So I started a new job at the beginning of 2021. An interesting time to start a new job, you know? Covid deaths/cases were skyrocketing to record levels, we were back under a strict lockdown, unless you happened to reside in Downing Street, and I remember a lot of grey and drizzly days.
Anyway I started a new job in an ICU on the 5th of January 2021. I’m actually writing this 18 months later; I kept deleting the previous attempts to write this all down because frankly it was all still too real, too painful in a lot of ways. What I was putting down didn’t feel right, maybe it won’t this time. There are things inside me that need to come out, stay out, and be seen.
For me the song ‘Hungry Like the Wolf’ by Duran Duran is linked so heavily to these memories, hence the title of this post. I listened to it many times while writing the majority of this, I did however manage to avoid interspersing the text with lyrics. They just didn’t fit. I thought it’d be a neat literary thing to do, but alas. It was the song at the top of the main playlist I’d made myself at that time, and even when other things were added, it would generally be the one that got played first as I got to a staff room, dripping with sweat. The memory of putting my headphones on, pressing play, and wanting to just break down into tears. The converted patient bay turned into a staff room on the second floor. The reception area, now a general seating area on the fourth floor. The feel of the chair underneath me, the unbearable weight of the stress and adrenaline that just would not subside.
January 6th, 2021, my first clinical day. The most important thing to happen in the entire world on that day, that’s for sure. The day before we got sort of shown around; I say sort of, because so much of the expanded empire of the ICU (from one floor to three!) was behind the lovely covid signed double doors. Yellow and black tape everywhere.
Fuck me I was not prepared. I want to state that I’m lucky compared to many others – as I was brand new I spent most of the first four weeks there working alongside another ICU nurse, rather than alone. I think this worked out well for whomever I was working with, as unlike 90% of the people who were drafted into ICU to help, I did have a basic knowledge of ventilators (due to surge 1), and a great knowledge of everything else that happens in critical care. I still never felt like I did enough. Not once.
Usually the day starts with a very brief overall unit handover; this was no longer the case, just allocating people to their assigned patients for the next 12 hours. I go to the first bay, just me and the experienced nurse. We have four patients there. 3 proned, 2 CVVH1. So thats three out of four patients who were unwell enough to need to be put onto their front as we couldn’t effectively ventilate them properly. Two of them with acute kidney failure, needing the type of dialysis we do in intensive care. All sedated, all ventilated, all on some form of blood pressure support, at least on noradrenaline2 if not requiring more aggressive drug treatment. Various other concerns as well, almost all at this point have a superadded infection on top of the covid ravaging their lungs. At least one had had a pulmonary embolism, a clot that occurs in the lungs. All of them died over the course of the next few weeks.
Why am I getting this into the weeds with the patients from my first day? Because I want to illustrate how fucking sick these people were. All four later died. All within two weeks if I recall correctly. The usual staffing for this would be at least 2 more experienced nurses for the CVVH machines, and 2 other ICU competent nurses. We had 1 experienced nurse, and then me. And we were well off that day. This took place on a day surgery unit, not on the intensive care unit. We had fit all four patients and the copious machinery and monitoring into a room that would normally barely fit 4 beds, 4 patient chairs, and 4 small bedside tables. There was no room for curtains. Privacy was maintained by the fact everyone was too unwell and to sedated to notice if they weren’t staff. This was a common thing in every unit we operated. Either we fit more patients between other patients, or we needed that space to put life support or monitoring.
Dignity died for a few months there. You’d die in full view of everyone, alone. Families were generally allowed a visit for an hour only, and that was it. If they survived past that hour then they died alone. We couldn’t sit with them. We had to work on the living. Sometimes agreement was reached to withdraw care. One instance of this I starkly remember is on one of our normal ICUs, in a B bed. B referred to the fact the bed was in between two normal spaces. Kinda where the curtain would go, so there was no curtain. We withdrew care. We stopped all medications other than sedation, turned the ventilator from 100% to 21% oxygen (that’s how much is in the air around you now). Prior to this we had to turn a patient to face the other direction because they were sedated only lightly, and would’ve seen everything. Probably not a good view at the best of times, let alone when you’re floridly delirious. I really hope the delirium protected them from the worst of these memories.
