‘The trauma? That will come. What we’re seeing stays with you’
Physiotherapist Ashley Boffa cried when she was called back to the frontline before Christmas. A year into the pandemic, she and thousands like her are only just realising the price they have paid.
Ashley Boffa is having a breather. She has peeled off the full face mask that has pressed a deep crease down her cheek, and is sitting in the “rest and recoup” room for staff. Some chat. Others just sit alone, looking a little bit shell-shocked.
Usually she’s a physiotherapist, but now she is one of thousands summoned to the front line from all parts of Britain’s National Health Service to care for the onslaught of coronavirus patients threatening to overwhelm intensive care.
“I cried when I got the call,” says Ms Boffa, 33, who was at home with her two-year-old son when it came.
She spent enough time watching patients die alone during the first wave, comforting them when their families could not, that it took all her nerve to walk back into the intensive-care unit (ICU), the pandemic’s last-chance saloon that is steadily expanding across an entire floor of Epsom General Hospital in Surrey in England.
“The first time, you just went with it. This time you know what you’re getting in for,” says Ms Boffa, who found herself having panic attacks well into the summer. She fears they will come back.
“If I let myself go into it, I’ll probably burst out crying. Everybody is so stretched. This time so many people are just exhausted. It’s a big thing to do again, but you’re doing it to help people.”
After the first surge she took part in group counselling, and thinks it might be healthy to have some one-to-one sessions once this is all over – though the end still feels a long way off.
“I think a lot of people didn’t deal with how they were feeling last time. They got through it and just put it under the carpet, thinking, OK, it’s done. I’m just ticking along at the moment, trying to be OK,” she smiles, steeling herself and picking up her mask. Break’s over. It’s time to go back.
As with so many other hospitals across the country, COVID-19 has forced Epsom to change the way it does almost everything. The cancer patients have been redirected to private hospitals nearby. Elective surgeries have been cancelled. What was once an immaculate orthopaedic ward has been transformed into a frenetic intensive care unit. The theatres where surgeons used to operate on knees and hips are now three-bed bays where patients lie in varying states of consciousness.
To anyone else less fluent in the beeping language of touch and go, it’s hard to work out who is in the most danger. The man whose windpipe is still red and raw from the tracheostomy? The man whose neck is lumpen and swollen from the ventilated air leaking from his chest cavity? Or the lady in her seventies who lies still amid a tangle of wires and tubes?
Normally the unit here would have eight intensive care beds and a small handful of specialists giving one-to-one care. This month, Dr Matt Varrier has been supervising a team of dozens, including staff who have returned from retirement, midwives lending a hand and consultants from other hospitals, as they care for 21 patients. The eldest is 73, the youngest a 31-year-old man too breathless to speak.
There are no big, dramatic moments. Just constant worker-bee activity. It’s steady. Relentless.
“All of these are the sickest patients we might have on a normal day,” says Dr Varrier. “In the wintertime when we’re full, we might have [a maximum of] three patients who are as sick as these people.”
When The Times visited during the past week, four people had died over four days. Of the 21 remaining COVID patients in the unit, two were also on kidney dialysis having suffered multiple organ failure. In these circumstances, says Dr Varrier, “the mortality rate is 70 per cent”.
The empty beds tell their own story. Only hours previously, one had been occupied by a patient who was a fellow NHS worker. She didn’t make it. Her bed had been stripped, the monitor cleaned, bearing a label “clean and okay”, ready for the next occupant.
Staff in intensive care or the intensive-therapy unit (ITU), as it is also known, are of course used to dealing with the sickest of patients, but losing patients at this rate is not normal, says Simone Hay, the unit’s director of nursing.
“ITU are used to seeing people get quite unwell and then get better. But now they are not necessarily getting the rewards they are used to,” she says. When they enter intensive case, “you hear [their relatives] saying ‘I’ll see you when you wake up’ and you’re wondering, will they?”
In some cases, Dr Varrier says, “we’ve had quite a few situations where they’ve been unconscious while other members of their family have died [of COVID]”.
In others, the worried relative calling for updates has already lost other loved ones to the virus. Infection control and the sheer volume of patients means there is little time for the other part of the job – supporting families.
“Normally, there are patients whose families you build up quite a rapport with – you might see them on the unit, say hello, give them an update. Now I don’t have time to personally talk to 25 different families on a regular basis.” Most of his contact now, he sighs, is to “ring people to give them some particularly bad news”.
For the new staff redeployed from elsewhere in the NHS it has been particularly tough, he says.
“Let’s say you’re a physio. You might have no more experience of people dying in front of you than [the average person]. Even some nurses have very limited contact with death, dying and palliative care. This is not their chosen area.”
While they’re having a baptism of fire, he says, the critical-care specialists have the added burden of supervising and training new recruits.
