Hospital intensive care wards are unlike anywhere else in the NHS.
Patients are mostly sedated, their beds surrounded by towers of equipment which emit a grim chorus of beeps and alarms. Banks of monitors display vital signs and heart rhythms, and sound the most disconcerting alerts when they detect changes.
Those that doctors waken from induced comas emerge traumatised and terrified.
They find themselves entangled in a web of tubes and wires going in and out of their bodies. The most powerful pain relief is pumped directly into their veins—and with the drugs come hallucinations and horror.
Working on these wards as a nurse has always been tough, but the huge influx of very sick Covid-19 patients is making the job much harder.
“We take over the running of a patient’s body. We control their heart rate, their blood pressure, their breathing. The patient’s life is in our hands and it’s a huge responsibility,” says Joan Pons Laplana, a senior nurse who often works in intensive care units in South Yorkshire.
“We have to monitor patients constantly because change can happen so quickly. Any fluctuation in their blood pressure or breathing could mean adjusting their treatments, or could be a sign that they are deteriorating.”
That’s why hospitals generally allocate one nurse for every intensive care patient.
But the pandemic means treating more people than ever. And it’s driving some London NHS trusts to insist a single nurse can oversee the care of up to four seriously ill people.
Joan has serious worries about this.
“I think this is really dangerous. Most of our patients are very sick and some carry multiple infections. That can mean their vital organs are affected and they can deteriorate so quickly,” he says.
“It only takes a minute for a patient that looked like they were coping well to be at the point where their blood pressure is on the floor. Their heart rates goes up to compensate—and then they stop ventilating.
“That can happen so quickly. But a nurse can normally see signs of a coming crisis by noting some fluctuations in a patient’s vital signs, and that gives them time to put measures in place.
“But if you have more than one patient, and you have to attend to them for a few minutes you might miss the clues and that can be crucial.”
The pressure on intensive care nurses is already immense, says Joan.
“I’ve often woken at night worrying about decisions I’ve made during my shift. Sometimes I’ve been so worried, I’ve phoned my ward to check on a patient to see if they're ok.” he recalls.
“Or I’ll text colleagues to ask about someone. But this is when you should be sleeping.
“If we can’t keep the ratio of one nurse to one patient that pressure will only get worse. Nurses won’t be able to deliver the standard of care they expect, and when that happens they will feel guilty.
“You will think to yourself, if only I hadn’t gone to attend that other patient, my first patient might have done better. If something goes wrong, you’ll feel responsible, but what other option did you have?”
Some hospitals are trying to maintain their nurse to patient numbers by bringing staff from other wards into intensive care. But intensive care nursing is a very specific skill, one that uses equipment and drugs not generally found elsewhere.
“Teaching nurses to work in our units takes a lot of time, not just a few weeks,” said Joan. “I think we’ll be putting those nurses under unreasonable pressure. You press a wrong button on a piece of equipment you are not familiar with and a patient can die.
“And, it will likely mean turning our existing intensive care nurses into supervisors of other nurses, rather than people who work directly with patients.”
There are no easy solutions to the problem of staffing intensive care units. Demand is set to carry on rising until at least the end of this month, but many hospitals are already overwhelmed. Specialists and treatments are already being rationed.
For Joan this problem has been years in the making. He points to studies done in previous years that concluded that the NHS needed to massively increase its number of hospital beds.
“Under the Tories, we have far fewer intensive care beds than most countries in Europe,” he explained. “We have been left with the bare minimum.
“Boris Johnson made great play of plans to build new hospitals—just as they did with the Nightingale Covid-19 hospitals around Britain. But it was clear that these would never open because where would all the staff come from?
“If you don’t have the staff to run the existing wards, where are you going to get people to run the new ones?
“We went into this crisis with a minimum of 100,000 vacancies in the NHS. One in ten nursing posts were unfilled. The NHS has been overwhelmed every winter for more than ten years. Not that long ago the Red Cross declared Britain to be in a humanitarian crisis.
“That fact has a massive impact on the quality of care we can give now.”
“For me, the biggest mistake that the government has made in this pandemic is putting profits before people. Doing that was always going to end in disaster.”
Patients are being ‘dehumanised’
Joan told Socialist Worker about conditions on intensive care wards now.
“You have to be so alert now. You can’t lower your guard for a moment. If you make a mistake [with your infection control] it can cost you your life. Obviously, we have to wear full PPE protective kit and that makes work very difficult. There’s so much planning involved now,” he said.
“It’s extremely hot and you sweat a lot during a long shift. But you can’t simply lift your visor to wipe your face and have a drink of water. Instead, you have to plan your breaks so that you can take regular sips of water.
“You can’t go to the toilet without carefully removing all your kit, and then putting it all back on again. So you have to plan that too.”
And Joan says the strict measures needed to protect staff and patients has severe implications.
“Before the pandemic we used to meet families and get a picture of our patients’ lives,” he said. “We had some idea of who they are as people, the little details matter to us.
“The human side of nursing is extremely important. But now we usually have only a few minutes to talk to a family, and the only time you see them is at the last moments of a patient’s life.
“That dehumanises the patients, and affects us too.
“Nurses have a real problem trying to disconnect from their shifts. There doesn't seem to be any space to rest.
“You go home, turn on the TV and the only thing you see is more news about Covid-19—it’s Covid, Covid, Covid. So you try to use your days off so as not to be overpowered by it all, but it's very hard.”