This an account written about my time working in ICU during the COVID-19 pandemic. The events are described almost exactly I experienced them. These are not exceptional stories. For those working in Intensive Care medicine, walking on a knifes edge with death at one side and life on the other is an everyday occurrence. These accounts come from the perspective of a naive medical student in this harsh environment and describe the experience of being involved in the care for patients whose lives hung by a thread.
There are four stories in this account. It is a long read, with the second and fourth being particularly detailed. For whoever reads this, please feel free to take it one story at a time, or come back as is comfortable for you. Feel free to contact me with any questions.
Since the announcement of postponing the Arclight India project, we have endured the brunt of part one of this pandemic in the UK. The wounds will take some time to heal, and when they do the scars will burn, especially for those who lost loved ones to this disease.
In May, I rode my motorcycle to Leicester to start work in an ICU for the University Hospitals Leicester NHS Trust. I was assigned the role of COVID-19 Clinical Responder and put to work alongside the nursing staff. Over 12 and a half hour shifts donned in a surgical gown, two pairs of gloves taped at the wrist, a tight-fitting respirator mask, visor and cap, we cared for the sickest of those with Coronavirus. Almost every patient was unconscious, sedated and intubated, with a mechanical ventilator rhythmically aerating their purulent lungs. The treatments were desperate attempts to breathe some life into broken bodies and for some people it worked, but for many it didn’t.
At the start, under the comforting wing of a different member of the nursing team each shift, I was trained how to nurse in the austere biohazardous environment. From putting up drips to proning patients, to monitoring a ventilator and re-dressing wounds, the training came thick and fast. I wrote in my diary at the end of my first week, “I see the nurses working with such fluency and I ask myself what help I can really be in 2 months?”. Now, as I write this, I am smiling to myself, proud of how much I have learnt and for persevering through the early gauntlet. My advice on this page also makes me happy to read, “when on the ward tomorrow, LISTEN, WATCH AND KEEP MY BRAIN ON”.
The hospital is a centre for a specialist treatment called Extra Corporeal Membrane Oxygenation (ECMO). It is a means of supporting the lungs by oxygenating blood outside of the body. The machine takes blood out of venous circulation via a large bore canula at up to 4 litres/minute, driven by a small motor spinning at 53 revolutions/second. The blood is then infused with oxygen, stripped of carbon dioxide and returned by an equally fat tube into the right side of the heart. The circuit is a feat of medical engineering and requires 24/7 monitoring by a specialist. Despite its extraordinary design, it does not compare to the efficiency and functionality of biological lungs. Sadly, in our ITU, the majority of those that went onto ECMO did not make it off the machines.
- Spravyash se dobre – You’re doing fine
What was discovered early on in the pandemic is that coronavirus is not restricted to single organ failure. It is a disease that can either directly or indirectly lead to fatal dysfunction of other systems. Subsequently, its ICU management is complicated and must by dynamic to match the unpredictable development of symptoms in different areas of the body. There are many times of reactionary ‘firefighting’, in which an acutely deteriorating situation is managed as they appear, avoiding death but not necessarily making great steps to recovery. Owed to this, I witnessed a range of different medical interventions, participating wherever I was able to.
One particular treatment, called Bronchoscopy, involves guiding a flexible camera and suction tube down the airway in order to clear some of the blood and secretions accumulating in the lungs. I will never forget a team of eight doctors crowded round the monitor as they took turns in attempting to remove an especially large clot completely occluding a patient’s left lung. The shiny red flesh lodged the bleeding airway looked like something out of a sci-fi film and I marvelled in grim disbelief at how the body can continue living with such a thing in the lungs.
That particular patient survived despite two bouts of sepsis and a treacherously fluctuating clinical condition. During his stay in ICU I looked after him several times. I would sit next to his bed in the final half an hour of my shift, after the 7pm observations were recorded and the drug infusions had been prepared out of courtesy for the nurse on night shift.
The only item that he had at the time he was admitted was a copy of the bible in English, which was odd given that he did not speak or understand it well. Regardless, in the evenings, with just him and the ticking ventilator to listen, I would read it aloud. I remember so vividly the story of Jesus calming the sea and then reading it again, and again.. “let your fear be quelled by faith” was his message to the disciples, as he settled the storm with a few soft words. Repeating this passage, in truth, was probably not for the patient, and much less for the ventilator, but for myself.
