In early March, Mike Brunner, an intensive care doctor at Northwick Park hospital in north London, saw his first few Covid-19 patients. They were arriving with mild coughs, but just hours later were relying on oxygen tanks to breathe, their lungs on the brink of collapse. Within days, three patients became seven, then 20, and from then on, said Brunner, “we were in it”.
For a while, Brunner felt as if he and his colleagues were the only ones who saw the huge change coming. “We could see this tsunami of people coming at us, and yet nobody else did,” said Brunner. Driving through London on his way to work, past people crowded together in shops and pubs and cafes, he felt as if no one understood that very soon life was not going to be the same. “It was an incredibly lonely feeling,” he said.
Stepping on to the ICU during this period was like entering another world. In a way, Brunner said, intensive care has always seemed like a place removed from life outside. The ward itself is hidden away behind closed doors, and inside, the only sound is the gentle, regular beeping of machines. “Because of all the machinery and complicated language we use, it has a unique atmosphere,” said Brunner. “It can be quite intimidating.”
By mid-March, intensive care was at the centre of the unfolding drama. ICUs were expanded to deal with the most serious Covid-19 cases, while surrounding wards were quickly repurposed to support them. As the crisis deepened and the prime minister himself was, for a brief period, cared for by an ICU team, critical care soon occupied a new place in the UK’s consciousness. Numbers of critical cases have since declined across most of the country, but Brunner said he and his team are still working harder than ever before.
Before the coronavirus outbreak, it was precisely because ICUs treated the sickest patients that they were isolated from the rest of the hospital. In TV and films, they are often presented as eerie and remote places, glimpsed briefly as a pair of feet disappears through the swinging doors into a bright, white light. “Patients who leave may have had no idea where they have been,” one nurse told me.
Studies have shown that few patients remember being admitted to intensive care, and most are disorientated when they wake up. The use of sedatives such as benzodiazepines mean that some leave with the idea they have been to a different place entirely. One doctor told me about an intensive care patient who converted to Catholicism after believing that they had been in a church where a nun had guided them through their treatment. The “nun”, the hospital team realised, was an oxygen tank whose white neck and black base must have looked like a habit. (The patient is still a practising Catholic.) Another doctor remembered a patient who was convinced they had been kidnapped by Colombian pirates. It is likely, this doctor said, that the hallucination was caused by a combination of the water-bed used to transport the patient and the Spanish-speaking nurses around them. These memories can leave patients traumatised and confused. Nowadays, an important part of ICU care is provided by a follow-up clinic that allows patients to return to the ward and speak to the staff who cared for them.
For many working in intensive care, these past few months have been not just gruelling and emotionally brutal, but also inspiring. “We have been able to give of ourselves what we always wanted to, and we are working very closely together to find answers,” one doctor told me. “I’ve remembered why I chose to do intensive care in the first place.”
When the NHS was born, more than 70 years ago, intensive care was not a recognised specialism, even though healthcare professionals across the world have long known that close monitoring can improve the chances of recovery for the sickest patients. The world’s first intensive care unit was opened in Copenhagen in 1953, by the anaesthetist Bjørn Ibsen, following a polio epidemic the previous year. Polio can cause paralysis and respiratory failure, and during the outbreak Ibsen had discovered that, after administering an anaesthetic, he was able to manually inflate and deflate the lungs of patients by rhythmically squeezing a rubber bag attached to a tracheostomy tube. Using this crude machine continuously, he and his helpers managed to keep patients alive until they recovered enough to breathe unaided. This use of machinery and constant monitoring became the basis of his intensive care practice.
From the 60s onwards, ICUs were established across the UK, bringing together teams of skilled staff to support people with failing organs. With continuing developments in technology came more sophisticated monitoring techniques and life-support machines. Among the most notable was the pulmonary artery catheter, which was developed at St Thomas’ Hospital in London by Dr Margaret Branthwaite and Prof Ron Bradley. It involved inserting a tube into a pulmonary artery to monitor its pressure, which could be used to diagnose serious problems such as sepsis or heart failure. When Prof Hugh Montgomery, who today works as an ICU consultant at the Whittington Hospital in north London, began his medical training under Bradley, he was among the first people to receive intensive-care training.
Like many ICU staff, Montgomery felt that before Covid-19, many people “were blind to the existence of intensive care”. During the height of the outbreak, the talk was all about ventilators – machines used to move air into and out of the lungs of a patient who cannot breathe unaided – but, said Montgomery, intensive care is about much more than breathing and ventilators. “Often the patients who come to us are suffering from multi-organ failure, which requires a series of very complex treatments,” he said.
Because intensive care patients need to be closely monitored, ICUs have the highest nurse-to-patient ratio in a hospital – usually one to one. At the peak of the crisis, the number of patients increased and their average length of stay in the ICU became longer. At times, Montgomery’s department had only one ICU nurse to six patients. “Working as an ICU nurse is like flying a plane,” he said. “It is highly skilled and they cannot take their eyes from the controls. They are very, very clever people.”
