Experiences of Covid-19 and Intensive Care

So Covid-19 is a disease caused by a virus called SARS-CoV2 and the main problem that SARS-CoV2 causes in our patients is a respiratory disease and in particular inflammation of the lungs. So, most people who have Covid-19 have a very, very, mild form of the disease that's not a lot worse than a bad case of flu, but a small proportion of patients get very severe Covid-19. And that can result in very severe breathing difficulties, low blood oxygen levels, and other problems as well.

The main learning around Covid-19 during the course of the pandemic has been helped by the fact that we have had such huge numbers of patients with an almost identical disease. Before the pandemic, I would see maybe two or three cases of viral pneumonitis a year as an intensive care doctor, and of course, during the pandemic we saw hundreds within a matter of weeks. And that allowed us to really understand the patterns of the disease and distinguish those from the patterns of differences between patients. And that in turn has allowed us to develop a lot of new treatments for Covid-19, many of which have been very effective in saving lives.

There's probably two main reasons why different patients become so unwell. I think the first point to remember is that huge numbers of people have been infected with this virus, and whilst only a small proportion of them become very, very seriously ill with life threatening disease, the massive number who are infected means that we still have a very, very large number of people who need intensive care.

I think that the first main reason why people become very ill with Covid-19 is because they're either of an older age group or they've got other medical problems. That means that when they get sick, they get more sick than a younger, healthy person, but it's also true that the genetics differences between different people have put some people at more at risk of serious disease than others, and we definitely have seen young, healthy people who've developed Covid-19 who've needed intensive care, including some of our own staff.

As an individual experience for one patient, the disease and the way it's treated is going to be very similar to normal intensive care as it has been before the pandemic. But when you've got 10s or even at one point, hundreds of patients in an intensive care unit with the same disease, the need to scale up [of] what is an incredibly complex bit of healthcare technology and staffing fourfold in a matter of weeks inevitably requires us to try and simplify what we do to allow us to deliver intensive care at a much, much bigger scale. And there were lots of different things that we did, in many ways we simplified the treatment that we were giving. And part of that was easier because everybody had the same disease. So, in intensive care when I do a ward round, I might see 15 patients with 15 very different things wrong with them, whereas on a Covid ward around I've got 15 patients, all with the same disease. And so that does simplify some things, and makes it very easy in in that way. But also, we had to simplify how we managed ventilators. We had to simplify how we manage things like renal dialysis for intensive care patients, and that was all aimed at making it as easy as possible to do it safely. Whereas normally we would strive to deliver the highest quality care that we possibly could, we had to really focus on not making mistakes during the pandemic, and that was because we had a lot of inexperienced new staff working with us and they needed to get it right in a way that didn't harm the patient and that became really, safe care became our real focus, rather than delivering the very, very best care that we ever could, and that switch was a very difficult one for us as staff, because we're trained to deliver the highest quality care all the time. And as it turns out, that's very much in our DNA and we found that incredibly difficult as doctors as nurses as physiotherapists, and so on to change that philosophy and approach.

I think it's valid to take note of what great patient care looks like in peacetime, in non-pandemic times, but also to remember that it wasn't peace time, it was the closest thing we would have to a war in terms of the decisions that we had to make and the judgments we had to make and the difficult choices about stopping doing things that we knew were important in normal times, but that we just couldn't deliver. Because we couldn't do everything the same way, we had to make some changes.

I think the interesting thing about listening to that patient's voice is how resonating it is, what you hear them say and how much I find that I agree with them about the frustrations that they have and feel frustrated myself that perhaps we weren't able to prevent those experiences from playing out the way that they did.

The vast majority of patients who needed to come to intensive care had breathing difficulties, so they had low blood oxygen levels, and some of those were treated with what we would call non-invasive things. You may have heard about treatments such as CPAP and non-invasive ventilation which really involved just a mask that you put on your face attached to a ventilator that supports breathing in that way. Higher oxygen levels - of course, we breathe air, that's 21% oxygen – a lot of our patients might have needed as much as 100% oxygen, and so supplying adequate oxygen and placing people on machines that are allowed them to get help and support with their breathing. Because when you get very ill with breathing problems, you actually have to work quite hard, your breathing muscles have to work quite hard to maintain blood oxygen levels and the machines reduce that work and make it easier for patients to breathe. A proportion of patients also needed to go on a ventilator formally where we had to put a tube down through their mouth, into their windpipe and sedate them and put them on a on a ventilator which we call invasive ventilation, and now that's a much bigger thing for somebody to experience and we did that when people were much more seriously ill.

And there are things that we do that can make you comfortable on the ventilator that might reduce your chances of survival. So, for example, if we wanted you to be comfortable, we'd very, very deeply sedate you. So that you didn't know what was happening, you didn't have any sort of conscious experience of being stuck in a bed with this big tube down your throat and not really being able to easily move and not really being able to understand what was happening. But we know from research pre-pandemic that if you very deeply sedate patients, they're less likely to survive and have a good outcome. So, we try to keep people as awake as possible while they're on a ventilator, and that's why you find that so many patients have a very, very difficult experience and recollection of their time in intensive care, and for a lot of them, it's very, very frightening. And whilst we try and do lots of things to stop them being afraid and to help them process and understand that experience afterwards, it's very hard to completely eliminate the trauma, the psychological trauma that they've gone through.