Having to do that is something that will stay with me a long, long time. We had nothing to hide the fact that people around them were dying. It fucking hurts to have to even consider doing it. People deserve privacy no matter what, but when you’re taking your last breaths? You should have dignity. If possible, you should have people who matter around you, to say goodbye. All we could do was put the bedside phone on loudspeaker and move it near the bed in the last few minutes. That is, of course, if you were lucky enough to be somewhere lucky enough to have a bedside phone.
There are other events that stick out, many in fact. The day we had to try and find one of our normal ventilators, because the relic we were using for one patient just wasn’t up to the challenge. The logistics of fitting it into the space it needed to go into, as well as all the equipment that was still there. The fact that I know it wasn’t enough, because that patient wasn’t there a week later.
So much of what we did wasn’t enough.
My conscious memories of the entire January to March period are sort of a blur. I remember the feelings. How could you not? The constant hyper awareness. All you could do was fight whatever fire appeared when it did; and there was not enough water for them all. Literal blood sweat and tears went into what we did during this time. You could step outside for a break, remove the PPE, and put on your headphones and eat whatever shit free food was on offer that day, but you couldn’t switch off. You could go home, but the feeling would go with you. It’s still with me, more often than I’m comfortable admitting.
Years ago I read an article written by an ex soldier about their experiences with PTSD post their tours of service, and it spoke of their hyper vigilance all the time. The fact that they almost felt they needed to go back to Iraq/Afghanistan to deal with it. I never really got it at the time, but apparently it stuck in some subconscious part of my brain until it resurfaced last year when for months and months all I could feel was the need to be at work, and for it to be a shitshow. For context, I absolutely have always enjoyed and thrived in emergency situations, I’m good at it and I feel good doing it. This was… it was different. I felt it was how things had to be, and when it wasn’t, I wouldn’t feel right. Like I needed the level of physiological stress that goes with these events to function normally. Sitting there babysitting a long term weaning patient without much going on was slowly killing me once things calmed down. I couldn’t relax, I had to be on, always. The article made a lot of sense when for some reason it came back to me.
I broke down in may 2021. I’d be on a slow slope downwards; my mental health has been a complete omnishambles since I was in my early teens; I’m pretty good at realising what’s going on these days. I think the final straw was another night when I’d woken up drenched in sweat, it’s like 0330 or something. This was actually a perfectly normal thing to happen at the time. It still does occasionally. I turned over and my ex partner was lying there in bed, in the perfect swimmers prone position. I could actually for a split second see the lines, the tubes, that would go alongside that. Anyway I had a big old panic attack about it as quietly as I possibly could to avoid waking her, and went to work a few hours later. Within a week I couldn’t function. The panic attacks were almost constant. Crippling. The adrenaline was just off the fucking chart. I spent a month off work. I couldn’t bring myself to do a fucking constructive thing for weeks. That changed a bit, and honestly it’s partly because my GP, in as gentle a fashion as possible, kinda told me off for not doing anything. I think about that phone conversation a lot. I owe her quite a lot for that, I think.
I now work somewhere where it’s normal for us to have posters in the staff room with the title “could you have PTSD?”. They went up late 2021, and honestly, I smile and suppress a laugh every time I see them. I have a very normal, very cool job. The story above where we had to turn a patient on their side to avoid seeing us let someone die? I’m in that bed space area often. I think about it every time. I always will. The bay from the first day? I can’t go to that entire floor anymore. I didn’t really remember the nightmares I knew I was having, but I do know that I thought about the corridor onto that day surgery unit very often. I still do. It’s the entrance corridor from the area where we would don our PPE, and you’d have to enter that way. I had to go to another part of that floor later in 2021, and doing that took half a day of quietly amping myself up, and planning on how I wouldn’t need to actually see anywhere I would know from that time.