Among the hardest decisions intensive care staff have to make are about who to admit to their ward, and when. In the UK, intensive care beds tend to be limited, and available only to the most dangerously ill patients, but there is an ongoing debate about whether patients should be offered critical care before they get to this stage. “The idea of having a relatively small ICU for only the very sickest is historically quite a British thing, which is now changing – but unevenly so – across the country,” said Ganesh Suntharalingam, an anaesthetist and intensive care doctor at Northwick Park, who is also president of the Intensive Care Society (ICS), the leading charity in the UK for the support of intensive-care professionals. Bringing patients into intensive care at a lower threshold of severity may allow earlier and less invasive treatment, and increase chances of a better recovery. “Keeping you alive while you are at your sickest is only part of what we do,” said Suntharalingam. “ICU is just as much about ensuring and reinforcing your recovery.”
In recent months, for instance, physiotherapists have played a crucial role in intensive care, helping Covid-19 patients who have been ventilated for long periods. By doing breathing exercises with patients, they help them prepare for the moment when the ventilator tube is taken away and they start to breathe on their own again.
Talking to me from the staffroom at the Royal Preston hospital, where the intensive care unit has swelled to seven times its usual size, Dr Shondipon Laha, critical care consultant at Lancashire Teaching Hospitals, said that many patients they had seen had been suffering from sticky secretions in the lungs, and have relied on manual techniques to clear their airways. That‘s another point when the physiotherapists step in. “We’re like the snowploughs of the ventilator world,” said Molly Koziarska, a physiotherapist who was working with Laha. Koziarska recalled a recent example where, after a patient in the ICU collapsed with damaged lungs, she was brought in to manually inflate the lungs using handheld bags, and then physically shake the patient to dislodge the secretions. “We may then ask a patient to cough afterwards to clear their chest – I think we are the only group to ask patients to do this during covid!”
For all ICU staff, the initial stages of dealing with Covid-19 were defined by uncertainty. After 27 years of working in ICUs, Hugh Montgomery said he felt as though he was a student again. “We had to start from the beginning with this,” he said. Seeing how the lungs reacted to Covid-19 was especially shocking. “The blood vessels in the lungs were behaving in a really odd way – like nothing I’ve seen before,” he said. “I remember feeling cheated, as if our patients were not playing by the rules.”
The pandemic has brought together intensive-care professionals from around the world, trying to make sense of what they were seeing. The evening before we talked, Montgomery had chaired an online conference call with the World Health Organization and clinicians from nine different countries including China, the US, Germany and Spain. The call was hosted by the ICS and allowed clinicians to share ideas on topics such as CPAP ventilation (continuous positive airway pressure), fluid balance and antibiotic use. “Seeing Hugh bring out clinicians to share their experiences is like watching a conductor in an orchestra,” said Sandy Mather, the CEO of the ICS, who coordinates these meetings.
This is the first global outbreak in which digital resources have been widely available, and Mather said the online ICS conferences have been crucial in allowing clinicians to learn from colleagues in other countries, ahead of the virus’s march across the world. “What’s so moving is the dedication you see in clinicians to improve care,” said Mather. “Many participants are coming off an 18-hour shift, and yet they are there, speaking English as a second language, sharing lessons and wanting to learn how to improve their practice.”
Across Britain, intensive care departments have been taking part in trials of potential treatments. Among them is the Recovery trial, the biggest randomised controlled trial of drugs against Covid-19 in the world. It has recently shown positive results with the freely available and cheap drug dexamethasone, and further results are keenly awaited.
In his intensive care unit in Preston, Laha has been running research into possible treatments. Although it is the biggest, coronavirus is not the first pandemic Laha has experienced. In 2009, during his second year as an intensive care consultant in Lancashire, the H1N1 virus, also known as swine flu, spread across the world. “The 2009 pandemic overwhelmed us,” he said. “I remember thinking we didn’t have the capacity for it, even though, like the coronavirus, we all knew it was coming.”
H1N1 was forgotten about as quickly as it had started. Afterwards, Laha said, there was “no consideration of how intensive care could be improved nationally, so that we were more prepared”. He is worried that the same thing will happen after the current pandemic is over. “We have to be more prepared for when this happens again, which it is likely to. Pandemics may happen three or four times a century.”
The impact of the virus is often measured by mortality rate. However, as numbers of deaths in the UK are – for the time being – declining, the focus for many healthcare workers is now the prospects of recovery for those who leave intensive care. “There appears to be an assumption that admission to an ICU is like a magic golden ticket – you survive and are fully back to normal,” said Laha. But it’s not always like that.
A few years ago, one patient, who had been receiving intensive care treatment for an aggressive tongue cancer, began hallucinating in hospital. In her mind’s eye, she would see the surgeon who had been treating her in the form of a butcher trying to kill her. These visions continued as nightmares long after her stay in the ICU. Soon the patient developed post-traumatic stress disorder (PTSD), which was triggered by sensory experiences that reminded her of the ICU: cool air, certain smells, memories of her hallucinations. “She thought she was going mad,” said Kate Tantam, an ICU sister at University Hospitals Plymouth NHS Trust. “She didn’t know that delirium was so common and completely normal, and so kept it to herself.”
