Humankind cannot bear very much reality.” TS Eliot, Burnt Norton
Human memory is fickle. Only a few brief months ago, many intensive care units (ICUs) across Britain came close to being overwhelmed by patients with a novel coronavirus, unknown to medicine before January of this year, and causing potentially life-threatening lung disease in up to 20% of those it infects. With the relaxation of the lockdown, however – only possible because it had been so effective – and the good summer weather in which we have been encouraged by Westminster to eat, drink and be merry, we have begun to forget. We have rapidly forgotten the fear and anxiety that rightly held Britain in their grip throughout the spring of 2020, the 40,000 people who died from a single infectious disease within a few brief months and the incalculable suffering caused to their families. We have forgotten that more than 600 health and social care workers died as a result of their work caring for others.
The Royal Gwent hospital in Newport, where I work, forms part of Aneurin Bevan University Health Board (ABUHB) and serves the socially deprived populations of the former south Wales mining communities of Caerphilly, Torfaen and Blaenau Gwent, including Nye Bevan’s old constituency of Ebbw Vale. In addition to the well-recognised links between social deprivation and chronic ill-health such as obesity, diabetes and high blood pressure that we now know predispose to severe, life-threatening infection with Covid-19, ABUHB also has one of the lowest numbers of intensive care beds per head of population of anywhere in Europe.
Alex Owen, a recovery nurse, at the end of a long shift. Danny Waters, an ICU staff nurse, on a break.
It was against this background of social deprivation and historical under-resourcing that preparations began at the Gwent for the greatest single challenge that the NHS has ever faced. By the beginning of March, rumours were rife on social media of ICUs in northern Italy swamped with patients; of doctors being forced to make triage decisions on who was admitted to ICU and, most terrifying of all, of a high death rate among the staff caring for patients infected with what we now know as Covid-19. The sense of anxiety and fear throughout was palpable as the realisation dawned that the virus had taken hold in Britain and was making its way west from London towards Wales. Experienced colleagues admitted to waking in the night racked with worry about what the coming weeks might bring. Colleagues made wills and talked of letters they had written to their children in case they died. The greatest fear of all was of the unknown that lay ahead of us.
Nicola Rogers, an ICU sister, wearing a reusable face mask. Dr Shree Champanerkar, from Mumbai, India.
Susan Thapa, a staff nurse, normally works in orthopaedic theatres. Mary Waters normally works as a scrub nurse in theatres at another hospital.
It was also obvious that what was happening had to be documented, but there was a ban on all visitors to the hospital, including the press. It would have been unjustifiable to allow a photographer into the hospital while denying families the right to visit dying relatives. So I found myself picking up my camera to record the impact of the pandemic on the lives of colleagues and patients. Within the constraints of my work, I tried to capture the experience of the doctors and nurses, but also the people in the background, the unknown and the unrecognised, whose stories are rarely heard, who frequently get paid little but without whom the system would come crashing down.
As winter gave way to an unseasonably warm spring, our ICU beds began to fill, slowly at first, with patients with respiratory failure from Covid-19. The first patient was admitted on 9 March but less than three weeks later we had breached our increased capacity within ICU and were forced to ventilate patients in our operating theatres, on anaesthetic machines never designed to ventilate critically ill patients for prolonged periods. Newport was hit with one of the highest infection rates in the UK outside of London. By the middle of April we were running close to 300% of our normal capacity.
To be a patient in an intensive care unit is to be vulnerable, perhaps more vulnerable than at any other moment in our lives. Depending upon the severity of a patient’s illness, almost every bodily function can require support. Consciousness is frequently suppressed by sedative drugs that, combined with the patient’s illness and the ICU environment, can lead to disturbing hallucinations and delirium. The role of the lungs to transfer life-giving oxygen into the blood is taken over by a ventilator, while the heart and circulation often require support from powerful drugs to maintain an adequate flow of blood to vital organs. Kidneys may stop working and require support by dialysis. Unable to move for themselves, the patients require turning every two hours so pressure sores do not develop. Despite being fed by a tube into their stomach, the gut will frequently not work, so nutrients are not absorbed and the patient’s bowels will either be stubbornly constipated or given over to profuse diarrhoea, which requires the patient to be cleaned and bed clothes changed at regular intervals.
This care is delivered by a multi-disciplinary team in which each person plays a crucial role, but at the heart of which are the intensive care nurses. Without intensive care nurses, you can have as many beds and ventilators as you like, but you will not be able to admit patients. This was illustrated by the number of patients reportedly turned away from London’s Nightingale hospital because, despite an almost unimaginable number of beds, there were no nurses to staff them.
Dr Teresa Evans, a consultant, organises a video call with a patient’s family. With families unable to visit, this became an important way for awake patients to stay in contact with their loved ones.
We were only able to care for almost three times our normal number of patients because of the extraordinary efforts of former ICU staff who returned to help and those from other wards and areas of the hospital, particularly the operating theatres, who volunteered to work in intensive care. For them, the intensity of the environment, sophisticated equipment and exposure to large numbers of deaths frequently lay far outside their normal working experience. At the peak, with beds placed between our normal beds and a number of temporary units created, many admitted to finding the experience terrifyingly overwhelming, and told of returning home after their shift exhausted and unable to stop crying.
