We were approaching the end of April. We had just come through a CQC inspection, COVID was in full swing on our 13 bedded unit, running 3 times our capacity having spilled out into our main theatres, anaesthetic rooms and recovery.
We were making plans from the moment we knew in January; the international critical care community was already active through social media. I was instantly transported back to a talk given at an ICS conference by Prof Stewart from Toronto and his experience with SARS. A distant memory became stark reality of mortality among the population, but also healthcare colleagues.
Things weren’t moving at the pace as I needed them to. ICU Ventilators requested early in February were ordered but taking an age to appear; they didn’t appear. Same bits of information were repeatedly requested from our matron and myself by everyone – local, regional and national, “how many people can you ventilate?” My response, “have we got enough oxygen?”
By mid March, we had put many things in place with our colleagues; we were as ready as we could be for the unknown. But I was going to bed around midnight and awake by 4. I was beginning to feel physically sick as the bed modeling from required us to ‘give assurances’ that we could ventilate 60, 70, 80, 90 patients. The comprehension of numbers of skilled healthcare staff required to not only keep people alive, but rehabilitate them back after critical illness appeared lost at a political level. Many people were anxious of my apparent woolly responses and frustrated to not being able to pin us down to a definite number. We relented and gave them a number. Thankfully we have not got to that…
Talk the talk, walk the walk…
I enjoyed the clinical work; consultant delivered critical care, with effectively continuous feedback decision making and actions. Initially some colleagues couldn’t understand why there was so little differentiating information at handover. After a few shifts it all made sense. ‘PRVC on 80% P:F 10, not for ECMO, proned again last night, next in line for a filter.’ We were in close contact with my clinical lead colleagues across the East Midlands Network including an ECMO centre, which was invaluable and cathartic. Our Locum Consultant colleagues weren’t able to come and our new appointed Consultant had the ultimate baptism of fire. We doubled our DCC instantly, whilst still doing all of the other stuff which needed to be done. Religious showering during and at the end of shifts was the norm and after a bit of peer-debriefing, setting off for home after 10pm. Along with an excellent group of SAS, doctors in training, consultants, nurses and AHPs, we provided the best critical care one could hope for whilst applying accepted ethical standards for admission to a UK ICU. Around 85% of our admitted patients have survived to hospital discharge, for a density of extreme sickness deemed as one of 3 capacity-overwhelming hotspots in the Midlands.
We know how hard you are all working; enjoy your days off
Fear of missing out. I don’t think anyone really had a day off. It was all well-meaning; they all knew days off weren’t really days off. Keeping up with information sapped the life out of me. WhatsApp review from 5am, scouring Twitter for new learning to help us locally and regionally; MS Teams meetings one after another, reviewing articles and guidance, everchanging PHE releases helpfully released late on Fridays, reviewing the nth version of our ventilator surge plan, ‘response requested by COP 10 PM today’ along with trying to communicate this up, across and down. My wife, a senior sister in critical care in a neighbouring trust, had her own anxieties working clinically in COVID areas. Tag teaming childcare days between us, with three young children at home, trying not to take up the key-worker school places. Not able to get out to the shops as a result was often soul destroying. Who knows what the risk of what we were bringing home was and potentially spreading to others? It was tough. Our families became background noise. We had a go at setting some house rules when it came to work, they never lasted.
They’re worried about us…you should talk to someone
I saw an offer on one of the FICM e-mailshots offering clinical psychology support for senior leaders in ICM. The opportunity to talk with someone external to my position to help me rationalise and recalibrate in a new world of ultimate VUCA (Volatility, Uncertainty, Complexity and Ambiguity) was welcomed. I had my sessions through May and June with an NHS clinical psychologist with awareness of critical care, appointed by the ACP, who was excellent. We set out my main concerns: 1) running out of clinical capacity either physically or colleague sickness/death 2) either one of us or both dying leaving our three young girls as orphans split up from each other and finally 3) becoming progressively more reactive to well-meaning colleagues, who appeared not to empathise or be aware of the decisions we were having to make at a clinical and operational level, to provide a cohesive critical care response, way beyond the perceived technicalities of ventilating patients with severe respiratory failure.
Reflect, rationalize, recalibrate, respond…
The sessions allowed me to reflect, rationalise and make key decisions for the short to mid-term 1) what I want for my future career and 2) to blend other interests into my life.
Of the many light bulb moments these sessions facilitated, two stick out. The first was when I realised my psychological bucket was overflowing. I wasn’t able to devote time, energy or headspace to address the never-ending requests at work and life laundry; everything was now piling up on top and leading to ever more curt responses to colleagues, family and friends who just didn’t get it. The second was learning to become comfortable with what I control, influence and accept, particularly the latter. Some things have to give.
The validation from the psychologist was welcome; whilst a bit early, it was unlikely I would have PTSD or need psychotherapy. What we did was talk uninterrupted one to one for an hour or more every other week, something I have not done for many years, and highlight the need for coaching. The current NHS isn’t mature or equipped to provide this level of mentorship and coaching, particularly doctors in leadership positions with ongoing heavy clinical commitments at service level on the scale required; but it would be invaluable if we want the best out of the investment in senior clinical staff. I am a firm believer of the leadership thousand-day rule and as such I’ve probably done as much as I can in this role at this time. Whilst I enjoy my role as a true generalist-intensivist, I have given myself permission to explore something else and am ready to pass the baton on.
Dr Som Sarkar is a an Intesivist and Anaesthetist. He is the Clinical Lead for Critical Care at Sherwood Forest Hospitals NHS FT.