This extract from Breathtaking: Inside the NHS in a Time of Pandemic, by Rachel Clarke (published in the United Kingdom by Little, Brown Book Group Ltd, January 2021), is part of a series in which OECD experts and thought leaders — from around the world and all parts of society — address the COVID-19 crisis, discussing and developing solutions now and for the future. Aiming to foster the fruitful exchange of expertise and perspectives across fields to help us rise to this critical challenge, opinions expressed do not necessarily represent the views of the OECD.
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In January 2020, novel coronaviruses are nowhere on my mind. Like everyone working in the NHS, I am steeled for a home-grown catastrophe. For no matter how many patients lie on trolleys in corridors, how many ambulances sit trapped on hospital forecourts, how many photos go viral of toddlers slumped on their parents’ coats, receiving oxygen on the floor of a beleaguered A&E, nothing ever truly changes. These days, the annual NHS “winter crisis” is both dreaded and reliable as clockwork.
The numbers are so large, and repeated so frequently, they have long been leached of their force: 17,000 hospital beds lost since 2010; only 2.5 beds per 1,000 people in the UK, compared with three times that number in Germany; unfilled vacancies for more than 10,000 doctors and 40,000 nurses.
NHS staff dread winter because nothing quite curdles the soul like pouring your all into a system at breaking point. Up close, the failures of care are the furthest thing from an abstraction. They assail you in the cries and whimpers of elderly patients with dementia abandoned on trolleys, in the sourness and sweat of the crumpled sheets in which a patient has just died, alone and unnoticed. They come in the form of verbal abuse from relatives at breaking point who turn on the doctors and nurses because we are there, the human face of all the underfunded dysfunction. They can make you want to cry or quit. You brush yourself down and carry on.
“How do you think it’s going to be this time round?” a colleague asks me.
“Well, we don’t seem to have been on black alert as much as usual,” I answer cautiously. “Maybe flu hasn’t hit as badly as people feared?”
For safety reasons – in order to manage surges in demand – hospital bed occupancy should sit below 85%. Yet year round in today’s NHS, occupancy is nearer 100%. There is absolutely no spare capacity. The severity of a particular year’s strain of seasonal influenza may thus spell the difference between keeping heads above water or full service implosion. A virus so tiny it requires an electron microscope to be seen can, in short, bring the NHS behemoth to its knees.
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There always has to be a first time. And though intubation is the emblematic procedure of the pandemic, this moment, this patient, this pair of wide and roving eyes, is the hospital’s first time. Four people loom around his bed in the semi-darkness, swathed in blue plastic, masked and gowned, disguised behind thick Perspex visors. Normally, in an ICU, it is the patient who becomes dehumanised, punctured and crisscrossed by a cat’s cradle of wires and tubes.
Tonight, though, it is the doctors and nurses who appear less than human. Veiled behind their protective equipment, they hover like ghosts at the bedside, preparing nervously to act.
Even in normal times, intubation is a serious business. In order to connect a patient via a tube to a ventilator, they must first be anaesthetised and then paralysed with drugs. Once the patient is unconscious and limp, the intensivist can set about the delicate business of depressing the tongue with a metal blade and steering the tube downwards, past the vocal cords and into the trachea. Few procedures in medicine have higher stakes. Losing an airway – failing to access the lungs – leaves a patient entirely helpless, immobilised on the edge of suffocation. Most doctors cannot cope with the intensity of managing airways. The pressure is too great, the requisite skills too daunting. Those that can – intensive care doctors, anaesthetists and emergency medics – earn their colleagues’ utmost respect for possessing nerves of steel.
It’s Sally, an intensive care nurse, who tells the patient. She takes his hand and leans in close, hating the necessity of raising her voice above the layers behind which she is barricaded. “We’re going to put you on a ventilator,” she says. “We can give you much more oxygen that way. It’s going to help your breathing.”
His eyes, above his mask, start to skitter wildly as if searching for something or someone to help him. The machinery bleeps as his blood pressure surges. Sally keeps holding his hand. Over and over, the same words to soothe, a litany she hopes may offer comfort. “It’s going to be all right. We’re here for you. It’s going to be all right.” But his face is white and bathed in sweat. She’s convinced he can sense the uncertainty, somehow intuiting how out of their depth they are, the small team that is meant to be saving him.
