Last April, Damian Whitworth visited the intensive care unit at the Royal Free Hospital in London to find out how staff were coping in the fight against Covid-19. As they deal with the second dramatic surge in cases, he catches up with them again and hears stories of exhaustion, heartbreak and plummeting morale.
One evening last April, I walked out of the Royal Free Hospital in a state of shell shock. The Times photographer Jack Hill and I had been given access to staff at the hospital in northwest London over the course of a week at the peak of the pandemic. We had just spent the afternoon in the dystopian environment of the intensive care unit (ICU), where doctors and nurses in full PPE tended to desperately sick and dying patients. Most of the patients were sedated and hooked up to mechanical ventilators, hovering on the edge of existence.
As my brain raced with the upsetting scene we had witnessed, I inhaled the fresh air of Hampstead Heath. But my relief was tempered by the sobering thought that the wonderful doctors and nurses I had met would be going back in again the next day. And the day after that. And the day after that.
I thought about them frequently over the following months. I recalled watching Dr Mark Carrington painstakingly checking the chart of a man who would die within a few hours. I remembered Sean Carroll, one of the ICU matrons, telling me fiercely that no patient would die alone on his unit, and Martha Sarpong, a support nurse, becoming distressed as she described sitting with a dying patient. And I could not forget the tears of joy shed by Eduarda Rodrigues, a ward sister, as one of her patients was wheeled out along a corridor of applauding staff after recovering from Covid.
Towards the end of last month, after deaths and hospital admissions for Covid in London reached a peak that extended into a plateau and the Royal Free was full, I spoke to several of the staff again about their year of fighting Covid and why this second "surge" in cases has been so much worse than the first.
I am sure they won't mind me saying that they all looked shattered. Some seemed to have aged physically since I last spoke to them. Others have managed only a handful of days off since the pandemic began. Emotion bubbled up as they described an ordeal that for them still seems a long way from ending.
While most of the country enjoyed some respite from Covid lockdown over the summer, staff at the Royal Free were working to prepare for the winter resurgence. They had only two weeks with no Covid patients, at the end of September and beginning of October. But even they weren't expecting the second wave to be as terrible as it has been.
In the spring, intensive care beds were increased from the usual 34 to 70 by putting beds in operating theatres and recovery areas. More than 300 patients are being treated for Covid in the hospital, which has been extensively reorganised to accommodate them all.
A matron in the intensive care unit. Originally from India, he has worked at the Royal Free for 19 years. His wife, Bincy, a nurse from a different hospital, is temporarily working with him at the Royal Free's ICU.
"The past two months have been horrific in ICU. After the first surge [last spring], people were already worn out and didn't get time to relax and come back to their normal mental state before being hit by the second surge.
"I never thought we could have this many intensive care beds in our hospital and we still need more.
"I think we had 4 or 5 patients and then in 24 hours it became more than 20 – and then 30, 40, and it never came down. So I don't think we were prepared for that extent.
"One ICU nurse is looking after four ventilated patients, where they are trained for one-to-one. Yes, they have help. Nurses have been deployed from other wards and the army came. But people really work hard and they're angry now. People come out with real emotion. When they finish the shift, they don't even look at us any more. There's no eye contact; there's no smile. Even if you say, 'Is there anything I can do to help?' they don't want to hear anything. They're angry because they've been worn out completely. Looking after three or four patients is heartbreaking for them.
"I'm really tired this time. It's mentally really, really draining. Your brain is going at 100 miles per hour. Even when you come home, if you're going back tomorrow there's not much time because you come back at maybe 10pm and are going back for 7am. I can see emails from my managers at 1am, so you can see what they're going through as well. The pressure and the demand is far, far, far higher than last time.
"If I reflect back in a few years, the thing I will remember will be the tears. A family on the phone crying; staff crying. That's how I would describe both surges: tears.
"I saw one patient passing away yesterday. And that's so hard. I just happened to be there as I was on my round. I went over to hold his hand. He was a man in his sixties who had been in for a couple of weeks.
"It's supposed to be their loved ones there. It's someone's last minute, last seconds. It's inhuman, people dying in that way.
"My wife, Bincy, is a theatre nurse at Edgware Community Hospital. They came to help us, so we're both working in the same Covid area at the moment. Sometimes we don't see our sons, who are 15 and 12, because we go before they wake up and they are asleep before we come home.
