Jonathan Silver is the Head of Clinical Engineering at a major London teaching hospital trust. These are extracts from a personal account he has been writing of his experiences in an intensive care unit throughout the pandemic.
This article is part of a week of reflection on the past year and what it has meant for individuals, communities and local government. Unlocked: local stories from a global pandemic.
24 March 2020
Been ordered to take a day off today to prevent burnout, having spent eight long days straight at work doing everything possible to prepare for the onslaught of up to 600 critically ill patients to our 60-bed intensive care service.
One thing is clear: we are a facing a situation close to battlefield medicine. We are forced to dispense with our usually very high standards of care, safety and dignity in order to give the masses a chance to survive.
Amazed by the way that people have stepped up without complaint and with such energy, from the (perhaps unexpectedly) pragmatic and caring executive team, to local people and companies eager to donate their goods and their hands, to my indefatigable nursing friends on the front line with barely adequate protection.
Please stay at home.
25 April 2020
Had lots of questions about how it’s going with Covid at work so here’s a quick update from my perspective.
Q: Are things calming down now?
A: Yes and no. Thanks to lockdown (better late than never), the rate of new Covid admissions has reduced dramatically from a couple of weeks ago. We have been able to mothball a lot of our temporary ICU beds. However, over the last couple of days, we’ve seen a fresh uptick and some new patients needing ICU – probably related to non-compliance over the sunny Easter weekend.
Q: It must be much easier for you now!
A: Well, there’s not the panic of a few weeks ago where we were pulling equipment out of everywhere else and using it to assemble ICUs in a matter of hours. Now, for the medium term, we need to restart some routine services, urgently before any waiting patients come to harm, and so we have to decide how to balance rebuilding theatres and other areas with the inevitable reduction in ICU capacity that goes with it.
Q: Is it going to get worse again?
A: Judging by the increase in cars on the road the last few days, we are about to experience a new surge, and it’s not going to be pretty. In terms of the next few months, I have heard that we are anticipating further surges in May, Sept-Oct, and February 2021. In any case, it’s not going away any time soon.
Q: Did you run out of ventilators?
A: No, absolutely not, but we ran out of proper ventilators. The “ventilators” we’ve received from the government have been little plastic boxes intended for providing a bit of assistance to people who snore and forget to breathe in their sleep, rather than for keeping critically unwell patients alive (think needing a car and getting a pushbike).
Q: What other interesting stuff have you been doing?
A: We’re having to use a lot of new equipment in ways that we have never used it, or even in ways it was not designed to be used. This has required a lot of testing, risk assessment and compromises – and has allowed us to answer questions like how to assemble ventilator tubing to get best performance while protecting staff from aerosolised virus and conserving oxygen; what equipment we put in which ICU in order to reach a compromise between flexibility, function and complexity; and calculating how close we are to running out of oxygen, air and electricity across the site and how to prevent it happening.
Q: Is it a case of “too many chiefs”? Are managers and pen-pushers really key workers?
A: Never underestimate the amount of management support needed to achieve anything. Try reallocating several thousand staff to a new rota in a new department in a matter of days. Try and open a new ICU larger than the combined ICUs in three local hospitals – without management to ensure nurses are called in and paid; to assess safety risks to patients and staff; to ensure the electronic medical record can keep up; to arrange a continued supply of drugs, PPE and hundreds of other small items needed to look after patients; to organise cleaning, porters, switchboard, pathology, resuscitation teams; and to monitor the situation on an hourly basis and ensure that we are doing everything we can to meet demand responsively yet conserve resources for when we need it even more.
Don’t forget that pharmacists, physios, occupational therapists and dieticians are needed more than ever. Every ICU patient sees each of them every day, and this is fundamental to getting them better.
We have had plenty of support from the executive team and they understand the challenge as well as we do.
Q: How has it personally impacted you?
A: There were a couple of difficult weeks: 12-13 hours at work every day, followed by 3-4 more hours of management at home in the evenings, five days a week plus about 6 hours a day at the weekend; dealing with 40-45 phone calls a day; sometimes 25,000 steps! Have been able to cope with it thanks to a fantastic group of colleagues who have stepped up wonderfully with enthusiasm, teamwork and without complaint – even people seconded from radiation physics and rehab engineering – who have put in the hours too.
I have had moments of overwhelm; I’ve been unable to string sentences together on occasion and people were stopping me in the corridor to ask if I’d had any rest; now people are stopping me to say how much better I’m looking!
I have seen quite a lot of death, but nowhere near the amount that our true frontline staff have. The thing I find most difficult is that people are not able to be with their loved ones, particularly those that have died or are dying. I have listened to doctors having to break devastating news by phone every day; it’s horrible for everyone.
Q: What has been the mood of your colleagues?
A: Almost unendingly positive. The whole hospital has a different feel to it, mostly by a new common goal, and probably helped by having virtually no patients or visitors walking around – which means that people feel a little less ‘on show’, and can relax a little and enjoy some camaraderie – invaluable in keeping morale up in awful circumstances. There is also less hierarchy than before, particularly as everyone is wearing identical green scrubs no matter their role.
Update, end of Jan 2021
So it went up, and up, and now we’re at the “bumpy top”. We are at a sustained peak of demand, where the infection numbers are apparently going down again, but the pressure on our services remains as yet unchanged. We have not been able to close any temporary critical care areas: we still have a critical care department with (by my count) 230 per cent of its usual capacity, although we don’t have the staff to have all those beds open all the time.
Because there’s less change every day, stress levels have started coming down slightly, but everyone on the shop floor is utterly exhausted. I cannot stress enough how tough it is for an ICU nurse to spend 7pm to 8am every night not looking after one but responsible for three critically unstable patients, which becomes six every time another nurse goes for their break. There are redeployed “support nurses”, healthcare assistants and even the odd surgeon doing what they can, but that’s like a flight attendant filling in for the co-pilot, at least until the support nurses have learnt the principles of critical care nursing.
This is where the news bulletins are misleading. They show Covid ICUs across the country as a maelstrom of hurried activity, with eight-strong pit crews in riot gear descending on patients, preparing to flip them over or stick tubes in. There are moments of plenty, like this, but once they’ve done what they need to do, they move on to another patient somewhere else, and the floor is empty again. Most of the time, there is an eerie quiet; there are more unconscious patients than staff, and more beeping and hissing than chatter and bustle.
Soon, the numbers of patients will start coming down, lagging a couple of weeks behind the drop in infections. As the pressure comes off, the most important thing we as a health service need to do is manage that transition so that exhausted staff get a break. We will be expected to get straight back on the accelerator and face the huge backlog of planned treatment. And this is the right thing to do, but if we do not strike a balance and give everyone a breather, we will utterly break a whole generation of clinical staff – and that’s those that aren’t already broken.
In fact, every step about managing the pandemic is about finding balance: usually the balance of risk. The decisions my colleagues and I make every day are all about balancing one risk with another, and there’s usually no right answer, just our best guess based on science and experience.
Things are looking up, and if the vaccinations go well (I’ve had my first dose) and they don’t end the lockdown too early, we could be heading for a relatively normal summer. My final thought is about what it will be like for us to return to normal work. Most staff will be hugely relieved to again be able to deliver the quality of safe and compassionate care they signed up for. But – and in spite of all the trauma and tragedy – there might be a part of us that will miss having new challenges every day.