A hush descends as the intensive care doctor moves into position for the intubation. They are huddled like supplicants around the bed, these four staff peering down on one patient. It is intimate to the point of claustrophobia. Even the air they share belongs to them and them alone. For the five are sealed inside a room specially designed to sequester infections, its negative pressure drawing in air from outside while clinging to its own contaminated vapours. That air, of course, reeks of invisible danger. Every surface and every one of the gowns and masks they wear will be thickly coated in particles of coronavirus. As they work, each team member is managing the fear that the person whose life they are trying to save may yet be the death of them.
You cannot get much closer than this. The doctor leans over directly above her patient’s now slack and gaping mouth, decisively angling her blade downwards. An inch or two more and they could almost be kissing. Normally, she would have spent several minutes clutching a mask to her patient’s face to fill their lungs with pure oxygen. It buys time. By elevating blood oxygen levels to nearly 100%, it gives a margin of error – five minutes to play with – should something calamitous go wrong. But this time, the patient is already on pure oxygen. There is nowhere higher to go. Even worse, the moment she takes off his mask to commence the intubation, his oxygen saturations will plummet. She knows she has to act lightning-fast.
At her signal, the mask is removed. A cacophony. Every alarm shrieking in unison. The patient’s blood oxygen levels are dropping second by second. The monitor reads 80%, then 75%, then 70%, and still the decimals flicker downwards. Even when her blade triggers a spasm of involuntary coughing, the intensivist maintains her poise. Aerosols of Covid now plaster her visor. No time to consider that now.
Sally is still gripping her patient’s slack palm. Get it in, get the bloody thing in. Sats at 60% now. Dangerously low. This is critical. In a few moments, the patient’s heart will stop beating. 55%. It’s looking disastrous. And then, those grimly exultant two words – “I’m in!” – and even as the tube is hooked up to the ventilator, the patient’s sats are soaring upwards. The whole team collectively exhales.
I am at the hospital after pleading with bosses of the Katharine House Hospice where I work to let me join the hospital team. I cannot bear any longer this feeling of impotence while the country careers into crisis. The only way I know of managing my fears is through action, trying to help, focusing on one patient, and then another, and then the one after that. It has been agreed that I can split my role, partly working with Covid patients on the wards of the hospital, partly caring for our hospice inpatients.
Today, in the emergency department (ED), some new recruits have been assembled and I’ve been asked to assist with their hastily arranged induction. The 25 freshest members of the ED team are so young and inexperienced they have yet to qualify as doctors. In the scramble to build capacity for the expected surge in patients, Oxford’s medical school has asked its students whether they would like to help. The response has been an overwhelming yes.
I commence an online teaching session from within the ED about death and dying in pandemic times. I try to convey what it looks and sounds like to be dying of Covid. How quickly and remorselessly a patient can be overwhelmed. Which drugs we use to help ease their fear and hunger for air. How hard it is to convey warmth and humanity when trussed up behind a visor and mask. All the while I watch the students’ faces as I try to steer a path between alarming them and supporting them.
One of the students, Emma Flint, a 24-year-old in her final year, finds herself posted on the front doors to the ED. In pairs, the students direct patients and paramedics to the appropriate part of the department, trying to sift the infected from the benign. Swiftly, this sieving and dispatching of patients becomes straightforward. Infinitely harder is the task of vetting the loved ones who accompany the patients here, deciding who is permitted to enter, and who to send away.
The visitor restrictions are a particular cruelty of Covid. Emma recalls meeting a young woman who arrived at the hospital in the act of having a miscarriage, doubled over on the forecourt as her partner endeavoured to keep her upright. Both their faces were white as bone. “I had to explain to them that he couldn’t stay,” Emma says.
Once, a man appeared at the front doors after being called by the hospital to say that his mother, rushed in by ambulance a few hours earlier, was now dying from coronavirus inside. His words tumbled out, a torrent of beseeching: “I know it’s probably not possible, but could you just ask if I might be allowed to see her? Just for a moment. So I can tell her I love her? I just need her to hear that.” Emma disappeared into the Respiratory ED, promising to do what she could. She re-emerged, forgetting that a smile can’t be seen behind a mask, and beamed as she offered to take him to his mother’s bed. He never stopped talking as she helped him into his PPE. “Thank you so much. I can’t tell you, it means the world to me that I can be here at the end for my mum.”