Even for those habituated to the unique pressures of intensive care, the work was gruelling. Distinguishing patients from each other became almost impossible as they were all so similar; relatively young and fit with relatively mild diabetes or high blood pressure, usually male, often Asian and ventilated for severe respiratory failure caused by the same unfamiliar disease. Not only were we treating unprecedented numbers of patients, but we were also having to learn how to treat our patients as we went along. The cognitive load was enormous, and you became intellectually exhausted as well as physically and emotionally. With everybody wearing face masks and frequently a visor as well, it literally became impossible to hear yourself think as everybody raised their voices to make themselves heard and understood.
An anaesthetist inserts a central venous catheter into a newly admitted patient with Covid-19. Without the invaluable help of staff from other specialities, particularly anaesthetics, ICU would never have coped with the number of patients it was required to treat.
In an already high-pressure speciality, operating close to capacity even before Covid-19 hit, it is unsurprising that the experience of the first wave proved too much for many across the NHS. Both those within intensive care and those who courageously volunteered to work there paid a high psychological price for their generosity that no amount of clapping, rainbow paintings or free food can make up for. Many staff members have been broken by their experience of working through the first wave and show evidence of anxiety, depression, sleep disturbance, physical exhaustion and early signs of PTSD. They must feel a growing sense of fear and despair as they watch case numbers rise again.
If patients are physically vulnerable in ICU, their families are emotionally vulnerable. To have somebody you love in intensive care is to be confronted with paralysing uncertainty, and we take great care to offer as much information and support to families as we can. The sheer volume of patients with Covid-19 and the ban on visitors meant that this became very difficult. We were forced to have conversations that should take place face to face over the telephone while wearing full PPE. I began every telephone conversation with an apology for these limitations and invariably the response came back: “Please do not apologise, doctor. We understand. It is what we all have to do.” Despite the extraordinary patience shown by relatives, the most emotionally jarring memory I retain from the first wave is the sound of disembodied crying coming down the telephone in response to bad news, or simply when the absence of progress in a partner or parent, last seen fighting for their breath as they were driven away in an ambulance, became too much to bear.
Vince Lovell and Molly Murphy, mortuary technicians, had never previously experienced anything like the increase in deaths from Covid-19 that they were required to deal with.
It is a testament to all who worked tirelessly in, or supporting, ICU at the Gwent that our mortality rate during the pandemic compares favourably with the best in the UK and is very similar to that for severe respiratory failure from whatever cause. Nevertheless, about one-third of patients admitted to ICU with Covid-19 died. We have become used to images in the media of staff clapping as patients left ICU, but this risks glossing over an unavoidable truth and doing a disservice to the many patients who died and the families who mourn them. No matter how uncomfortable or open to criticism it may be, this was part of the story that I also had to illustrate. While talking to our mortuary staff, they suggested that I should photograph the temporary mortuary built to accommodate the almost unimaginable increase in deaths that they were faced with.
Of all the photographs I have taken during the first wave, those of this vast tented and refrigerated structure are, for me, the most powerful and bring home with great clarity the brutal lethality of Covid-19. Built to accommodate 480 bodies, I visited it at the beginning of June, shortly after the last body had left. With the long shadows cast from the scaffolding and an eerie, reverential silence, it felt like some modern, secular cathedral from which the congregation had just left. It would have been impossible to stand in that cavernous, cold space and not take seriously the reality of the threat that Covid-19 presents, not only to Britain but to the whole world.
A week after taking her first steps, and thanks to the intensive rehabilitation provided by an army of physiotherapists, A&E staff nurse Cindy Sulit is now able to move around the ward.
At the beginning of August, three months after her admission to ICU, Cindy is making extraordinary progress on the rehabiliation programme based at the National Velodrome in Newport.
After a too-brief summer of respite, case numbers are predictably rising again, with Caerphilly, Newport and Blaenau Gwent now in local lockdown and our first admission of the second wave admitted to ICU this week. More will follow. We do not yet know how the second wave will play out. Will it result in a massive surge as big as, or even bigger than, the spring, or shall we be confronted with a constant and manageable flow of patients throughout the winter? So much depends on how the public responds, and the signs are not encouraging. The advice from the Welsh government throughout the pandemic has been clear, consistent and proportionate but so much news in Wales comes via the London media. The inconsistent advice and U-turns from flippant Westminster politicians – for whom truth is something to be manipulated in the service of power – and an alarming increase in lies and misinformation spreading on social media, playing down the deadly nature of Covid-19, will encourage people bored and fatigued from the first lockdown to think that they can ignore social distancing and local lockdowns with impunity.
Dr Joan Hoare, a retired GP and former Gwent anaesthetist, volunteered at the start of the pandemic to do whatever she could.
Anxiety is growing again in the hospital, and I am deeply concerned for those who have not recovered from the emotional distress and exhaustion of working through the first wave. While there is no room for complacency, if we are confronted with a large second wave this autumn and winter I believe that the intensive care community can be quietly confident. We are no longer dealing with a new disease and while our understanding of it is far from complete, we know so much more than we did in March. Thanks to the largest Covid trials in the world run by the NIHR/UKRI Rapid Response Initiative, we are also beginning to understand better how to manage it. There are no magic bullets but treatments such as the long-available drug dexamethasone do appear to reduce the chance of dying in the most severe cases. We know that PPE works, and have confidence in it and sufficient supplies to see us through the winter, along with stockpiles of the drugs that we came within days of running out of in the spring. The systems and protocols needed to manage large numbers of cases are in place and have been refined through use.
We now wait and hope. A definitive vaccine is still some way off. Without the public recognising that the part they have to play in reducing community transmission, even among the young and those who experience mild or no symptoms, is as important as anything we can do in the NHS, it is going to be a very long winter.