I have spent the last few days in self-isolation with, by the grace of God, mild symptoms of Covid-19. A tickly cough, a few aches and pains. Like a vast number of Britons, I have felt lonely at home, but my overwhelming feelings have been of guilt and frustration. I am an anaesthetics and intensive care doctor at a London hospital – my colleagues are on the frontline of the fight against coronavirus, slogging away to help the unstoppable rising tide of patients. I want to be there to help them. But while I am at home, I want to share a picture of what life is like on an intensive care unit (ICU).
I feel wary when I hear the Government talking about ‘green shoots’ – that isn’t the situation on the ground. My last few night shifts have been the most intense of my career to date. We are busier than ever, with increasing numbers of patients requiring mechanical ventilation. Worryingly, I have seen a rise in the number of younger patients who are otherwise fit and well needing our help. It is not simply a case of putting them on a ventilator for a week, then waking them up and sending them home a few days later to carry on life as normal. It takes a long time to wean them off respiratory aids and some need tracheostomies.
We do not have enough ventilators for all patients at the various stages in their ‘Covid journey’, so we have started using anaesthetic machines and smaller domiciliary ventilators. Regardless of experience, doctors and nurses are learning to adapt on a daily basis. It is an alien and frightening environment for some.
No two patients are the same and we have more to learn about Covid-19, which can be challenging and exhausting. I try to remind myself that this is one of the great joys of life as a doctor – and one of the reasons I went to medical school at University College London in 2007.
The conversations we have with patients are difficult. We try, where possible, to use non-invasive ventilation, such as continuous positive airway pressure (CPAP), which could be what Boris Johnson has been receiving at St Thomas’ this week. But when this fails I explain the next steps – mechanical ventilation.
“I can see that you are struggling and the CPAP is no longer working,” I say. “The next logical step is to give you an anaesthetic, pass a tube into your lungs, and put you on a ventilator. Otherwise you will become exhausted. There is a risk that you may not come off the ventilator… You may still die… I do however promise that I will do my best to take care of you.”
What if my best is not enough? I am tired – what if I make a mistake? They struggle for breath, frightened by what they have just been told and the stark realisation of their situation. Some call their spouses to say, “I’ll see you when I wake up.” Many don’t.
Work is like a war zone; we are constantly fighting fires. You have to force yourself to pause and have a drink. The daunting reality is that it is only getting worse. This is not going to be a short, sharp inconvenience to day-to-day life; it will go on for months.
I challenge anyone who says, “you’re a doctor, it’s your job, it shouldn’t affect you”, to spend an hour in my shoes. On a recent evening, my first task on duty was to withdraw life support for a man who had gone into multi-organ failure. We weren’t going to win. Some people think the role of a doctor is to keep people alive, but that couldn’t be further from the truth at times. My job is to relieve suffering, be that through making a patient better, relieving symptoms, or allowing someone to have as pain-free, dignifying and natural death as possible.
With visitors banned from ICU, I was the last voice he heard. I played a soothing song at the request of his family, held his hand and stroked his forehead as he took his last breath. I thought about my father-in-law, who recently died in a hospice, and had to fight back tears beneath the full PPE I was wearing. There was more work for me to do – my shift had just started.
Our ICU is now spread over three clinical areas on two floors. We have enough beds for patients, but we simply don’t have the staff. Nursing is the backbone of intensive care, much more so than the bed, ventilator, pumps, and monitor. There is normally a nurse-to-patient ratio of 1:1 when a patient is on a ventilator. Like other hospitals in the UK, we now have a ratio closer to 1:6. That could get worse. It is not uncommon for patients to deteriorate rapidly and without warning – when that happens you need staff there straight away. We need more nurses and doctors.
I worry for the junior doctors who are being thrown headfirst into ICUs. Having graduated seven years ago, I have seen more patients die than I can count – suddenly, violently and inhumanely, as well as in dignified and peaceful settings. How will junior doctors react to seeing death for the first time, then again three more times within a single shift?
I am also concerned for the retirees returning to the frontline. It is honourable and selfless, but these doctors and nurses are in a similar demographic to the patients we see in our ICU. There have already been reports of healthcare professionals being hospitalised and dying of Covid-19. Rather than helping the NHS in its hour of need, it could end up causing further harm.
As well as a shortage of ventilators, we are also low on infusion pumps, used to administer drugs; specialist ICU beds; scales to weigh patients; and tape measures to calculate their height. This means we are left to guess-timate the quantity of drugs to give patients. Another problem that has been reported recently is lack of oxygen. Medical oxygen is piped around a hospital from a vacuum insulated evaporator (VIE). If the demand on the VIE in one area outstrips supply, the pressure drops and compromises patient safety. Ventilators have alarms to detect this, but on wards where patients are only on face masks, it could go unnoticed until it’s too late. In order to relieve stress on the system, we have to shuffle patients to different parts of the hospital – and thinning out the capacity of intensive care staff.
Accidents can happen – a patient can disconnect from a ventilator, coughing and self-extubating, for example, or a syringe of medicine supporting their blood pressure can run out and go unnoticed. If there isn’t the staff there, they will die.
We try to keep ourselves safe, but many of my colleagues have already gone off sick – thankfully all with mild symptoms so far. PPE should protect us, but it isn’t failsafe. Working in PPE is also hot, tiring, dehydrating and uncomfortable. We all have pressure sores on our faces from the masks. Communication is difficult, as you might expect. After work on the Covid-19 unit, you come home feeling dreadful, much worse than you would on a ‘normal’ shift. Not needing to go to the toilet for over 12 hours is a common occurrence – the patients probably have a better hourly urine output than I do on shift.
The crisis will have long term physical and psychological effects for all of us in ICU. People are putting on brave faces when in fact they are crying inside. I had my first ‘Covid cry’ before the crisis really hit – when I was looking at what was to come, already feeling exhausted. On Wednesday night, after a hellish night shift, I bawled when reading Matt Kelly’s poem, ‘Our Heroes’. Although we try not to let our emotions affect our work, it isn’t always possible. We will use humour – sometimes macabre – to prevent us imploding. Even the most hardened of us are at risk of burnout. At the end of the day, we are human beings.