Emma took him through the double doors, past the beeping monitors and hissing pipes, the urgent conversations, the bobbing masks. There, behind a curtain, her hair white and wild, lay his mother in a dishevelled hospital gown. Emma found a chair and quietly set it down at the head of the bed. Just before she turned away, she saw two eyelids flicker open above the oxygen mask; two hands in blue gloves enclose a gnarled set of fingers, moisture glints on the face of a grieving son.
At home, I unlock the front door and reach for the hand sanitiser. Before I have even rushed upstairs to the shower – this is Mum’s new routine, every night she’s home from work now – Dave appears in the hallway, looking stern. “We need to talk,” he says.
My mind leaps compulsively to death and disaster. Dave’s parents, my mum? Has someone succumbed and been rushed into hospital? “No, no,” says Dave. “It’s Abbey. We just need to talk.”
As quickly as possible, I try to scrub every speck of infection from my skin beneath the shower. I know that on one level I am trying to erase what I have seen and heard and sought to palliate today – yet understand that these experiences, whether I like it or not, are indelible. Still damp, hair dripping, I find Dave and he explains what has happened.
“Abbey started to cry, Rach,” he tells me. “She doesn’t want you to do anything at work that could end up killing you.”
My head slumps into my palms. Finn was two years old when I became a doctor. Abbey was born during my second year of practice. In all that time, over and over, my children have suffered as the hospital has consumed too many hours, just too much of their mother. The anodyne phrase “work-life balance” doesn’t come close to capturing the forcefulness with which medicine clashes with parenthood.
“I’ll talk to her,” I mutter to Dave, too ashamed to meet his eye. “What I’m doing really isn’t high-risk. ICU is much more dangerous.”
Abbey and I sit on her bed behind closed doors. “Hey,” I say gently, as she picks at the duvet. “Dad said you got upset today?” Her voice is harsh and hostile, completely out of character. “Why do you have to be the one who sees all the coronavirus patients in the hospital? Why can’t it be someone else who doesn’t have children so if they die, it isn’t as bad?”
I hesitate. How can I possibly tell her I have volunteered, that I want to be the one helping these patients? Yet equally, how can I lie to her? I take a deep breath and grope for the right words. I try to articulate the nature of duty in terms a nine-year-old can understand, this irresistible tug to use my training to help in a crisis. “Well, what about your duty to me? And to Finn?” she asks defiantly.
We reach an uneasy truce when I swear to be as careful as possible, avoiding high-risk areas if I can. As a mother, I’m not sure I have ever felt shabbier.
Back in the hospice, we are preparing to admit our first patients with Covid when Charlie, the medical director, asks me into his office for a quiet word. “We have a problem,” he tells me. “We don’t have anything like enough PPE.”
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Under a new government directive, any non-hospital clinical setting – be that a care home, a general practice or a hospice – has been issued with the same standard PPE pack. It contains a roll of plastic aprons, some gloves and a box of 300 paper face masks, some of which have a best-before date of 2016. To put the inadequacy of these supplies into sharp relief, at the hospice we are estimating a daily requirement of at least 150 masks. The government has provided us with a stock of masks that will last, at most, for two days. You might as well push a passenger out of a plane with a handkerchief in lieu of a parachute.
“What about the emergency PPE line?” I ask Charlie in confusion. “Haven’t they been able to sort it?”
“We’ve been calling and emailing the Supply Chain all week,” Charlie tells me. “Multiple times. You leave messages, no one calls you back, it’s a disaster.”
I’m so angry, I can scarcely breathe. Tears sting at the corners of my eyes.
I send a message to a friend and colleague Dominic Pimenta, a London-based doctor who has set up a charity called Heroes aimed at protecting and supporting health and care workers. In a matter of weeks, Dom’s charity has raised more than £1m.
My message is distraught:
Dear Dom, I’m sorry to bother you when you are probably 1,000% too busy, but I am desperate…
Dom’s reply is terse: “I’ll see what we can do.”
I try not to feel too crestfallen. I am absolutely certain he will help if he can. That evening, though, I am distracted. “You keep looking at your phone more than us,” complains an indignant Abbey.
When my phone rings I lunge for it. Dom has indeed – you absolute legend – been quietly at work behind the scenes.
“I’ve sorted it. We will deliver 1,000 masks to your hospice tomorrow morning.”
I literally burst into tears on the phone.
