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A Letter

from the ICU

A Letter

from the ICU

A doctor working on an Intensive Care Unit (ICU) in a London hospital reports from the COVID front line.

All this talk of ‘easing’ the lockdown fills me with apprehension. I lack the expertise to comment on political matters but I’ll speak from a place I know: at the foot of your hospital bed, wearing cobbled-together PPE, struggling to keep you alive.

In January 2020, news of a novel coronavirus trickled in from Hubei province. Me and my colleagues in a major London ICU were complacent. Like with SARS and MERS, it felt tucked away; happening ‘over there’. It wasn’t until my night shift on March 5th, when the duty Consultant Intensivist relayed the shocking hospital statistics coming from Italy, that reality struck me. Out of 2000 hospitalised COVID patients, 250 of them were being ventilated in intensive care.

This meant over 10% of Italian hospital admissions required respiratory support. Such numbers seemed unimaginable. In the ICU I normally care for four patients at a time; how would I cope with intubated patients in unending rows? And with healthcare staff dying, exposed to greater viral loads than the general public, many of us started writing our wills.

As a doctor in ICU, I am your last port of call. For every intensive care bed there’s a plethora of expensive and complex equipment for organ support (not just ventilators but kidney filters, monitoring devices, syringe drivers etc) and frequent assessments by ICU doctors, as well as nurses, physiotherapists and dieticians. It isn’t a setup designed for scaling up; but from the 60 beds in our trust, we were now ordered to magic up to 300 beds. Healthcare staff of every stripe were redeployed en masse, our working schedules were intensified, and surgical theatres, specialist wards and even waiting rooms were transformed into COVID units.

War metaphors aren’t terribly helpful; for one, I didn’t sign up to be a soldier or to risk my life. But there are times where the imagery that evokes feels appropriate. I remember, as COVID cases started mounting in late March, seeing multiple body bags leave our unit as I started a shift. Never had I seen so many deaths at once in my career. All our patients were critically unwell, many younger than expected: first in their fifties, then in their thirties and twenties. Patients of all ages, even some without previous medical problems, dying from what naysayers were calling ‘just another flu’.

The main condition precipitating a COVID admission to ICU is Acute Respiratory Distress Syndrome, where the lungs fail to oxygenate our blood due to widespread inflammation. But patients with COVID can also develop kidney failure, severe blood clotting and fragile hearts that require significant organ support. The government’s fixation on ventilators has masked other vital issues: the lack of haemofilters for kidneys, nurses to maintain the golden ‘one-to-one’ ICU ratio, and anaesthetic medications to help keep ventilated patients appropriately sedated.

And PPE has of course been a huge problem nationwide. As an ICU doctor, I am most at risk from contracting the virus (it is shed in copious amounts by ventilated patients and during procedures involving the airways), and so I am prioritised PPE access. But even then, it quickly ran low at the beginning of the outbreak, and I was instructed to purchase my own goggles (hiked up to four times its normal price) and reduce toilet breaks in order to keep using the same gown. Outside the ICU, medical wards were not even getting gowns and masks. And our trust fared better than most.

I am at a loss when asked about my feelings on the crisis. Some days I feel like a numb worker who must simply carry on. But when the nation watches press briefings where a thousand deaths are breached, I try to dress those numbers up with a human face; the seventy year old, a previously healthy man, who caught COVID and died from a heart attack; or a woman my mother’s age, braindead after persistent oxygen deprivation, whose family requested I whisper in her ear ‘your family love you and will bring you home’. Some days I have come home and cried, imagining my loved ones in their place. Behind every statistic is a heart-breaking loss, and it jars to see that reduced to a chart.

What I hope the public remembers is that we aren’t gods or heroes, but painfully human. We have lives outside hospital too, and families. Being a member of Generation Rent, I’ve been lodging at my parents’ house to save up for a mortgage, but now I fear for them both. Terrified that I could bring the virus home, I’ve had no choice but to isolate myself in the garage bedroom which has a separate exit to the road. I’ve lived in this tiny space, alone, separated from my loved ones and my partner since the middle of March; were it not for Skype and Facetime, I’d have gone mad. Of course, many young people are similarly cooped up, frustrated and alone, and not all are as lucky as me to have a stable income. But splitting my life between near complete isolation and fighting COVID on the frontlines, with all the responsibility that entails, has felt a bitter pill to swallow. It has become my entire existence.

Yet, in the end, we are told that we coped. We were not rushed off our feet. The NHS survived the great first COVID wave, ICU capacity outstripped need, and the Nightingale hospitals are barely occupied. COVID admissions have fallen over the last fortnight and my shifts are suddenly easier. So why, despite having the highest number of deaths in Europe, were we not as deluged as Italy or Spain in our hospitals?

The jury’s still out, though I suppose it boils down to our rapid organisation and preparedness as we tracked Italy. What we could not tolerate in the NHS was the possibility that an eligible patient may be denied intensive care due to a lack of beds. Also, the majority of COVID cases in Italy were concentrated in Lombardy; similar numbers may have similarly overloaded our NHS had they been in one region only. And care home deaths – a patient group we would never see in intensive care – factors into this too.

But this raises an important question when it comes to the handling of the pandemic response: is the provision of surplus intensive care beds ultimately a false reassurance? Regardless of medical effort, a large number of patients died anyway, and will continue to die, and the only way we could have avoided this was to lock down sooner. So it stands to reason that the most effective way of avoiding future deaths is not to ease lockdown too early.

As a doctor, it’s difficult not to feel like a scaremonger. Continued lockdown measures risk deepening the recession, which in turn endangers lives; but I have seen the pandemic at its worst and know its capable of much more. We were ‘ready’ the first time, and over 30,000 died. Can we afford to lose that number again?

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