For many, working in an intensive care unit (ICU) was brutal enough before Covid-19. The job requires enormous concentration and attention to detail. We deal with the most complex diseases and sickest patients, and we live with the uncertainty over whether they will survive – and guilt over whether we made the right decisions.
Normally, between 20% and 30% of patients admitted to ICU will die. Families can be very distressed when seeing their loved ones suffer, and absorbing that distress or anger can be hard for our staff. Understandably, some families insist on ICU care when we know that this will cause suffering and the outcome will be poor. This leads to moral burnout: staff are forced to do things which they would not want done to themselves or a relative.
This job is particularly tough on the nurses. They are all clever and motivated. They are administering antibiotics, looking at monitors, taking and responding to blood samples (often hourly), giving potassium salts, adjusting fluids and drugs to support the heart, and altering settings on breathing machines. It’s endless. And they can’t let their attention drop for one second. Meanwhile, they are comforting and caring for the patient, keeping them clean and comfortable, while communicating with family. All this for meagre wages and a much longer training than for many other nursing specialities.
We were already in a difficult place before Covid-19 but since then the number of patients has doubled. The patients we now see are extremely unwell and deteriorate quickly. This has put a huge strain on staff. Normally there is one ICU nurse to one patient, but recently one nurse looked after six.
This has added a huge moral pressure as these nurses know what standard of care they want to achieve but have been unable to deliver it. Many leave their shift feeling they have failed their patients. They haven’t, of course. They did their absolute best.
It has not been uncommon to see nursing staff in tears. People are tired of death, the alarms, the kit, the uncertainty, the telephone calls to loved ones. All this happens, remember, while they are wearing full PPE, so they can’t easily hear their own voice or other people’s.
Then there are the colossal educational pressures. The number of staff working on ICU tripled overnight. There have been people coming in from all specialisms, even dentistry, to help us, and they have had to learn a lot of new skills very quickly. The rest of us had to learn about a completely new disease.
We need to fund ICU education because we are going to have to continue rapidly upskilling people as we learn more about the virus. At first, we learned it caused lung problems, then clotting and kidney problems, then strokes. Learning how to deal with these new challenges requires webinars, discussions and research.
The situation in ICU is not going to ease up soon – especially as we reboot normal NHS services – and staff will be damaged and traumatised. They rarely complain but they need support. The NHS cannot provide this. That is not a criticism. It’s not in its remit. This is where the Intensive Care Society – the national charity which supports ICU staff – steps in. Last week it launched an urgent appeal for funds to provide psychological and educational help to those at the very front of the front line.
I absolutely love my job. I chose intensive care. We have a great team, and it is rewarding to know that you have saved someone or allowed them kind words or a good death. But I have been doing 20-hour days for two months now, whether in the Red Zone or in an organisational capacity. Many, many others have done the same. I am resilient, but I’m beginning to feel the effects of the relentless pressure.
The danger with this work is that it can cause you to feel emotionally detached and depersonalised, which is hard to return from. I admit to feeling guilt about whether I have failed my patients. I have heard of others who are suffering flashbacks or sleeplessness. Everyone has had a battering.
By giving to the ICS charity, you will be saying thank you to staff, enabling them to be supported as well as educated if they are new to the field. If we do not act now, people in ICU will leave – at a time when we need them more than ever.
To donate, visit the Intensive Care Society crisis appeal
Dr Hugh Montgomery is professor of intensive care medicine at University College London and an ICS council member