"You don’t have a minute to process the trauma when you are working with Covid patients in intensive care, you have to get on with looking after the next patient, who may be delirious from lack of oxygen, thinking they are being tortured, and the patient after that, trying to save their lives,” says Nicola Rudkin.
She is the deputy associate director of nursing surgery at the Royal London Hospital in Whitechapel, managing the critical care nurses on the Covid frontline. She sounds drained of energy, saying that she “has never been in a situation this challenging in 15 years working at the hospital — people need to understand that what we are facing is far beyond what it was during the first peak, in volume and pace.”
“The nurses are so stretched, they feel they can’t give the one-on-one standard of care they are used to,” she continues. “A lot of nurses will leave because of this and it is difficult as there is nothing I can say or do that will make what they are enduring any better. We have never seen mortality levels like this.
The worst was seven deaths in a shift, which is huge. Nurses will be on a video messaging call with a dying patient’s family so that they can say goodbye, then at some point they have to hang up that call and switch their mind to treating the next person. There is no let up.”
Barts Health Trust, which includes The Royal London, as well as St Bartholomew’s, Mile End, Newham and Whipps Cross hospitals, is one of the worst hit in London. This week they have 831 patients with Covid and a week ago, management at the Royal London emailed staff saying that they were so overwhelmed by Covid that “we are no longer providing high standard critical care, because we cannot”. Since the start of the pandemic 1,110 patients with Covid have died, including five members of staff. 6,792 have recovered and been discharged.
“It feels like we are shouldering a big part of the burden in North East London and it is a struggle for staff that they can’t do as much as they usually would for patients because their workloads have been doubled,” says Rudkin. Normally at the Royal London there are 211 nurses for 44 beds in critical care. At the moment there are 126 patients in critical care.
A new critical care unit has been built to help the hospital cope and other, non-urgent treatment and operations have stopped. More nurses have been deployed from other areas and there are 300 critical care nurses now, including people like Ajit Abraham, who is usually a trauma surgeon specialising in cancer but volunteered to work nurse shifts to help out. “I don’t know how effective the NHS has been at communicating how stretched we are,” he says.
"This new strain has come at us hard. We’ve never seen mortality levels like this and we aren’t even at the peak"
Rudkin found it “humbling” to see Abraham, who she knows from working with as a surgeon, turning patients over and washing them. “It is frightening because we are not at the predicted peak yet,” says Rudkin. That’s expected on Monday. “But it doesn’t mean the day after it is going to stop,” she continues. “The patients are still going to come, hopefully in lower numbers, but the impact has several months to run yet before that pressure on the frontline workforce eases.
Even at the end of March if the numbers aren’t climbing we will still be in the thick of it. When you come off a ventilator you need months of critical care.” Abraham is concerned about the long-term impact on non-Covid patients, whose treatments have been paused. “Stopping that has not been without impact for patients and I worry about the strength of our workforce to cope with that afterwards,” he says.
They saw this coming but “this is tougher than we expected”, says Dr Teresa Cutino-Moguel, the trust’s clinical lead for virology. She oversees testing at the hospitals — they are doing 2,000 tests a day at the moment.
Rudkin “felt a sense of dread at the start of December”. “Our staff were already exhausted. They have been working non-stop since March and lots are off with post-traumatic stress. Many are young and live alone far from home. Many are from abroad, Europe, India, the Philippines, they haven’t been able to go home and see their families. I just wanted there to be a little let up for them at Christmas but it has come at us again and it hasn’t stopped.”
“It has been overwhelming to see how this new strain of the virus is transmitting. It feels like the patients are getting sicker,” says Terpsi Karpasiti, a senior specialist dietitian for critical care at St Bart’s. She makes sure patients who are ventilated have the nutrition they need. “I’ve seen patients lose 14 per cent of their body weight because of Covid. A lot of staff have been off with Covid and we are all terrified. The amount of deaths you see is crazy and very sad.”
Laura Walters, a specialist physiotherapist at Royal London works with patients to help them breathe and make sure there are no long-term repercussions. Her team expanded before Christmas and has expanded again. “The number of patients coming in is a strain,” she says. “I’ve been struck by how it has affected patients in their thirties and forties. It’s a long road to recovery and to speak again after a tracheostomy [when a tube is placed in the windpipe to help air enter the lungs]. Patients are so fatigued.”
When lockdown was announced this week it was a relief. “Until vaccinations are rolled out, lockdown is the only way we can control the number of patients pouring in,” says Rudkin. “We are already at a humongous level of stretch, if that tap is not turned off I am not sure how long we can keep doing what we are doing and continuing to expand at that pace.” One of the most emotionally gruelling differences on Covid wards is that no visitors are allowed.
The disease is too contagious for that. “Usually family members can calm patients down, hold their hands,” says Abraham. Zoom is better than nothing but patients can be confused and wonder why their family are on a screen, like TV. The chaplain team, which includes a Muslim chaplain, have been doing prayers and last rites outside rooms via iPads.
Are staff afraid of catching the virus or passing it on to their families? Rudkin had Covid at Easter last year, “and felt immense guilt at not being at work helping”. “The fear factor does creep in for staff, but we are now more confident in our supplies of PPE.”
"You ask staff a million times what can I do to make your day easier but the one thing they want I can’t give them: more ICU nurses"
The other change since March is that we have a vaccine. “It makes us feel this is the beginning of the end; before there was no hope,” says Rudkin. Cutino-Moguel tells me she is proudly wearing her sticker to say she’s had the jab. Still, even when everyone is vaccinated, Covid will leave scars. “My team will be changed forever,” says Rudkin. “Lots of nurses are staying to get through this but I am not sure they will all be able to stay long term. Nursing will be changed. And Brexit will have an impact.
Europe was a massive pool to recruit from. If that’s narrowed it will have a significant impact unless nursing numbers are massively ramped up in the UK. Some European nurses already want to go home. You ask staff a million times what can I do to make your day easier but the one thing they want is the thing I can’t give them: more ICU nurses.”
“It’s a steep learning curve,” says Cutino-Moguel. “There are days where you feel daunted or can’t get the equipment you need — the whole world wants to do the same thing so there is never enough. But there are days where you move forward. We have done this before and we will do it again.”
The only way to cope for Rudkin is not to think too much about the patients’ stories. “It is not because I don’t care but because if you think about every patient, every family affected, it becomes harder to function.” Walters was particularly touched by a 90-year-old patient who wrote her team a poem and reads it to anyone who comes into her room.
Abraham has introduced meditation for staff, many of whom say it is hard to switch off. He says “small acts of kindness” keep him going. “I was looking after an elderly man with Covid who was very ill and distressed. You don’t want to ventilate unless it’s a last resort so we were trying to calm him down but lack of oxygen can be disorientating.
He wanted his family and the nurses moved heaven and earth to get an iPad so they could Skype. Even though he had had a tracheostomy and couldn’t speak, the positive impact of seeing his family was obvious and very moving. Stories like that make this job doable.”
He continues: “There are those who say that lockdown is an impingement on our freedoms. I don’t see it as that. It’s something we must do so that we can have the London we all love back. We all want that.”