Most doctors have a relationship directly with their patient and the patient is the person they get to know and the patient is the human being that they are trying to help in whatever way they can. In intensive care when your patient is unconscious, you for many weeks sometimes don't ever get to properly meet them and understand who they are and their personality, their character. You know, whether they're fun or whether they're serious or whatever it might be. And so, the way in which we get to understand the patient is through getting to understand their loved ones, their friends, their family and so on. So, we are very used in intensive care before the pandemic to communicating an awful lot with family, whether it be when we're going around on our ward around and it's maybe in the evening and the family are in visiting patients and we say hello at that point and often answer questions. Or maybe it's arranging a particular meeting to discuss the challenges we've got with a particular patient and how best we solve them, how we understand what that patient's wishes might be. Really so few patients write down what their wishes are before they become ill that we’re critically dependent on family to explain all of that to us. And obviously those very difficult conversations are much better had in person, and we've always done it that way, and we spend a huge amount of time with our patients’ families. To have that taken away from us was actually really difficult. Because it was almost like having the patient's personality taken away from us. That human being in the bed. We didn't really know them like we used to know them and all of that is very hard. And certainly, you know, I mean, I can remember a particular case of having to stand by someone's bed and phone their wife to tell them they were dying. It's not easy. It's not easy because they can't see them, they can't understand, they can't visualise or picture - if that's somebody who's never visited an intensive care unit before, they're not going to be able to truly picture their loved one and understand why they're so ill and they're just dependent on our word and our professionalism. And, you know, so those two things together, the lack of support as a doctor or a nurse from the family and the extra burden of them relying on us together is very, very hard, and I'd say that was the hardest thing. Certainly, for me the hardest thing in the pandemic.

And how has that changed over time if it has?  

Well, very early on, I mean obviously, so many parts of society would shut completely shut and hospitals were completely shut and hospitals aren't designed to be closed places. They're designed to be places for people to come and visit and come and go. And you know that that's the normal for hospitals and so closing them and making them such closed spaces in the first wave was big shock to us, was very difficult. We didn't really have any technological response to that. It may seem absurd, but a lot of hospitals weren't even equipped with Wi-Fi, so, you know, using tablet computers to make Zoom calls or Teams calls or whatever it might be was not something that we ever did before, and actually probably most of society wasn't that used to online video calls either. We're all completely up to speed with it now. Pretty much everybody, but before the pandemic, nobody really did that, and we certainly didn't do that with patients. And it took us quite a while to set up those systems so that we could have in many cases we have medical students coming around with tablet computers and giving them to patients so that they could speak to their family or their family could see them if they weren't able to speak, so that we could say hello so that the family could see the doctors and the nurses looking after their relatives, their loved ones. And more and more over time actually using that as a medium to communicate directly with the family ourselves. But there were so many things to do. There were so many systems to set up and scale up, and that was one of the slower ones. And I'd say that was the one of the ones that we perhaps underestimated at the beginning. The impact it would have and the need and the importance of that need. I think by the second wave most hospitals were super-efficient: We had communication hubs. We put special messages in the notes in in the Covid ICU that are all closed, so people working on computers outside the intensive care unit could pass those messages to family and those teams would feed back to us if there were particular problems or if we needed a particular phone call. We had to schedule phone calls to make sure that everybody had had an equal opportunity to speak with doctors and nurses if those things were needed. And like so many things in life it's often the better-off people who have the communication skills to get what they need from doctors and nurses and so on, and it's the underserved who don't have those skills and who are often the most neglected. And making sure that didn't happen was a very difficult thing for us.

So, a patient's discharge from intensive care when we believe they're well enough to be safely and well cared for on a standard hospital ward. They must be free from any of the high-tech technologies that we use, such as ventilators or drugs to maintain blood pressure. They must be free from the need to have special additional monitoring, so heart rate or blood oxygen levels and so on and so on. So that's the first big thing, but also, they've got to be free from the need to have intensive nursing and that ability to just sit themselves up well to get out of bed and so on are quite crucial to be able to deliver some self-care in the ward environment to maybe help with washing themselves. Because there are far fewer nurses on a on a standard ward and so patients need to be much more self-caring. In intensive care we literally do everything for them every single thing that you might do in your day, from the moment you wake up to washing, eating, drinking, going to the toilet, how you sit in the bed or sit in a chair. Everything of those things that you do for yourself, nursing staff do for our patients in intensive care. And so that's quite a big step down from an intensive care to a ward, and that's often quite a scary transition for patients and their families, because they they're so well supported and so well looked after and it's quite a big difference in the ward environment. And we need to make sure that transition is safe, but also not too frightening.

I think after ICU, obviously we're transferring care to a ward-based team. Ward based doctors and nurses who who've got a different type of training and a different approach to patient care. But we do see a small number of our patients that, the sickest patients in follow-up clinics after they've gone home, to help them understand the experience they had in intensive care, to make sure any problems that they may still have, physical problems that they may still have, that specifically related to the way we looked after them in intensive care: Tracheostomies for example, when you put the breathing tube in your neck, sometimes have ongoing problems that we need to solve. And we have special intensive care follow-up clinics to deal with all of those problems afterwards.

And was that in any way different during the pandemic; were there challenges...?

Well, a lot of that didn't really happen. And the two main reasons why it didn't happen were firstly the vast number of patients who came to intensive care and secondly the fact that most outpatient clinic appointments were being delivered online rather than in person, and it's the type of support that's very difficult to deliver online because you need to examine the patient as part of, you know, that clinic visit.

So, a Covid patient being admitted to ICU today would get that same standard of care that we delivered before the pandemic as an intensive care patient but would benefit from all the learning we've had in terms of special treatments and special drugs that have particular benefits for patients with Covid. Before the pandemic of viral pneumonitis was very, very little extra that we would do apart from support the patient, the ventilators, and so on. There were some antiviral drugs, but they weren't very effective, whereas now we've had five or six treatments that typical ICU patient may benefit from as we treat Covid-19.