"Our 15-year-old, who wants to be in the army and help the country, is very supportive. He helps put everything together for the next day and irons our clothes."
An operating department practitioner at Chase Farm (part of the Royal Free London NHS Foundation Trust) who was transferred to work as a support nurse in ICU at Barnet Hospital. A mother of three daughters, she returned to her normal job but this month she is due to be redeployed to ICU again after two months' sick leave.
"At the beginning of December, I caught Covid and isolated with my daughters and partner. I felt like I had been hit by a truck. It was worse than labour pain. I thought, 'I'll be better off dying.'
"I was having nightmares. At one point I felt I was in the middle of the pandemic in ICU and people were shouting, 'Martha! You need to come.' And then I woke up sweating. I didn't want to go to hospital knowing how busy it was, so I just managed my pain at home.
"And then I was told that I had been redeployed again and I had anxiety, stress and a bit of depression, because I couldn't believe we are here again. I spoke to my GP and I'm receiving talking therapy. It's helping because I'm sleeping a bit more now.
"I'm due to go back to work. I cannot just sit back. I feel guilty staying at home, seeing how they are struggling. Most of my colleagues are saying they cannot sleep – they are stressed and upset. I am a very strong person – anyone who knows me knows I can do anything. But when it came to this, I'm having therapy. I've never had therapy in my life before.
"I start panicking, crying, thinking, 'What's happening? Why am I going back to ICU?' That is the bit I'm struggling with: why are we here again? [After the first wave] we thought we'd done it. It's one we could tell our grandchildren about.
"I really do love my [usual] job. On my annual leave, I do overtime. The problem with going back is that I feel I'm going to see the same faces. The obese patients, the young ones. People die at all ages. Covid has no respect for anybody.
"My neighbour around August threw a party in her house – more like a rave. I refuse to talk to her, because if you have that many people in your garden in the middle of a pandemic, you're being selfish. That's why we are where we are. People don't believe it. They think we are making it all up. We could lock down for 100 years, but if people don't do the right things we'll never get over this pandemic."
One of the matrons on the ICU, he decided after the first wave to take early retirement in the summer to spend more time with his family. After a two-month break, he returned to work two days a week on the unit.
"It's very, very busy compared with last time and things are quite a bit worse. The number of patients is big and staff are feeling upset.
"There are lots of patients dying and, sadly, as soon as a bed is empty, there will be another patient to fill that bed. And that's very, very difficult to take on board, because you've had the emotional upset of seeing a patient die. We allow visitors to ICU to spend time with their loved ones before they die. It's not rushed but, as a patient dies, the family will sit with them and have some time with them. But those relatives will leave and that patient will be washed, cared for and sent to the mortuary fairly quickly.
"And as quickly as that patient goes to the mortuary, the room will be turned around for another patient. It really is that desperate in ICU in London. There'll be another patient waiting to come into that bed. And that's something that is very difficult for staff. They may have been looking after that patient for a week to ten days, may have got to know them, then the patient dies and the nurse literally has no time even to think about it, because there's another patient waiting to come. Some patients come for very short periods or die fairly quickly and another patient can come. You could potentially look after three patients in a day.
"We're seeing ICU nurses focusing on the technical side. They don't have the same amount of time to do the personal side: the mouth care, the eyecare, brushing the hair, talking to the patients."
Dr Mark Carrington
An ICU consultant. Last April, we watched him as he arranged for a relative to visit a dying patient. Although relatives are allowed to visit dying relatives on ICU wearing full PPE, many are unable to do so or decide it is too risky.
"With the sheer volume of cases coming in, you've got many more patients than you'd normally have. So you're spread thinner than you normally would be. And as well as managing that, you're juggling new admissions all the time. Normally we would have longer to spend at each bed space.
"Of course we're still trying to do that, but there is sensory overload. We've got our walkie-talkie system, and I'm also carrying an on-call phone. And there are lots of inputs all the time. It means that it's difficult to be able in a focused way to spend the time on individual patients. I've been struggling with that aspect of it in recent times. And I think that's what 'overwhelmed' looks like. It's just the sheer volume of patients. And these patients are really sick.
"I want things to slow a little so that I can concentrate on the one thing that's happening, but of course it isn't like that.
"The nurses are the people who are the unsung heroes of this entire process. Our nursing staff are really close to breaking point, as they are across the UK.