I have nothing but guilt over the fact I feel like I could have done more. I don’t know what, and I don’t know how. I’m so sorry to the people whose relatives and loved ones we failed. I honestly would’ve swapped places with them if I could. There was at the very beginning of Covid the story of an ICU nurse killing themselves mid shift. I thought about that a lot. I had easy access to everything I’d need to do that. We use all three components of the traditional lethal injection copiously in intensive care. Sedation, potassium, paralytic.
There were successes, of course. I’m glad we had them. I wish I could say they brought me comfort, but I think that’d be a lie. It didn’t make it all worth it for me. I’m so glad we had those moments, but they aren’t the ones that stuck with me this time, unfortunately.
It’s the entire family who lost three generations. It’s the 30 year old with a very similar medical history to my partner at the time. It’s the people who managed 5-6 months in ICU to finally die. It’s the non Covid patient who died with me, alone, because they sat on their acute cardiac failure too long. Didn’t want to take up our space, apparently. It’s the fact we could lose an entire room of people, refill it, and lose most of that room too. It’s the fact that often you had no idea if these people survived because there were almost 100 of them and really who has time to check? I don’t even know if many of the people I cared for lived, and that really gets to me. I wish I did, it might have helped. Might have moved the needle just a little out of the bad.
At different times I’ve written this and centrered it around my anger that it was allowed to happen at all after the first time. My fury at the incompetence that led to these events. I don’t want to pretend that I don’t still hold those feelings, right at the fucking surface. However, for me, the lasting thing has been the sadness, the moral injury, the feelings of guilt, and even now ongoing just being on fucking edge a lot of the time. I still struggle to see people lying on their front. How stupid is that! It’s been so long! Someone I was seeing recently often sleeps on her front. She looked very cute doing it. Stressed me the fuck out! How ridiculous! I can’t say that enough!
I still watch the case numbers, a lot less than I did then, when I needed to know. I needed to know what to expect. Any time they’d be better than the day before it felt like just a little bit of hope, which would then be ripped away the next day. I watch again now so that I can prepare if it happens again. I’ve said multiple times if I had to return to the second floor if it happened again I’d walk out. You and I dear reader, I think we both know that’s a lie.
My life and approach to it is very different now than then. I’m unsure if it’s for the better. I don’t know how much I can blame Covid. I’m still picking up the pieces of myself. My views on life, what I think I might want from life, and what my impact on the world around me has changed significantly. Small changes really. I have no idea if any of these things are good or bad yet. I don’t know if I have a destination in mind for life anymore. I always thought that the phrase “its about the journey, not the destination” made sense, but honestly, now it really does to me. Death comes for us all, and it isn’t often at a good time. It’s not my own mortality I think about, its that of everyone around me. Within a few months another once in a lifetime event could occur. There’s been a lot of those in my 32 years on this earth. The ways I feel changed as a person now compared to entering 2020 are an entire post on its own.
If you’re out there and feeling the same way I feel, you aren’t alone. I know I’m not. There’s no way we could be. We’re going to get through this. What other option is there? There isn’t one. There wasn’t one when we went through this, and there isn’t one now.
1CVVH stands for continuous veno-venous haemofiltration. We run it differently to standard dialysis because if you did the kinds of fluid shifts you do on those patients to the average ICU patient, you’ll probably kill them. Can run 24/7 or less as needed. We pull usually 180-200mL of blood out of the body a minute, run it through the circuit, and then pump it back in.
2Noradrenaline is a neurohormone the body produces naturally. We infuse it into sick people because it makes all the blood vessels squeeze tighter, which raises blood pressure. There’s a lot more to it than that, but thats the gist. Has a half life of 2 minutes, so any interruption of treatment is very problematic. Needs continuous monitoring, hence needing critical care environments to administer it.