In some moments, often quiet ones, the thin wall between emotion and duty can turn to dust. When this happens the mixing of the particles that make up these entities is tempestuous. Waves of emotions end up soaking the rocks of resilience that are barely kept dry at the best of times. On reading the story of Jesus calming the storm, the wall vanished and salient amongst the rising emotions was fear – not only for the life of the patient, hanging like a fragile crystal from a single thread, but for a future of humanity that I am not designed for. Where do we find faith in such bleak and uncertain circumstances?
Two days later, the man’s ventilation had improved and he began to wake from his sedation in a spinning delirium. Although uncertain that this time would come, one of the nurses who spoke his language had written down some phrases on a piece of paper and left it in his notes. After repeating it to him countless times, “Spravyash se dobre”, (“you’re doing well”), found its place in my memory and became a personal motto for reassurance as I walked out of hospital on particularly heavy days … Spravyash se dobre Hugo, Spravyash se dobre.
2. In the waiting room with death
Thankfully I was not on my own the first time I experienced it in ICU. I was paired with an expert nurse called Rose, to whom the process of guiding a patient through death was familiar. I remember being told in the bustling nurse’s station at 7:20 am that the patient we had been assigned looked as though she would not make it to lunch time. “Ok”, is all Rose said with a dutiful nod whilst donning her dark ventilating hood. A faint dart of sorrow escaped through her renitent acceptance but was whooshed away from detection by her ventilating mask.
I took longer than normal to don my PPE that day, testing my mask more than I needed to and re-doing the tape on my gloves because it wasn’t quite straight. Several long breaths later, I was through the two sets of doors and back in Bay A to take a futile handover from the nurse who had spent all night with this dying patient.
That morning, Rose displayed an ethereal skill in enabling of a peaceful and respectful death. Like a midwife preparing a mother for bringing a child into the world, Rose created a safe and comfortable space for this woman’s passing. Despite the hostile nature of the ICU unit, which is an environment dependent on apparatus for artificial living, this death did feel natural and free of suffering.
Firstly, the curtain was drawn. The thin pieces of non-descript cotton formed a forcefield around us, providing the privacy to carry out the task at hand. We then got to work cleaning the bed space of literally everything that did not need to be there – the sharps bin, spare parts for the ventilator, spare dressings, oxygen cylinders, the fire evacuation box – all redundant paraphernalia banished beyond the cotton fortress into another world where the fight continued for other patients. We disconnected drug infusions of the abandoned treatment regimen, keeping only one that chemically drove the beating of her heart. We stopped her feeding drip and turned off the alarms of the monitors that could not, with their simple machine minds, comprehend the futility of their cries for attention.
With the bed space transformed and protected by the thin cotton curtain, we cleaned her face and laid her thick black hair neatly on the white pillow. We dimmed the lights, and with our gloved hands in hers, began the wait. The ventilator clicked away solemnly in the background like the sound of pallbearer’s footsteps across a stone courtyard.
One of the registrars knocked on the window and Rose and I slipped out of our cotton enclosure to talk to him. Over the radio with a defeated indignant shake of his head he said ‘pull the norad, now’ which is to say, stop the final drug keeping her alive and let her go. Rose, repeated the same “ok” as she had done at the beginning of the shift, but I shuffled in discomfort and made some exasperated sounds that were not quite words, semi-consciously prompting her to add, “im fine with that, but I don’t think Hugo is”. She passed me the walkie-talkie to explain myself. Stunned and scared and this sudden contest with a doctor in uncharted territories, I explained that given how the family had only been informed in the last half an hour that she would die today, we could keep the drug going to give them time to get here. The Registrar looked at me with what felt like a mixture of bitter annoyance and endearment, perhaps even disbelief belief at having to explain himself. His head was slumped at an angle and he let out a sigh that was almost audible through the thick glass. Still though, he composed himself and gave a thoughtful reply through the radio. “she is my patient, not her family, and with 15mls/hour of double strength noradrenaline being administered to her, it is more harmful to keep going than to wait.”
As he said this, another doctor appeared through the criss-cross of bustling nurses in the clean area. Rose and I still stood observing the conversation from the other side of the window. Their interaction was brief but with greater frustration bellowed in the body language of the registrar, “right, well the family are on their way so keep it going” came through the radio. The registrar’s frustration was not toxic or personal, it was a cumulative result of too many impossible situations ending in tragedy.