"We want to support them as best we can, but I'd like some national recognition and some way of looking in the future at how we honour and thank our nurses for their sterling efforts in response to this.
"I think I probably did the first withdrawal of therapy for a patient of anyone on the units. And this was due to unsurvivable complications from Covid-19. I wrote to the family to give reassurance that we tried to make sure they had as good a death as possible. It was a very sad situation that still makes me quite upset when I think about it. I've done lots of withdrawal of care before – that's part of being an intensive care consultant – but that one particularly pulled everybody's heart strings because it captured the difficulties and stress of this viral outbreak.
"It was the first patient we were moving towards an end-of-care scenario and it was going to have to be done down a phone on speaker, with me wearing PPE and talking through a mask, and the family weren't going to be able to come and see their loved one.
"I asked if there was anything else we could do to help in terms of the end-of-life care and [his wife] said he was a massive Pink Floyd fan. So we played some of The Wall and, to be honest with you, there wasn't a dry eye in the house at that point.
"I was trying to get my head around how this family are managing this, and what we could do as a medical team to make sure that they don't have a lasting image of this patient in a corner somewhere not being attended to, not being given the basic care that everybody would want with end of life.
"I had a letter back from the wife and that's something I'm going to keep and treasure for the rest of my career. She sent me an order of service for his funeral, with a picture of her teenage sons with him. And that means it's that much more real for me. They're not just patients; they're fathers, mothers, sons, daughters."
An ICU matron. Originally from Wexford in Ireland, she is married and has a son, aged four.
"The staff are finding this one a lot more traumatic. The first time it was very much, 'We've got the energy. Let's do this as a team and we can get through this.' We did. This time, I think the staff are quite traumatised by what they witnessed the first time. They're finding it more difficult because they're just so burnt out. It's like post-traumatic stress.
"Intensive care nurses are absolute perfectionists. We are used to one-to-one nursing care. One-to-one nursing care is there for a reason: because these patients are so unwell.
"That's very difficult on the staff, not being able to give that care with the patient.
"We would always make sure a patient has somebody with them at all times when dying. The other day an eye doctor, who has never worked in intensive care, was there to hold a patient's hand. It was so heartfelt the way the nurse was explaining to the doctor, 'I know it's a bit scary, but you need to sit with the patient and hold their hands. Make sure they know somebody is with them at all times.' This poor doctor, who examined eyes all day, was traumatised. He was like, 'You guys do this every day?'
"The first time the ratio was one nurse to two or three patients. Now it's mostly up to one to four. Sickness is huge because of burnout and anxiety levels, and with track and trace they are falling like flies. That's crucifying us.
"It's heartbreaking to watch because these are young kids. I'm quite worried about the nursing profession in general. These are nurses who are thrown into this scenario that is very, very challenging to work in and they're so distressed by what they are witnessing, and feeling, 'This is not what I've come into nursing for, this constant trauma every day.' For them it feels like: is there an end in sight?
"We're seeing families come in. A mum and a daughter, both really, really unwell, a couple of weeks ago in the aftermath of families gathering at Christmas.
"My son is four. He gave me a sword to take to work to fight the virus. The other night he said, 'If the virus wears a suit of armour and the virus can only live on people, why are people still gathering?' This is a four-year-old and he was so right."
Dr Kulwant Dhadwal
Was the clinical lead for the ICU, managing the department's response during the first wave. After planning the hospital's response to the second wave, she relinquished the management role in December to return to clinical work on the unit.
"I was still tired from the first surge. I was feeling burnt out, so I felt it was time for a change, someone fresh to come in.
"I was working continuously seven days a week.
"The case mix that we are seeing is different. We're seeing a lot more younger patients and that's affected a lot of the staff. We've had 30-year-olds and 40-year-olds pass away, and that's a shock to all of us and really hit our morale even more. I've seen a lot of nurses upset and a lot of doctors upset.
"Everyone's feeling that this lockdown is not the same as the lockdown in March, April time, where the streets were empty and that really did work.
"All the hospitals have got more inpatients and more ICU patients. There is that sense that the government is not giving the right message this time round. There is slight anger from some of my nurses, when they have just finished a long shift, that we need to go back to that lockdown.
"Everybody in the country has been affected. Just a couple of days ago, my grandad passed away. He had heart failure. We'd managed to shield him for a year and then they found out that he also had Covid."
Written by: Damian Whitworth
© The Times of London