Hazel McHaffie

Intensive Care Units

Decision making on the Covid frontline

Jim Down is an anaesthetist and intensivist in University College London Hospitals. He was working as a consultant there when the Covid pandemic hit this country, and in his book, Life Support, he has captured the slowly emerging horror. We all know so much more about it now, but back in March 2020, not even those at the front line were fully up to speed with what was required. Reports were patchy and conflicting; provision was far from satisfactory; knowledge rudimentary.

By his own admission, Jim Down is a worrier, so what should he do in the face of this emerging crisis? Should he go home to his young family? Should he visit his elderly parents? How close should he get to people? Should he wear a mask? In many ways he felt safest at work protected by layers of suffocating PPE.

I confess, the work of an anaesthetist is much more far-reaching than I was aware of. (Apparently 50% of the country still believe they aren’t doctors!) But in reality, as Dr Down says himself, there are few departments anaesthetists don’t support in one way or another. And throughout the pandemic, it’s been the tribe of c11,000 anaesthetists around the UK who have been vital to the Covid response, converting all available space into fully-functioning Intensive Care Units in record time, delivering care to eye-watering numbers of patients, and designing protocols for some of the most dangerous procedures.

Amongst his other responsibilities Dr Down was given ethics to oversee. Forgive me if I home in on this aspect of his roles – it’s part of my personal raison d’etre, as you know. He set up a ‘three wise people system’ for all major and controversial decisions, and established an Ethics Group for the Trust. But questions and dilemmas presented at every level.

The cost of a day on ICU is approx £1700; what benefit does that need to accrue to be cost-effective? What constitutes a meaningful quality of life? When does a therapy become futile? What risk/chance of disability or suffering makes life not worth living? What constitutes meaningful life? Who decides? When resources are stretched beyond capacity in a pandemic how do we compare relative benefits between patients? All questions that haunt medical practice, but with Covid there were three new crucial differences from the normal balancing acts: the sheer number of patients, the flimsy knowledge of this new disease, and the unusual speed with which decisions might need to be made.

Ethical dilemmas presented too around how far to go, when to stop, when to call family in, in situations where so much was unknown. Then there was the matter of how to effectively deploy limited resources – equipment, drugs, people. The staff themselves were suffering from emotional and physical exhaustion, giving them a diminished capacity to empathise with others, poor concentration, irritability, feelings of helplessness, frustration. Not a good foundation for making sound judgements – thereby increasing stress still further.

Dr Down himself adopted a benchmark: What would I do if it was my brother, sister, mother, father, wife, child? It felt like as good a test of a decision’s rigour as he could muster.

But the personal toll was colossal; the work loads unprecedented. One trained ICU nurse to up to six patients instead of the usual one! One consultant to 42 patients. Teams of medical students and surgeons roaming the units twice a day just to turn people from supine to prone or back again. So much was unknown and unknowable. The patients were extremely sick, for a long time, very fragile and unpredictable, and denied family support. With no simple solutions, very few fixed protocols, the staff constantly questioned themselves, worrying about the repercussions of what they were doing.
We are all acutely aware that something could go wrong for any of us at any time. When it happens to a friend we are reminded of our vulnerability.
They were caring for
the biggest cohort of the sickest patients we’d ever seen, and we were desperately trying to work out how to manage them.
And at times they were treating their own frontline colleagues. Sobering indeed.

This book captures the everyday reality, the swing from the sheer mundanity of meetings and conversations at one end, through the anxieties that proved to be damp squibs, to the overwhelming responsibility of far too many competing demands, the crises at all hours, the inability to support everyone all the time. The frustration of insufficient staff or equipment to carry out the fundamental tasks. The constant questioning.

It underlines the enormous debt the whole country owes to the key workers who bore the heaviest burdens for us all.

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