In the end, it didn’t make a difference. Rose and I returned to into the darkened room enclosed by the thin curtain and we sat at either side of our patient, holding her cold hands in ours. Intuitively, I whispered the same short prayer that my grandmother had said when my grandpa died peacefully with us all around him. It is coincidentally the same thing my mum would say to me and my sister each night before turning the lights out to sleep, always accompanied with a kiss aimed roughly somewhere on the top half of my face. Now, the prayer is no longer exclusive to the nostalgia of childhood. It has become a gravely fond greeting spoken when I share space with death. Each time it sparks a wave of icy heat down my spine and through my body – “May god bless you and keep you and may his light shine upon you” it goes.
After about 30 minutes gazing at the face of the dying woman in front of me, with her hand in mine, I felt an overwhelming wave of tiredness and began to drift off. I didn’t fight it, and lulled in and out of consciousness softly.
Eventually, her ECG trace lost all regularity and her blood pressure started to decline further. 50, 45, 40, 38… 30.. 20..
As her heart was fluttering in a final convulsing dance, mine beat through my chest slowly and strongly, as if it was trying to get closer to see the spectacle. I felt the pulse from my fingers straying into her palm and returning with each throb. I caught Rose’s eyes and nodded towards the monitor. She looked at me, blinked and slowly returned her gaze to the patient, stroking her hair with compassionate finality.
The lines on the monitor ran flat for about 5 minutes. My mouth felt as though it had been glued together and the wind removed from my body so that no sound could be made. A fine thing for a space where no words spoken by us would ever have been important.
With my hand still interlocked with hers, I studied the face of the woman once more. Her square jaw was tense and stern, but her eyes lay gently in a state of sad satisfaction. Her soft chin rested on a bristly white towel supporting her breathing tube, framed on right by the black plait of thick hair on the white pillow.
I found myself thinking about the times in her life where she may have rested with a similar transcendent expression, which could have been perfectly appropriate in moments of bliss as well as in death. Perhaps during slow mornings lay next to her husband and child with the sun streaming through the window, shedding the hope and light of a new day on any fear or resentments of yesterday. She looked as though her final thoughts may have been of such times as well.
Eventually, with red eyes and damp cheeks, we stood up and Rose offered her arms out to hug me in our curtained enclosure which now was a fortress of solidarity. I leaned into her with the full weight of the happenings heavy like lead in my heart. The small blue-eyed nurse held my wounded soul with the comfort of an angel and supported my heavy body with the certainty of a horse. All I could think of and finally verbalised was “you are such a good nurse” – I just hope that Rose knew that this meant as the antithesis of a platitude, and that I was truly in awe of her.
The patient’s brother did make it to the ward eventually. I wasn’t there to see him, but I was told that he sat with her, said a short prayer and left his sister to rest.
With the voyage of life from her body, we left her alone behind the magic curtain until the doctors came to officially declare her death. In this time, I took off my PPE and scrubbed my hands before scuffling like a frightened rabbit to the changing rooms. Here, I sat by the window and pulled out my notebook to scribble down my thoughts.
“After sitting by the side of a dying patient and holding her hand as the life faded from her body, I now listen to the space around me. The wind still surges softly amongst the flowers, my ears still ring with high pitched familiarity, my shoulders are still mine, but the saliva in my mouth rests like concrete against my gums.
She passed without suffering, in peace, guided by a masked angel. Her skin was cold but not icy and her hair was still neatly plaited, thick dark and shining.
I can still hear the cars rushing past on the roads around the hospital. A modern time chorus of forever and always, a soft rumble in the distance. The light comes through the window next to which I sit. A gentle breeze from outside flutters into the messy changing room, giving life to the thin cotton curtains that brush against my skin.
I felt my pulse in her hand, stronger and clearer than normal. Still now my heart beats slowly but with a message in its heaviness”
After some time and a cup of sweet milky tea I returned to the controlled area. The woman was still there, much to the dismay of the nurses who thought it shameful of the doctors to take so long to pronounce the death. In fact, three hours passed and the doctors had still not visited. I did not share the frustration of the other nurses. I was glad that she was undisturbed immediately after dying because it felt more natural to let her be than to quickly proceed with taking her to the mortuary.
