zarb Adami says that the unit attempts to save other patients who either sustain gun-shot wounds, ones involved in industrial and traffic-related accidents, and those who encounter major postoperative complications, and occasionally foreign patients who require intensive care whose country of origin is ill-equipped to deal with critically ill patients, such as North Africa.

He highlights that Malta is not too keen to receive such patients due to “our limited resources” and when these patients stay for a long time it “deviates our line of work”, such as performing major operations.

He continues: “We accept foreign patients when it’s a matter of life and death and the patient is left with no choice but to seek treatment here.”

One would say that the greater number of complex machines a patient is banking on, the more serious the illness. Is this true, I ask Dr Zarb Adami.

“Yes. The ITU is a place where patients suffering from a reversible failure of an essential bodily function are admitted; a special area which hosts a concentrated team of specialised doctors and nurses and where patients, to some extent, bank on artificial life-support machines.”

Giving an overview of the machines the unit has, he says that certain machines take over the function of the lungs and kidneys while others help the heart function better, apart from the intravenous feeding methods used.

“These machines are backed by a dedicated team of professionals.”

When asked what is the best thing that happened to him in his career concerning his patients, Dr Zarb Adami says that “as much as it’s sad when you lose a patient, you walk 10 feet tall when a patient was about to lose his life and recovers as a result of the care we provide,” likening the situation to accomplishing one’s dreams.

He adds that it is pleasant to see young people taking up the challenge to become intensive care specialists.

“We have a most comprehensive training programme which includes lectures and tutorials; apart from this the hospital plays host to a patient simulator.

“A computer-controlled dummy is used as a ‘patient’ which can go into cardiac arrest, talk, can be treated for a lack of oxygen, allergic reactions, and the list goes on.

“Trainees, who are filmed throughout the episode, are placed on the spot to deal with a sudden electricity failure in the hospital as well, for instance.

“After the episode is over, trainees are requested to view the video footage and are debriefed on their performance. This helps them identify where they went wrong and how they can improve their skills next time around.

“It is an important component for trainees to build both competence and confidence in a safe environment,” he says.

Dr Zarb Adami adds that the hospital runs specialised courses on cadavers to learn how one can alleviate pain in patients by blocking nerves.

The intensive care department’s mini-lab also hosts a machine which is capable of producing blood test results in an instant.

“What we're talking about is getting results on six or seven blood tests within minutes, a machine which is very accurate.”

Anyone who has undergone a battery of blood tests knows how long it takes for results to be produced but this machine enables intensive care unit doctors to analyse blood in minutes.

Dr Zarb Adami explains that every ITU shift is staffed by 16 nurses while six consultants work weekly shifts and resident specialists work on a 24 hour basis, with two changing shift every day.

He says that after having spent a week in the ITU, intensivists return to give anaesthsia.

Asked what the main role of an intensivist is, Dr Zarb Adami says that intensivists coordinate all the care.

“In certain countries physician-surgeons run intensive care departments but it is anaesthesists who normally run the show, as is the case in Malta.

He points out: “The father of intensive care is Bjorn Ibsen, who was an anaesthesist.

It all started by aneasthesists following the 1952 polio epidemic outbreak in Copenhagen.

“This is when anaesthesists sought ways to improve the survival of patients who had been hit by the epidemic.

“When I visited Copenhagen in the 1980s I found that patients that had been stricken by the disease were paralysed but still alive by means of artificial ventilation… and this was 30 years after the epidemic struck; it was highly interesting how they looked after the patients,” Dr Zarb Adami said.

The department, which comprises 85 doctors, of whom 63 are specialists and 22 are trainees, is the largest department within Mater Dei.

“Something we are proud of is that the department was given an anaesthesia teaching recognition award by the European Society of Anaesthesists (ESA) who came over to Malta specially to present us with the certificate of excellence.

“There are only 50 other hospitals in Europe that enjoy this certification.

“Other awards include the Gieh ir-Repubblika medal (National Order of Merit) and other achievements related to the control of infections.”

The unit has been acknowledged for managing to keep the department free of Methicillin-resistant Staphylococcus aureus (MRSA) - a bacterium responsible for several difficult-to-treat infections in humans – for 300 consecutive days.

Normally, the National Order of Merit is awarded to individuals and not groups, but due to their sterling work as a team, both the ITU department and the Armed Forces of Malta Maritime Squadron had been awarded this prestigious medal.

Turning to one of his roles, that of an anaesthesist, he says that today, the mortality as a result of anaesthesia is three in 100,000 worldwide opposed to 30 years ago which was 300 in 100,000.

