Our NHS doctors and nurses are no strangers to dealing with death. But even the most highly trained staff are feeling broken by the toll of the pandemic. Anna Moore hears their harrowing stories and asks how they will cope with the emotional fallout.
For Abi Carr*, 45, a senior intensive care unit (ICU) nurse in Buckinghamshire, there’s a Covid-19 patient she’ll never forget. A woman in her 60s, ‘she had two sons like me,’ says
Abi. ‘She came in struggling to breathe, so exhausted she wanted to die.’ The woman was first given CPAP (continuous positive airway pressure) – a tight-fitting mask that floods the body with oxygen. ‘She was very sick and I fought hard to have her ventilated. When a consultant finally agreed, she arrested and died while it was being done. Did I do the right thing? Should I have pushed harder so it was done sooner? I still wake at 3am thinking about that lady. She’ll be with me for ever.’
For 31-year-old Dr Maddie Wells, a trainee anaesthetist in an ICU in Central London, the patient who stays in her mind is young like her. She is a new mother, but is yet to see her baby – instead she is sedated and on a ventilator, fighting Covid-19. Thankfully, says Dr Wells, she is now ‘doing well’.
For Dr Emily Kelly, 38, an ICU consultant in the East of England, the phone calls to relatives remain her darkest memories. ‘There’s no substitute for sitting down face to face with a family and talking through what might happen to a patient, carving a relationship over time,’ she says. ‘Phone calls don’t cut it. Since Covid, I’ve phoned complete strangers and told them their mother or father has died. I’ve called an elderly man and given him the news that his son has died. I remember hearing his wife faintly in the background, trying to figure out what was going on. I’ve lost count of the number of phone calls that have culminated in the person on the end of the line asking in disbelief, “So I’ll never see their face again?”’
While the number of Covid cases continue to drop and most of us welcome the easing of lockdown, critical care staff are left with a head full of memories like these. Although they have always worked under pressure, the past few months have been, as Dr Wells puts it, ‘pressure-cooker pressure’. And though the death rate in critical care has always been higher than most areas of medicine, with Covid it has doubled to one in two. ‘I’m used to death, but I’ve not known it in these numbers before,’ says Dr Kelly. ‘Less than half the patients I placed on mechanical ventilation have survived. I’ve looked after multiple members of the same family, and you can’t help begging the universe for some sort of pity when you’re treating the relative of someone whose death you witnessed not so long before. This volume of trauma and tragedy is new to us.’
Add to this a whole range of extra challenges: a new disease we don’t yet fully understand; extraordinary hours; colleagues off sick, perhaps seriously ill themselves; layers of PPE to slow you, make you sweat buckets and separate you from colleagues and patients. Then after work come the lockdown rules. Dr Wells and Dr Kelly, who both live alone, return to empty homes. Old coping mechanisms such as meeting friends or hitting the gym are no longer possible. Others, like nurse Abi Carr, a wife and mother of two teenage boys, have lived with the daily dread of bringing the disease back to their families. ‘I leave my shoes in the porch then go straight up to our loft room, shower and wash my hair before I see anyone,’ she says. ‘My husband doesn’t sleep there any more – he’s in our son’s room. No one’s allowed at the top of the house except me. It’s like a contaminated area.’
For all these reasons, the national charity the Intensive Care Society (ICS) has launched an urgent appeal in order to fund specially tailored psychological support for the UK’s critical care workers. Dr Ganesh Suntharalingam, ICS president and himself an intensive care consultant, believes this has never been more vital. ‘Everybody fears a second wave of the virus,’ he says, ‘but we also need to worry about the real possibility of a “second epidemic” of burnout and post-traumatic stress disorder [PTSD] in the people we need to look after us. When staff were in the midst of it, everyone threw themselves into work and found ways to cope. It’s when things go quieter and you’re on your own that it can hit. That’s when critical care workers might ask if they want to do this all over again in a few months’ time – and, with the best will in the world, they could be too exhausted.’
Dr Julie Highfield agrees. As a consultant clinical psychologist embedded in Cardiff Critical Care, her job is to allocate half her time to supporting patients and the other half to supporting staff. It’s an unusual role. Only one in five UK hospitals has a psychologist dedicated to intensive care, and most are there for patients. In recent months, the number of staff self-referring to Dr Highfield for therapy has tripled. Studies of healthcare workers in previous pandemics such as Sars and ebola found almost one in four suffered PTSD, while one in three suffered psychological problems such as depression and anxiety.
According to Dr Highfield, critical care in pandemics typically moves through three phases: preparation, active phase and recovery. Each brings separate psychological pressures for staff. ‘The preparation phase is when people are urgently planning for the unknown with limited time and resources,’ she says. ‘For staff, it was a logistical nightmare: repurposing beds, redeploying personnel, creating isolated areas where you can contain a virus. There’s a lot of uncertainty. It’s very high stress.’
For Dr Wells, who had only joined the critical care unit in February, this was the most frightening point of all: ‘Seeing it play out in other countries before it arrived in the UK, everyone talking about it and not knowing what would happen, dealing with the uncertainty and feelings of dread.’ Dr Suntharalingam vividly recalls the first time he entered his hospital’s hastily created ‘expansion area’ for Covid patients. ‘You know about it,’ he says, ‘you’ve heard all the planning, but the first time you put on PPE, unzip your way through the plastic airlock and walk into this long ward filled with beds and ventilators and people in PPE, it’s like stepping into a science-fiction movie. You adapt very quickly but the strangeness and disorientation never leave.’