Eventually, the doctor did come and carried out the tests to confirm her death: A lack of pupillary response to light, a lack of response to painful stimulus and a lack of heartbeat or breathing.
We then had to wash her and put her in a white zip bag before moving her to a trolley to be taken to the mortuary. By the time we were able to do so, her joints were stiff with rigor mortis and her face was set in the same stern serenity as before.
Rose and I opened the cotton curtain to the outside world and wheeled the bare metal bed to the doors. We were met by a young porter, who, with a reassuring smile and dutiful nod took control of the bed and wheeled it down the corridor and out of sight. That was the last I saw of her.
We then cleaned the bed space thoroughly but without the ordinary haste of ICU nursing. There was no rush and we needed the time even if we did not consciously create it. Every surface from the mattress of the bed to the feet of the resting ventilator was wiped down. We did this without talking, lost in thought as we worked in autopilot indulging in deep catharsis. I remember feeling sentiments of thanks to each member of the inanimate team of machinery that had been deployed in an attempt to safe life. The ventilator, now sleeping that had supported her broken lungs, the ECG monitor that had tapped into the electrical circuitry of her heart alert us to any abnormalities, the infusion pumps that delivered her drugs with perfect precision.
Although this was a sad day in many ways, I slept well that night. I was grateful to Rose for showing me a perfect approach to death that I will use as a gold-standard in my professional and personal life. The whole process was so human, so heartfelt and utterly respectful. I was re-assured that death in a hospital, even in a biohazardous environment, can maintain its gravity and specialness.
When drifting off to sleep that night, I felt a strange feeling of friendship with death. It seemed as though there was a polite silent dialogue to digest and reflect on before our next meeting in the waiting room.
Above all, I felt honoured to have played a part in facilitating the peaceful passing of this woman.
May god bless her and keep her, and may his light shine upon her.
3. Little miss delirious
In July the number of COVID ICU admissions had steadily declined despite a local flare up of cases that pushed Leicester back into lockdown. We braced for a wave of very sick patients to mirror the local outbreak, but it never came. In fact, we cleaned the larger Bay A and re-instated it back as a normal ICU to receive patients freshly out of cardiac surgery. In a smaller area, Bay C, we had just four COVID patients left.
On a shift in Bay C I was looking after a very sick woman who had been in ICU for a long time. Thankfully though, she was getting better and had been successfully extubated.
The road to recovery from covid is long and tortuous and unique to each individual. Once death looks as though it has been avoided, an intensive multidimensional rehabilitation is implemented. The ventilator machine, which is depended upon for life cannot be stopped abruptly and neither can the drugs. They are gradually weaned to re-introduce the body to supporting itself naturally.
For this patient, we were beginning ventilation weaning in which we planned to turn off the mechanical ventilation and to let her breath independently for the first time in weeks. This would also allow her to rediscover her voice again albeit with the hallmark graininess of someone sick with respiratory illness.
The day went smoothly, except for a delirium that give her the attitude of a frightened girl and the movements of a boisterous drunkard. She would frequently burst into tears and with slow laboured arms repeatedly tried to pull the tracheostomy tube out of her throat. For example, when I explained to her that she cant get up and walk to the toilette and that she didn’t need to because of the urinary catheter and bowel management system that was in place, she screwed up her face in protest as if I had broken her favourite doll.
Attempting to communicate to her the importance of getting on top of her behaviour was actually quite funny, like giving futile stern instructions to a young child who is certain to ignore them. “My dear, please do not pull out this tube or the lines attached to it, you really need those to breathe” I would say to her. She would nod at me with a look to say “of course not my friend, wouldn’t dream of it”, accompanied a sleazy slow wink to solidify the successful lie. Two seconds later, the alarms would go off and she would be lay there revelling in her guiltiness. Air would gush out of the ventilator and I frantically had to reconnect the breathing tube, glancing up to see her cheeky grin which lifted my lips into a smile under the mask as well.
By the end of the day she was tired and was dozing off. Usually I feel sad for the patient, but she was so belligerent in her delirium that I couldn’t help but feel a bit pissed off and humoured at the same time. She was getting better and it had been a good day. I was ready to go home.