For example, the scramble for ventilators means the unit now has three different brands, each with their own different operating requirements. “Familiarity is extremely important. That’s built into the safety of what we do.” All these details add to the scale of the challenge facing his team.
This time last year, Jamie Short was doing his finals. Now the 23-year-old junior doctor is in the thick of it, “trying to help as much as I can” on his eighth shift in an intensive care unit.
“It’s not an area of medicine I’m familiar with,” he says. “I mainly speak to families when people are going in the right direction, trying to approach those conversations as sensitively and honestly as I can.”
The physical risk to staff remains. Ms Hay was due to get her second jab at the weekend, as recommended by Pfizer, 21 days after her first. That has now been cancelled on the government’s recommendations and she must wait 12 weeks like everybody else. “It makes me feel quite vulnerable,” she says. “I’m in the heart of it, every day.”
She questions the wisdom of postponing what could have been a huge, much-needed boost to morale. Epsom and St Helier NHS Trust says that around 4000 of their 6000 staff have been vaccinated, although Ms Hay and some other ITU staff are still waiting for confirmation of when their second doses will be.
“We don’t know what the efficacy will be after 12 weeks, instead of three,” she says. “We don’t know where we are. It leaves staff feeling very vulnerable.”
Attention turns to the woman on a ventilator at the end of the ward. A senior nurse cradles the unconscious patient’s head, while a team of seven surround her bedside in preparation for “proning” – placing her on her front to improve oxygenation.
Dr Kate Tatham, a visiting intensive care consultant, says the proning position, though effective, leaves ventilated patients vulnerable to pressure ulcers, particularly on the face and nipples.
The team calls out for “one more” to help turn the woman on to her front, and settle her for the night.
“That was probably one of the hardest ones,” says Ms Boffa, “but it worked so hopefully it helped”. Later, we hear that her condition has improved.
The shifts are physically challenging, she says “I’m always sore the day after. This is not my niche. It’s a lot of pressure. You’re working out of your scope so you feel more vulnerable.”
Nearly half of intensive care staff reported symptoms of post-traumatic stress disorder, severe depression or anxiety, according to a study published in the journal Occupational Medicine.
Researchers found that about 40 per cent of staff who were surveyed in the aftermath of the first COVID-19 crisis had probable symptoms of PTSD, while more than one in seven clinicians and nearly one in five nurses working in ICUs reported thoughts of self-harm or suicide, prompting a warning this week from experts that NHS workers were “suffering more than combat troops”.
Many are also running on empty.
Mo Radha, a 49-year-old healthcare assistant, believes the pandemic will leave behind a traumatised workforce, who will need some help putting back together themselves. “The PTSD? That’s going to come in the future. What you see in ITU, it stays with you.”
He had his own wobble last week. “There was a lady who was dying. She had three young sons who visited, and the way they were talking to their mother …” He shakes his head. “I couldn’t sleep for a couple of nights. You like to think you’re brave but sometimes your subconscious takes over.”
There is a “cumulative burden”, says Dr Varrier, a 40-year-old father of two who is on day three of a ten-day stretch. He also worries about the welfare of the redeployed staff who will have to play catch-up on all the delayed treatments in other parts of the NHS when the crisis is over. “They’re going to have to go back in full steam,” he says.
As he talks, he is interrupted as a very sick patient has his ventilation tube removed. The nurse in full PPE pulls the tube from his throat as his legs twitch. The guttural gurgle rings through the ward.
The man has been on ventilation for 12 days. “Any longer his body will weaken,” Dr Varrier says. “He’s not going to be any stronger tomorrow than he is today, so we’re going to go for it.” If he can’t breathe without it, his last chance is a tracheostomy. The attending nurses try to offer the man some comfort but their words are muffled and fuzzy through their masks. Overnight, we will learn that two more patients have died.
Downstairs, Dr Claire Wells, respiratory consultant on the 11th consecutive day of a 12-day stint is looking after 20 patients on the respiratory ward. They are doing better, breathing with the help of non-invasive ventilators, which still need a close level of monitoring.
“Resilience is a word that’s used a lot,” says Dr Wells. “We’re very mindful that the baseline resilience has had a little chip in it.”
It has been “chip, chip, chipped away” since March, she says. Medics are missing the pub just like everyone else. They have nowhere to decompress, whether it’s (for her) going to watch a beloved rugby match or (for others) “taking it out in the gym”.
There are moments that make it all worthwhile, however. She has some good news for Chris Wilson, a 58-year-old supply teacher who’s sitting up in bed. He was very ill. Now he’s ready to leave critical care.
“So the plan,” she tells him, “is we will get you to the ward if we’re happy everything is stable.” She seems almost more delighted than he is.
“This is what you want to see,” she says. “That’s what you hope for.”
The Times
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