by Dr. H

“We need a bed.” Even Jonny can’t muster an upbeat tone eleven hours into a night shift. He’s the ICU doctor on outreach tonight, the link between the wards and our ivory tower.

“We’re full.”

“You know what I mean, you’ve got about 30 minutes.”


T-Minus 30

A few nurses are preparing a trolley with cleaning solution and fresh sheets. One has tears in her eyes. Mr. B, a 45M that was successfully extubated two days ago – one of our ‘winners – just had a PEA cardiac arrest on our CCU, our ICU stepdown ward. His heart was generating a valid electrical rhythm, but wasn’t able to produce an output compatible with life.

Another perfect game ruined at literally the eleventh hour. Irene is going to tell me off for jinxing myself on WhatsApp.

My usual ritual of taking five after a mortality to close my eyes and reflect is a luxury I can’t afford, thanks to Jonny’s call. I wonder how many corners I can cut before all that’s left of me is a circle? Maybe that’s what they mean by ‘well rounded’.

I run through the options: The Unit has precisely zero unoccupied beds. We’ve just gained a new CCU bed courtesy of Mr. B, but that’s not appropriate for a new admission. I skim through my list, there’s nobody on the Unit I can step down to CCU within 30 minutes. That only leaves one choice.

People deserve longer than half an hour to die, but maybe i’m an idealist.

T-Minus 25

Standing on the middle of the Unit, surrounded by all the patients in extremis, it’s easy to see the contrasting threads of fate. The Winners lie there peacefully, in single organ failure responding well to the ventilator. They just need a helping hand to overcome COVID. The Losers progress further into multi-organ failure. This one’s kidneys have gone, and a haemofiltration machine circulates and cleans his blood outside his body. That one looks quite yellow now that his liver isn’t interested in functioning.

I can tell the Winners and Losers apart with my eyes closed. But truthfully, i’m cheating – I just listen out for the machines that alarm the most frequently.

Mr. N is 66, with grown up children and a healthy pension. He likes gardening and walks in the countryside with his wife. He’s been fit and well all his life, and apart from his current three-organ failure, has no medical issues. His kids sent a hamper of food to the Unit two nights ago for us.

Mrs. P is 43, with teenage children and a job she loves. She’s fond of her dogs and apparently likes motorcycle racing. She’s overweight, has high blood pressure and diabetes, the Holy Trinity of a crap outcome. Her heart is also biologically on fire, and two days ago she sensitised to the only medication I could give her for it.

I phone the boss and he agrees.

T-Minus 20

“Good morning, is that Mrs. N? I’m so sorry to wake you, it’s Dr. H calling from ICU…Yes, i’d like to talk to you about Mr. N’s condition.”

The words come easily, I have this conversation at least once or twice per day.

“As you know we’ve really been hoping he might respond to all the treatment and start showing signs of improvement. I’m afraid I don’t have good news.”

You never get good at the part when the tears come.

“Are your family with you? Ok, I can set up a video call like last time. You’ll all be able to see him, and say goodbye.”

T-Minus 15

I prop up the iPad that a generous donor gave our ICU onto a table in front of Mr. N and open the right app. The call comes a moment later, and Mr. N’s family start popping up one after the other.

“Hi daddy, it’s your daughter, I know you can hear me in there…”

I leave them to it.

T-Minus 5

Oxygen down to 21%. Positive End Expiratory Pressure that keeps the small airways open down to zero. Noradrenaline that supports the blood pressure off. Stop the nasogastric feed. Disconnect unnecessary lines. Silence the alarms. Remove most of the ECG leads. It’s all just muscle memory now.

It doesn’t take long.

“Time of Death, oh-seven-fifty”

T-Minus 1

“Hello mate, is that bed ready? Emergency intubation en-route to the Unit now.”


John Appleby May 2, 2020 - 3:44 pm

Thank you for sharing, this was absolutely haunting. Not ashamed to admit I shed a few tears in the process. Words cannot express our gratitude to you and your colleagues.

Suthesh Thakar May 2, 2020 - 4:24 pm

Beautifully written but totally heartbreaking. I hope you and the rest of our NHS frontline get all the support they need after this is over. You are all heroes and we are forever grateful.

S Hashmi May 2, 2020 - 5:16 pm

Bless you for all the hard work. Your job caring for the patients is a roller-coaster ride of all human emotions at the same time with no time for yourselves.

Musseret Anwar May 2, 2020 - 10:05 pm

Heartbreaking , traumatic and breathlessly urgent with no room for human emotion to take it’s natural course. What an awful predicament to be in day in, day out! Absolutely devastating! Need strong faith and spiritual resilience to survive! Hats off to the frontline staff who bear the brunt. Totally indebted to you. May the Almighty keep you strong!

Katie May 6, 2020 - 1:04 pm

Thank you for sharing – how devastating. Are choices like this really having to be made? How do you explain to the families that you just happened to choose that moment to extubate their loved ones?

Hmm. I realize my above comment could sound accusatory. With everything you have been through, I can only imagine these choices have been excruciating. No accusation was meant. Thanks for all that you’ve done.

Dr. H May 6, 2020 - 1:41 pm

Katie, thank you for your comment – it’s a perfectly valid question. We aim to speak to the family of all our patients at least once per day to update them on their loved ones progress. For most of our patients that unfortunately pass away, it’s a process that occurs over a few days. Families will already be aware by that stage that despite maximal treatment, the prognosis continues to be extremely poor. Daily Consultant-led MDT meetings, where all patients are discussed, allow us to have provisional plans in place for all patients approaching the end of their life. In the vast majority of cases the withdrawal of care is not a surprise to families – but typically we aim to do this during daytime hours. If for an emergency reason this cannot occur, we of course communicate this. Thankfully all our patient’s families have been very supportive and understanding in this time of pandemic. I hope that answers your question, and thank you for reading the ICU diaries.


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