The active phase is the peak of the surge, when all those beds are filled and staff are in ‘full go mode’. Though high adrenaline and huge camaraderie can propel them forward, there’s the risk of sudden exhaustion with staff working all hours with no breaks, witnessing things they’ve never seen before. This was certainly true for Abi Carr. ‘It was hideous,’ she says. ‘It felt like the apocalypse. I couldn’t sleep, there was no time to eat, I lost weight, I spent all my time at work – I’ve done 100 extra hours. Horrendous waves of people were coming in with such low levels of oxygen and they were young – they could be my relatives, my mum; they could be me. There was nowhere to put them all. We were transferring some to other hospitals, picking who should go, who should stay. You’re always thinking, “Should I have done something different?” It felt like it would never end.’
This is when normal standards of care and ethical codes around ‘best practice’ and what counted as a ‘good death’ had to be routinely broken. Patients died without loved ones close by. Terrible news was delivered by phone. Difficult decisions to end treatment were made every day. According to Dr Highfield, this can trigger huge moral distress and self-blame as well as emotional disconnection in staff.
In Abi’s ward, CPAP patients often fought to remove the masks that kept them alive while nurses had to physically restrain them. ‘Those masks were tight and sore but they deliver 100 per cent oxygen – normal air is 21 per cent – and if they take them off, levels drop, their lungs collapse and their hearts can’t function,’ she says. ‘We lost patients who did this.’
In other cases, when it was decided that the patient could not be saved, decisions were made to deliberately remove the mask. ‘It was to “allow” them to die in more comfort, not to “cause” them to die,’ says Abi, ‘but it’s hard to watch and hard to do. The families couldn’t be there. We were the ones who sat and held their hand.’ Unlike ventilated patients, CPAP patients were awake. ‘They had a voice; they know what’s happening. I remember one gentleman we’d got to know so well. He was sort of conscious, was comfortable, he’d had enough.’ Critical care staff helped families say goodbye, often holding the iPads themselves when patients were too weak to do it. ‘You’d hear them say, “I love you, Dad”, “We miss you” and then crying,’ says Abi. Sometimes staff arranged for a patient’s favourite song to play as they withdrew treatment or read out letters from family members. Some took handprints of patients for families to keep, in the way staff do when babies die in hospital.
Twelve weeks since lockdown and past the peak, we’re reaching recovery phase, where staff might finally have time to step back and reflect. To Dr Kelly, this brings no relief. ‘I walked through an empty bay of beds in the Covid unit this week and for the first time, I felt like I was at a funeral,’ she says. ‘It’s hard not to look at those empty beds and just see dead people.’ Despite years of experience in critical care, Dr Kelly isn’t sure how she’ll cope in the long run. ‘I haven’t offloaded because it doesn’t feel a safe option right now,’ she says. ‘Who wants to open a door and find out if they’re going to fall apart, when they know that they need to pull themselves together the next day?
‘Recently, at work, I’d just finished a phone call to a patient’s very distressed son. I put down the phone and put my head in my hands and, although tears had welled in my eyes, I thought with the bulk of my mask and visor, nobody would see. A nurse came and put her arm around me and I realised it was the first time anyone had hugged me since the beginning of lockdown. I have no idea how this will change me,’ Dr Kelly continues. ‘Either I’ll dislike myself for not being affected enough by all the trauma that I’ve witnessed, or I’ll break myself trying to absorb what has happened. There’s probably a middle ground.’
The ICS want to fund enough psychological support to help staff find this ‘middle ground’. Dr Highfield has been seconded to oversee the programme. ‘As a charity, we can’t afford a full-time psychologist in every unit,’ says Dr Suntharalingam, ‘but we would like to go into every unit, talk to staff and offer sessions with a trained psychologist online.
‘It’s not just the 30,000 staff who usually work in ICUs,’ he adds. ‘We also need to reach the 30,000 workers who were redeployed from other departments. In most areas of medicine, it’s rare to see someone die – now they’ve been faced with that every day. When they move back to their former roles in a normal ward, it could feel very isolating.’
‘There has been a lot of comparing this pandemic to being at war,’ says Dr Highfield, ‘and the burnout, the PTSD, the anxiety and depression could be similar. The next six to 12 months is when we could see it emerge.’ Initial stress responses to trauma – replaying an event on a loop, being edgy, irritable and feeling constant dread – can develop into vivid flashbacks, nightmares and insomnia. ‘Emotional and physical exhaustion can take staff to a place where they believe they have nothing left to give, that whatever they do isn’t enough, where they struggle to even get out of bed and interact with family,’ continues Dr Highfield. Fortunately, specialised support can help prevent this – and PTSD responds well to therapy. ‘It’s more than a listening ear. It can help staff process what they’ve been through, formulate how they are coping and really get underneath it.’
Without this, Dr Suntharalingam fears for the future of ICU medicine. ‘In normal times, one in six people will go into an ICU at some point in their lives – it’s there for the strokes, the heart attacks, the car crashes. We need to look after the staff so they can look after us. ICU workers tend to be courageous, but if you know that this speciality means being hit by these waves, working extraordinary hours under enormous pressure with no support, there’s a real danger that it will put new people off coming and make the people already doing it want to leave.’
Abi agrees – in fact, weeks ago, in her lowest moment, she also planned to change career. ‘If you’ve got an option not to do this, why would you?’ she asks. ‘This is hard work, this is horrible. I told myself I was leaving nursing.’ Now though, ‘I’ve wavered,’ she says, ‘because this work is where you make the most difference. It’s a messy time, we don’t know what’s round the corner, we could be in those dark days again – but at the end of all this is a patient. And that’s why you do it.’
*Some names have been changed.