EDITOR’S NOTE: Since the publication of this article, NHS England has queried some of the claims made by the author. Their response can be read at the end of the article.
After much hard work, the ExCel conference centre has been refashioned as the Nightingale Hospital in East London. The new 4,000-bed facility was set up to lift the burden from London’s intensive care units (ITUs), many of which are doubling up bed spaces in an attempt to provide organ support for as many patients as require it while they recover from coronavirus. Similar facilities are under construction in Leeds, Manchester, Bristol and Birmingham.
This strain of coronavirus is ravaging critical care units across the world. Where normally there would be a mix of medical, surgical and trauma patients, our beds (at a non-Nightingale hospital) are dominated by Covid-19 patients. Our consultants have never seen anything like this, even the ones who’ve come out of retirement, which is a telling sign. Swine flu wasn’t this bad. You didn’t have an ITU just filled with one condition. We are living through history.
Despite this, there still isn’t an agreed-upon strategy for the minutiae of the patients’ care — although we receive daily updates from experts — and the devil is in the detail. Many of these patients will require additional organ support on top of ventilation to bolster their lungs, as well as optimising every level of their care.
Ventilation is the use of a machine to support a patient’s breathing via pumping oxygen and air under pressure into their lungs through a tube. Most patients will need to be unconscious and paralysed for this. We provide it for patients with coronavirus because it is the best way of supporting their lungs while they recover. Due to the potential for lung damage and other problems, it is not entered into lightly. Because of the high pressures and levels of oxygen sometimes required, there are consequences to ventilating a patient both while they require the therapy and possibly for years afterwards. These patients may need physiotherapy to build up their wasted muscles or psychological support from the mental trauma the intensive nature of critical care often demands.
The Nightingale is a warehouse to nurse previously fit and healthy people with lung failure and ventilate them. It will be staffed by over 16,000 well-meaning volunteers, largely from non-critical care specialties. It will not be an intensive care unit. The government would like you to believe that they have conjured an emergency critical care hospital in East London and everyone will survive with no long-term consequence. I would dispute this.
Tackling coronavirus is not just about footfall of healthcare professionals. Those patients with coronavirus who are unwell enough to need ventilators will need ancillary support and therapy during and after their ordeal. I do not see any plans or provision of service being put in place for this nor do I see a relaxation in our standards of care.
“Critical care is not a specialty in which we can rapidly upskill people. The nature of critical care requires difficult decisions to be made, often backed by years of experience.”
After a patient has recovered sufficiently to not require respiratory support, the job isn’t over. The Covid-19 crisis stands to create a huge burden of illness requiring aftercare: chronic airways and lung disease, kidney injury, post-viral fatigue and more.
A decade of chronic underfunding is likely to leave many specialist clinics with long waiting lists. At the time of writing, NHS Nightingale is not recruiting the expertise of physiotherapists, microbiologists, dieticians or other essential team members, nor does there appear to be any drive to improve the long-term provision of care in the community, and I find this concerning.
Critical care is not a specialty in which we can rapidly upskill people. I do not want to disparage those who’ve already put themselves forward; I admire their dedication to the public. However, the nature of critical care requires difficult decisions to be made, often backed by years of experience. It is not a matter of watching a few instructional videos or reviewing a cobbled-together management guide as many of my colleagues have been asked to do. These are well-meaning and helpful, but do not replace years of clinical experience.
Currently, in non-Nightingale hospitals, enthusiastic doctors and nurses are being seconded to emergency departments and ITUs. I now get to rub shoulders with orthopaedic surgeons, obstetricians, neonatology nurses and more. There is an interesting skill mix and a wonderful camaraderie among the redeployed — I hope this is enough to pull us through. We are benefitting from vital senior intensive care oversight, which is lacking at the Nightingale.
Rationing of healthcare technologies (not just PPE) will force difficult decisions on those clinicians who do not have the background to guide them.
I feel as though I need to state the obvious: there is huge potential for tragedy if this experiment goes wrong. The reach of morbidity created by coronavirus is likely to affect the NHS for many years to come. Managing this will require an overhaul of the NHS — better funding might do for a start.
When the dust settles, I expect that there will be panels and reviews examining what might have been done better and perhaps those who have failed to plan for a decade will face the music. But I doubt it. They’ve avoided accountability for years and will continue to do so.
Instead I worry, as ever, that the axe will fall on the people on the frontline. Those who went above and beyond their comfort zone are likely to be penalised for making mistakes due to poor resources and threadbare planning.
The author of this article is a doctor working in an ITU in London
NHS England has issued the following statement in response to this article:
“This anonymous blog is wrong and irresponsible. The Nightingale Hospital London has all the necessary expertise — including senior ICU consultant oversight on every shift and a full range of therapists (physios, dieticians etc) —to provide the most effective critical life-saving and recovery care for Covid-19 patients. This is in addition to the significant critical care capacity that exists across the capital, and all patients will get the ongoing care they need when they are discharged back to their local hospital.”