4. The silent conductor
One patient had been in ITU for almost 40 days. I had been with him when he was first admitted and it became routine to see his name on the board each morning. He was in single organ failure and was neurologically intact. For as long as this was the case, there was total cause to treat him, even if he wasn’t making great leaps towards a full recovery each day. With many hours spent caring for him, his management became quite familiar to me.
I had been looking after him one day and everything had gone smoothly. he was comfortably resting in the evening.
After 12 hours in the muggy Bay C, my shift was coming to an end when word came of a new admission to the COVID area. When they would arrive and in what condition they would be was not given with any certainty so I dismissed it in a way, thinking I’d be gone by the time they got here. I caught wind that the patient was very sick and may be coming intubated, but probably not for a few hours. In my mind I had not even considered that I may be moments away from an intensely traumatic experience.
Just 30 minutes later, a full team including a consultant ICU anaesthetist, a junior doctor, and a troop of nurses burst through the doors and positioned themselves in the side room. With them they brought an air of urgency and catastrophe and a very sick patient.
Attracted to the commotion and keen to make myself useful, I excused myself from the care of my familiar patient, asking the ECMO specialist to give handover. The new arrival, frightened and desperately breathless but still conscious was wearing a space-like inflatable bubble over her head. She was Indian, with a thin face and sunken eyes that darted about in terror, searching for some form of comfort in the alien environment. Her hair was clumped into black strands that stuck to the side of her face and she gripped the side of the bed as if attempting to stabilise the world shaking beneath her.
The team worked with effortless haste to prepare the space for intervention, connecting her to the monitors and ventilator. They did not know that it would ultimately be her deathbed in the days to come.
Amid the organised chaos, I prepared fluids and propofol and set them up in the infusion pumps. The consultant was outside preparing an aseptic field for intubation which he signalled to the rest of the team with a simple gesture of his thumb directed into his mouth. I quickly recognised that this is how he operated. Standing back, observing, thinking and conducting his plan in silence, not risking his voice getting lost in the sea of noise and movement. Everyone understood his commands as clear as spoken words in a quiet room – Everyone except for me, given that it was my first time in this team.
I stood to the right of the patient and asked if there was
anything she wanted. “Water, water, water” she rasped. I retrieved a cup of
water as fast as I could and put the straw through a valve in the bubble. Her
eyes shook with anticipation as I struggled to get it through the gap. She
re-hydrated with a desperation that I had never seen before, as though she had
been deprived water for a year.
I stood by her, acting intuitively to try and provide some comfort with her thin fingers in my hand. She kindly asked me with her eyes if I could cover her feet because they were getting cold. Her delicate legs lay crossed at the bottom of the bed and her newly painted toenails reflected the bright lights from the ITU ceiling. With the blanket straightened, she dipped her head in gratitude, tried to smile and gave my hand a short squeeze.
Eventually the aseptic field was wheeled into the side room and I let go of the patient’s hand, sharing one last look with her bone white eyes.
The Silent Conductor leant down to the patient and used his voice for the first time to explain to the woman in Hindi what was happening. With a single gesture to his own thigh, he signalled to the junior doctor to place a central line into her femoral vein. The young doctor proceeded to do so, whilst the captain began to meticulously administer sedative drugs.
To be intubated, the woman would need to remove the bubble over her head which was sealed tightly around her neck with air pressure. With great effort, she pulled it over her face, getting it stuck on her nose in haste. As she did so the bed was lowered and one of the nurses went to place an oxygen mask over her face. In a frantic struggle with waving arms like branches of an old tree in the wind, the world moved from underneath her and she was plunged into sedation.
The Silent Conductor took his position at the end of the bed and continued with the intubation whilst keeping a close eye on how the junior doctor was doing. Getting central venous access is not an easy task at the best of times and it was made trickier by the acuteness of the situation. But he was doing very well so the conductor remained still and silent except for his intensely thoughtful eyes that monitored everything in the room.
The alarms started to scream as her blood pressure plummeted to a level that would be incompatible with life if not treated immediately. I started the Noradrenaline pump and found myself by her side at the head of the bed. The Conductor looked up at the monitor, back to the patient and then summoned my eyes to his. The instruction this time was signalled with his two hands held in front of his chest, one on top of the other pushing down into the air and back up again. It took about second for me to clock that he wanted me to start CPR. For him this lag was an unforeseen lapse in understanding between himself and a member of the team. To clarify his command, he pointed to the patient calmly, and, with his eyes still locked with mine he dipped his head and lowered the corners of his lips to express his certainty.