The phrase post-intensive care syndrome, or Pics, was first used around 2010 to describe the collection of symptoms sometimes seen in ICU patients after discharge: cognitive impairments, mental health issues and physical health problems. Tantam said people are often shocked when they learn about Pics. She is finding that some Covid-19 patients discharged from intensive care are suffering from severe muscle weakness, while others have experienced delirium.
Tantam has long campaigned for a rehabilitation team to be embedded within the critical care structure. Her campaign began more than a decade ago, after she read an NHS questionnaire filled out by a young woman who had been treated at her hospital. The woman was close in age to Tantam, and went into the ICU when she was pregnant. During her six-week stay, she lost the baby. She had suffered terrible delirium, which later gave her PTSD. She was physically weak for a long time after leaving hospital. “It was a story that broke me,” said Tantam. “At the time I had just come back from maternity leave, and although I never met her, I felt really close to her and wanted to do something.”
Without proper rehab, Tantam thought, the ICU did not make sense: “Otherwise, what’s the point of what we do? What’s the point of keeping someone alive if they have no quality of life?” One of her first steps was to make a case for the importance of physiotherapists, who can begin exercises with patients while they are in the ICU and may be experiencing muscle loss and atrophy. “Often our patients need to be taught to walk again, breathe again, swallow again and talk again. That takes time, and it needs a team of people.”
During their stay in an ICU, at least 45% of patients experience delirium, according to a report in Annals of Intensive Care. “Drugs do not stop a patient from getting delirium in ICU,” said Tantam. “They need specialised therapy and psychological care after.” On leaving intensive care, in around a quarter of cases, delirium can lead to PTSD. Among her previous patients, Tantam recalled some who have thought she was trying to kill them, and mothers who imagined she and her colleagues were trying to kill their children. “I have had patients who after treatment have asked me or other nurses questions like, ‘Why did you tie me up in the plane when it was crashing?’, or ‘Why did you let that man abuse me?’”
It took four years for Tantam to assemble her rehab team. She found there was not much interest, because it didn’t have that “saving lives” quality – “but it’s about saving dreams” she said. Since March, Tantam and her multi-disciplinary rehab team – physiotherapists, psychologists, nurses, speech and language therapists, occupational therapists, dieticians – have been able to work across the whole hospital, seeing every Covid-19 patient. “The impact of this was remarkable,” Tantam said. “Every Covid-19 ICU patient has left the hospital walking. This is huge.”
‘When dealing with patients at the extremes of life,” writes Aoife Abbey, a doctor at University Hospital Coventry in her memoir The Seven Signs of Life, “there is an onus on doctors to be alert for the time when the burden of treatment outweighs the expected benefit for a patient. It is imperative that medicine knows when it is time to work with death, if it is to work at all. Intensive care, perhaps more than any other speciality, is defined by this specific sort of responsibility.”
During these months of treating Covid-19 patients, Abbey has seen patients come in with severe acute respiratory failure. Some patients stood to benefit from intensive care, while for others the escalation of treatments, including invasive forms of ventilation, were not deemed to be in their best interest.
The established ethical frameworks used to make these kinds of decisions have remained the same when treating patients with Covid-19. What has changed is the nature of the communication with patients and their families. According to Mike Brunner, one of the toughest parts of working in the ICU during this time has been seeing patients die without the company of their families. In many cases, staff have been the ones communicating messages of support, or holding someone’s hand in place of a friend or partner. Brunner remembers sitting with one nurse – who, before being moved to the ICU, had been working in the operating theatre – while she held the hand of a patient as he died. “It was very difficult for her, and she was distraught, but she stayed with her patient, holding his hand and comforting him while he died. She epitomised the care and compassion of all our healthcare workers.”
As the weeks have rolled by, Brunner said, he has become more aware of his own mortality. “You do worry, especially when you are looking after people who are your age. One morning I woke up and I just could not stop crying. My sister called and I just found myself telling her where my will was, and then weirdly, I felt better. Never have I worried about contracting anything that my patients have had – Aids, swine flu – it just hasn’t crossed my mind.”
Many doctors I spoke to were worried about how intensive care staff will cope when the NHS has to operate as normal again while caring for patients who are still recovering from the virus. Andre Vercueil has noticed that patterns have been changing in his ICU in south London. The hospital is experiencing higher numbers of trauma patients than they would normally have seen before the outbreak. Patients have been admitted to his ward after self-harming, taking drug overdoses or jumping off buildings. Admissions of patients with mental health issues are also on the rise. Vercueil said the changes he and his team in the ICU have witnessed have held up a mirror to society – “and not a very flattering one”.
Nevertheless, ICUs do things that few, if any, other hospital departments can. After we spoke on the phone in March, Kate Tantam, the sister in Plymouth, sent me some photos of flowers being planted in a garden behind her ward, which she and her team had been working on for the past few months. When we spoke again last month, she told me the garden is now finished, and that she and her team had been taking patients out there.
For some, it was a place to build up strength after treatment, to see some greenery and to remind them of the world outside their ward. For others, it was to take them outside one last time. “We cannot save everyone,” said Tantam. “Our job as nurses is to also facilitate a good death, and I’m lucky to be in a team who is working hard to do both.”