“Through the use of better equipment and training, there have been drastic improvements; this didn’t happen by accident and the numbers were reduced due to the cautious approach being taken,” he says.

Asked if he ever switches off after a day’s work, he replies in the negative.

“The only way I switch off is when my children turn to me to help them solve a big problem; my mind switches to another problem but never switches off,” he jokes.

He confides: “When we lose someone under our care, we carry out an examination to establish whether we could have done better; this examination is either done privately or in a group.”

He adds: “Personally, much of my work has been taken up by the running of the hospital, a role I was assigned around nine months ago when I was appointed a member of the senior executive management team.”

Questioned about the importance of technology in the ITU department, Dr Zarb Adami says that technology allows us “to better care for our patients and has been with us for years” but cares to point out that the first artificial kidney was developed in Nazi-occupied Holland in 1943 while the first successful kidney transplant was conducted in 1954 and the first heart transplant in 1967.

Asked when the first heart transplant was conducted in Malta, he said that the first transplant was performed at St Luke’s Hospital in 1996, still rather late when considering that the first heart transplant was conducted in 1967, nearly 30 years before.

Questioned if he is highly involved in the end-of-life discussions with families of patients who are on life-support and what the procedure related to organ donation is before ‘pulling the plug’, Dr Zarb Adami emphasises that a doctor’s job is to act in the best interest of the patient at all times when it is obvious that the treatment being given has become burdensome, where hope no longer exists, and the patient could be suffering as a consequence.

“It is also the doctor’s job to ‘let die’, not kill.”

The difference is that if a doctor administered a drug like cyanide it’s intended to kill, but if a doctor decides to stop administering antibiotics to the patient, nature would take its toll.

“This is done after the patient would have undergone a number of antibiotic courses, to no avail.

“Sedatives are not intended to cause death but doctors are aware of the fact that sedatives can have other effects, however the secondary effect is not intended to kill but to alleviate discomfort and which may kill in the process,” he explains.

He reiterates that doctors do not pull the plug on any patient who is alive; patients in intensive care can die while their heart still beats, while they are still warm and their body still produces urine but the brain is dead.

“It is in such circumstances that organs are retrieved for transplantation.

“After the organs are removed, it is then that the ventilator is switched off; we only switch the ventilator off on a patient who is pronounced dead,” he stresses.

He takes umbrage over the way the media portrays the situation, that doctors literally pull the plug and the patient dies as a result.

“It’s far from reality,” he says.

Dr Zarb Adami recalls a case where a patient was on a life-support machine for six years.

“Sadly, the patient never recovered, however we did have patients who depended on such machines for months on end and recovered.”

Dr Zarb Adami stresses that they transfer patients whom they feel do not stand a good chance of surviving to other wards which provide long-term care or to hospitals such as St Vincent de Paul, but patients they strongly believe have a good chance of recovering are kept at the ITU.

He refers to a particular case where a Gozitan girl was admitted following a horrific traffic accident.

“She has been on life-support for three years and her mother lives around her; in my opinion she has no chance of revival.

“We discussed the issue with the girl’s family but to no avail; other centres would let go but since we are sure of the fact that the patient isn’t suffering, we do not insist on our point of view.”

On a positive note, Dr Zarb Adami recalls a case of a patient who was admitted to intensive care who they were sure would eventually recover.

“When he was about to be transferred to another ward after months of treatment which did not produce good results, the patient woke up and kissed his mother, to our astonishment.”

Asked if there’s a time-frame when doctors decide to let go, he says that when the team believes that treatment is futile, then the emphasis changes from fighting to get a patient’s life back to letting go.

“Obviously, relatives of the patient along with ethicists help us doctors execute a decision.”

An ethicist is a person who specialises in or writes on ethics or who is devoted to ethical principles.

Dr Zarb Adami says that the hospital’s toughest decision is when they are tasked to decide which patients, out of the 40,000 admitted to Mater Dei every year, should be admitted to the unit.

“The decision comes after we are sure that the patient has a good chance of surviving; on deciding we are aware of the fact that we are about to spend thousands of the community’s money and dedicate a good portion of our resources to fight for the patient’s life,” he says.

Towards the end of the interview, Dr Zarb Adami says that the politicians have had their say on what is wrong with Mater Dei Hospital and now it’s their turn to air their views on the matter. He says that the debate which was aired on the State television station’s discussion programme Dissett is only the tip of the iceberg.

“Most things that happen in the hospital hardly make it to the press, our achievements and how we have reached them, such as the mortality rates tied to the administering of anaesthsia which have been drastically reduced,” he laments.

“We constantly conduct analyses to reduce mortality rates to the bare minimum,” he adds.