Instead of responding appropriately to the instruction, I froze. My peripheral vision blurred into a sea of grey-blue noise and an acute rush of shock soaked my body with icy sweat. For what felt like minutes I stood petrified with my ears ringing and my heart beating through my mouth.
My mind screamed in confusion at how this human who was holding my hand and thanking for covering her cold feet just two minutes ago was now moments away from death.
In reality, it was probably a matter of seconds, but time enough for an experienced nurse by my side to realise what was happening. He took my position swiftly and began to compress her chest repeatedly. The conductor adjusted to the change and signalled the instruction to administer the CPR slowly, just enough to support the heart whilst the noradrenaline combatted the drop in pressure caused by the sedatives.
I stood back with a feeling of nausea creeping like a spider up my chest, breathing heavily into my mask which was now wet with sweat and vapor. I was left undisturbed for a matter of seconds before the junior doctor grabbed my shoulder and said, “I need you to give this fluid, stat, as fast as possible, right now”, thrusting a bag of Volplex into my tummy and quickly returning to the other side of the bed.
I primed the line and hooked it onto the peripheral venous site on her left hand but there was no drip stand or infusion pump nearby. All I could do was hold the bag and squeeze to push as much fluid into her venous system as fast as I could. I figured that I could do this faster if I attached a syringe spike to the bag and drew out the fluid 50 ml at a time. I abandoned the position of human drip stand and went to get the bits that I needed. There were no spikes in the drugs trolley, none in the equipment racks at the back of the room, none in the bed space where I had been routinely caring for a stable patient all day.
Really now I panicked and quickly returned to squeeze the bag again. The fluids were not flowing, and I couldn’t understand why. I then looked down and saw that the peripheral line had actually come out of her thin veins and the volplex was spilling over her skin and onto the bed sheets.
Thankfully, I had gotten a good amount of fluids in and the infusion that I had set up before was still running. The combination of noradrenaline, filling her intravenously and CPR had kept her blood pressure compatible with life and it was now climbing to an acceptable level.
At this point, bleached white and hollowed out after 13 and a half hours in ITU, I asked the senior nurse if it was good for me to leave. I walked back to the changing room on rubber legs across a tinfoil floor, seeing the world through burning eyes. I remember feeling as though everyone knew about my hesitation and fumbling performance and was judging me for it.
This was the first time in ICU that I had been properly shaken and I sat the changing room on my own. It was some time before I felt ready to get on my bicycle and ride home.
Two days later I was back in Bay C looking after a different patient, but my feet took me immediately to the side room to see the woman. She was now unconscious and on ECMO. The large red cannulas transporting high volumes of blood lay along the right side of her neck like snakes. I stood in the door frame looking at her face which was now swollen and blue, remembering her kind eyes and cold feet with disbelief. Her vital signs indicated that it was likely for her not to make it to the afternoon.
The nurse looking after her spent the whole morning on facetime, allowing her family to say goodbye through a phone screen. From my bed space I could hear them crying. There were young children, grown men, elderly relatives on the other end of the call, all with distinct tones of sorrow. Their sobs drifted through the Bay which was thick with sombreness. I tried to keep my head down and pay attention to my patient but I could feel the weight of the situation liquifying the remains of the partition between emotions and duty. In truth, it had had been battered down two days before. The digitised sobs were like daggers in my back. I broke down in tears from across the room, re-living the final moments with which the woman dropped into darkness.
This was the most traumatic experience from my time in ICU and it took some time to get my thoughts back in order. In fact, I still feel shattered by the injustice of the situation. No person should ever live their last conscious moments in fear, surrounded by masked strangers who do not speak their mother tongue.
I spoke about this with friends and family but still there was a dark cloud of uncertainty around the whole situation. Why did she drop? Why didn’t she recover? May she have lived had we not intervened so aggressively? I could not silence questions that raced around my mind. I needed answers.
It was explained to me that by not intervening she was heading to respiratory failure and ultimately death. It also turned out that she had a congenital heart defect and that lowered the chances of success on ECMO and was probably behind the cardiovascular instability. They had no option but to try, and sadly, with the odds stacked against her, it didn’t work.