At the hospice soon afterwards, I meet Susan Price, who, at the age of 53, received the news that her breast cancer had recurred, and reacted with characteristic defiance. “Right. Come on then, let’s get the bastard,” she said to her oncologist in late 2019.
Chemotherapy was duly planned for the start of February 2020. “At least that was the plan,” she tells me wryly. “But then, very softly to begin with, Covid began rearing its head.”
Susan quickly intuited precisely where she stood in the pandemic’s patient hierarchy. “Here I was, a middle-aged woman dying from metastatic cancer. I wasn’t the cute child or the vibrant 20-year-old who would have everything thrown at them. I was very low down the list. I was the lowest priority.”
As I listen to Susan, I find myself wincing. No doctor wants to be part of a system that does its utmost for some patients, yet casts others aside. But Covid has overturned everything.
Despite her best efforts at shielding, she develops a persistent cough and has difficulty breathing. Increasingly, she finds herself fighting for air. Terrified that she has caught Covid, she dials 999. For a moment, when they arrive in full PPE, the paramedics appear on the brink of taking her to hospital. Then she mentions she is on palliative chemotherapy for metastatic cancer. Suddenly, everything changes. “In normal circumstances, we’d take you in,” the paramedics tell her. “But there’s Covid in there. It would be much better for someone like you to stay at home.”
Someone like you. “I believed I was effectively being told not to waste NHS resources. I felt as though someone had opened a bin and just chucked me in it,” Susan says.
Further conversations with her oncologist lead her to make the sombre decision to abandon chemotherapy, which is doing little to arrest the growth of her tumours while causing ever more debilitating symptoms. Now there is nothing standing between Susan and dying. Cut off at home in isolation with her family, she starts to feel overwhelmed with pain and fear. “I was terrified.”
Eventually, Susan’s family call the paramedics again and this time she is admitted to hospital. In her distraught, dehydrated and desperate state, it feels, she says, “like being dropped into Hades”. Blood leaks from the numerous puncture marks on her arms where a doctor has attempted and failed to cannulate her. Anonymous staff in PPE rush past. Screams and moans split the air. This is where I’m going to die, she thinks to herself.
When I meet her for the first time, it is several days after her transfer from the hospital to the hospice. She still appears wan and haunted by fear, but both her mood and symptoms have begun to improve. Through tiny acts of thoughtfulness – fresh jugs of iced water, little servings of ice-cream – the staff are managing to repair her shattered trust. I find it hard to hear Susan’s reflections on how Covid has transformed her experience of healthcare. “You think the NHS will always be there for you. You think it is this whole incredible edifice, but then coronavirus comes along and it all falls apart like dust.”
A part of me longs not to share those words here. I am so intensely proud of everything that NHS and care staff have managed, at such risk to themselves, to achieve for their patients. Highlighting any mid-pandemic shortcomings feels almost like an act of betrayal. But when I look in Susan’s eyes, at their intelligence and clarity, I know I do not have a choice.
When I happen to pull into our drive at eight o’clock in the evening of the last Thursday in March, I’m bewildered to find Dave, Finn and Abbey lining up on the doorstep. The idea of an impromptu ovation to express thanks to key workers has largely passed me by. But then, as I open the car door, applause begins to ripple and rise from my neighbours’ doorsteps. Dave stares straight at me, grinning and clapping. Finn is belting his hockey stick against the wall. Abbey smashes a spoon on a saucepan. The entire village, it seems, is whooping and cheering, yelling “N – H – S!” and letting rip this most thunderous of thank yous to the nurses, the bus drivers, the cleaners, the porters, the shelf-stackers, the doctors, the delivery drivers, the checkout staff, the police officers, the paramedics, the teachers, the carers and all of the other key workers who are out there amid the virus, braving Covid for the sake of others, playing their part to keep their neighbours safe and well.
And, honestly, I could fall to my knees at the sound. Its kindness and sweetness and community spirit overwhelm me with raw gratitude of my own. I stand on the asphalt, open-mouthed, tears streaming. All these people, this passion, this trenchant solidarity. It is the loveliest cacophony in the world.
Find out more about Breathtaking: Inside the NHS in a Time of Pandemic by Rachel Clarke (published in the United Kingdom by Little, Brown Book Group Ltd, January 2021)
|Tackling Covid-19||Health||New societal contract||Intergenerational Solidarity|
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