Critical care Psychological toll
None of that, of course, negates the difficulties of those early months – nor the exhaustion, trauma and moral injury that so many staff are feeling now. “There was real, genuine fear during the first surge, which was compounded by concerns about access to PPE and the fact that quite a few healthcare workers were dying,” says Cook.
A year in, the fear has eased somewhat – but the same cannot be said for workloads, which have remained extremely challenging. In normal times and under normal standards in the UK, there would be one specialist ICU nurse to every patient. At its worst, the pandemic stretched those ratios to three or more patients per specialist nurse, with support from redeployed nurses without specialist intensive care training.
Above: A healthcare worker in South Africa rests between shifts.
Previous page: ICU staff in Liège, Belgium prepare themselves for another onslaught in caring for Covid-19 sufferers.
workload, burnout and wellness have been just under the surface in critical care for a long time, but Covid has magnified that by a thousand. “The things we do every day are much more challenging when you put them in an environment where we’re working more, we don’t have certainty about how to care for patients, and we don’t have certainty about how to keep ourselves, our patients and our families safe.”
Particularly during the early months of the pandemic, ICU staff were dealing not only with unprecedented and growing demand on their resources, but also with huge unknowns about the disease itself. “There was a tonne of uncertainty about what Covid actually was and what treatments were going to work,” says Martin. “All of that was made worse by the deluge of literature coming out. People couldn’t keep up with the amount of new information, and particularly [with] trying to appraise it: ‘Is this high-quality or low-quality literature? And how does it apply to my patient?’”
“Issues around staff stress, workload, burnout and wellness have been just under the surface in critical care for a long time, but Covid has magnified that by a thousand.”
Greg Martin
In reality, he adds, much of this apprehension proved unfounded. “It really ended up reminding us that almost everything we do every day in other critically ill patients completely applies to Covid-19. That doesn’t mean there aren’t some unique things we need to do differently, but we know how to take care of patients who have pneumonia; we know how to take care of patients who require respiratory support and end up on a mechanical ventilator. The standards we’ve developed over years and decades in critical care were actually incredibly useful.”
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Similar ratios have applied to doctors, physios and other healthcare workers, Cook notes, but the heaviest burden has fallen to nursing staff. And beyond clinical care, he adds, one of the most overlooked challenges has been having to communicate with patients’ families by video or phone.
“A lot of what we do in intensive care is very technical, high-end medical care, often being done to a patient who’s unconscious and attached to machines,” Cook says. Restrictions on visitors have, therefore, been challenging not just for patients and their families, but also for the healthcare professionals caring for them. In normal times, he explains, staff get to know their patients, and make informed, collaborative decisions about care through ongoing bedside conversations with their loved ones. These sensitive and complex discussions are simply not the same when conducted through a phone or video call. “I don’t think people appreciate how difficult that has been,” he adds. “Staff have experienced enormous psychological distress from seeing a large number of patients who they couldn’t treat, or many patients who have died. These experiences have been very harrowing, and a significant number of staff have been psychologically harmed by working in this environment.”
Resource allocation It’s in this context, with staff spread so thinly, that Cook talks about the unenviable decisions they have faced around allocating resources and maintaining standards. For him, ICU resources can be considered as four ‘S’s: space, staff, systems and stuff. But, while you can reallocate beds, expand your physical space into disused operating theatres or manufacture new equipment in a crisis, the vital human resources of trained and experienced staff remain finite. This is aggravated, Martin points out, by existing staff shortfalls, as well as the increased time and complexity involved in caring for Covid patients. At
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