Prone

Published by The Polyphony as ‘Prone: Redeployment to Intensive Care during COVID-19’ and recorded for the British Library as part of ‘NHS Voices of COVID-19’ .
The essay was reviewed and approved for publication by the medical director of the Royal Free Hospital, the Vice President of the Royal College of Physicians, and by NHS England

I waited for the Northern Line connection to Belsize Park. I wore my Orkney jumper, tatty tracksuit trousers from cross-country in St Andrews, blue suede trainers, and a green and ochre rucksack my uncle gave me for my thirteenth birthday. In my pocket was the red lanyard I’d been given by the medical receiving team before my first shift as a doctor - night duty at the Royal Infirmary of Edinburgh, five years previously. I was on my way to the intensive care unit for the first time.

The picture wasn’t great. The twelve-storey tower of the Royal Free Hospital had over three hundred patients admitted with COVID-19, ninety of whom were on ventilators in an intensive care unit expanded from its normal capacity of thirty-four beds.

I’d sent Meryl a message the night before.
‘Do you have space in the evening proning shift tomorrow? I’d be happy to help if you do’.
I’d met Meryl, a consultant vascular surgeon, the week before and had helped her to set up a self-rostering system for the proning teams.
‘We can bring you in. Meeting point is ICU reception area 4th floor at 4.30pm in scrubs’.
I was admitted to SWAT Team Comms, the WhatsApp group used to coordinate the ‘Surgical Workforce and Access Team’ and picked up a pair of black scrubs from my UCL office on the way in.

To form a proning team you need six surgeons and an anaesthetist. Actually, since the process mainly involves heavy lifting, you only really need six people able to do as they are told. That’s where I came in.
Proning is a treatment for patients with severe acute respiratory distress syndrome. It reduces the collapse of alveoli, the tiny buddings in the lungs where gas exchange takes place, improves the drainage of secretions, increases lung capacity, and better matches ventilation to blood supply. It’s nothing fancy: you turn the patient over and nurse them on their front. You try it when patients are failing.

I met the surgical team on the fourth floor and introduced myself.
‘My name’s Adam, I’m one of the medical SHOs. I’ve never worked in intensive care before and this is my first proning shift. Please keep me right’.

We got dressed. The donning area was a small rectangular room at the entrance to the unit. It felt like some admixture of Sunday League football dressing room, medieval armoury, and 2001: A Space Odyssey. I put on a cap, an FFP3 mask, a long-sleeved gown, two pairs of gloves, and a visor. I tied the straps of the gown around my waist and reached for a felt tip pen to scrawl my name on the front. Behind gown, mask, and visor, we looked much the same.

Inside the double doors was a strange, muffled place. Rank upon rank of unconscious patients under bright, bluish light. Much of their physiology under mechanical or pharmacological control: ventilators regulate breathing, vasopressors prop up the blood pressure. They receive food and drink by nasogastric tube and central line. Around each patient, a stack of infusion pumps bolted to a metal pole - propofol, fentanyl, noradrenaline. IV fluids and nasogastric feed hung from the top like a sort of nightmarish hat stand.

Repositioning one gentleman, who weighed 150kg, I noticed he was blinking. 
‘Is that normal?’ 
‘Yes, that’s alright. He’s under mild sedation only'.
‘Right’.
An emergency alarm went off. Nurses and doctors hurried off. The surgeons continued. They had come here to prone.

We identified the first patient, lowered the cot sides of the bed, and made sure all the lines and tubes were in a safe position. We untucked the bedsheets and laid another two on top. The team lined up, three on each side, and rolled the edges of the sheets around the patient.
The physical act is like a rugby scrum. We pressed together on either side. Pillows are placed to reduce pressure sores. A slide sheet goes under the patient, the nurse waving the red fabric around like a matador. We slide them to one side of the bed, those on the near side stick hands below to grab the crimped sheets on the far side. On three, roll the patient to 90 degrees. Then, in a single movement, the patient is flipped onto their front. Crouch, touch, pause, engage.
We repositioned the pillows, reattached the monitoring, and secured the lines. We checked the endotracheal tube wasn’t pressing on the lips, that the ears were not bent, that nothing compressed the eyes. Then we moved on to the next one.

A few hours later, having turned a dozen patients across three floors, we took off our overalls and sat down in the reception area for a break. I spoke to Charlie, a consultant hepatobiliary transplant surgeon, who had shown me the ropes inside the unit. His weeks normally revolved around the pancreas, the gallbladder, and the liver - removing, resecting, transplanting. He longed to get back into theatre (‘I’m a right upper quadrant man’). But for weeks his lists had been cancelled: COVID patients lay ventilated in the theatre recovery area and the surgeons spent their days proning and reinserting vascular access lines.
He checked his phone. 
‘My son wants me to buy sesame seeds. Where am I supposed to find sesame seeds?'
‘You’ll probably get some from Marks & Spencer on Pond Street’.

The following weekend I was back in the unit as part of the medical team. A Hampstead newsstand pronounced ‘Royal Free at full capacity’. 

The intensive care team was by now supported by a motley assortment of medical and surgical help. Looking around I could see a consultant dermatologist, a plastics trainee, two medical students, a paediatrician, an A&E registrar, and someone I didn’t recognise with a badge declaring ‘ICU 4 Temp Staff’.

I was sent to an improvised extension to the intensive care unit on the second floor. Normally the space housed PITU, the Planned Investigation and Treatment Unit, for day-case procedures. The place had opened around New Year and filled with thirty patients in three days.

At a midweek induction I’d attended with thirty ophthalmologists who had been seconded to the Free from Moorfields Eye Hospital. We were told the bleep numbers for each area and the basic structure of the day in the unit. We were encouraged to work within our abilities.
‘Please don’t administer anaesthetic medications independently. Ask an anaesthetist or intensivist if they are needed’.
We nodded knowingly and breathed a sigh of relief.

The handover document contained the notes from the past day’s morning, evening and nighttime ward rounds with a summary of the patient’s main issues and their most recent advice from microbiology. You could look through the day and see those who were doing badly: increasing oxygen requirement, worsening imagery and blood work, no response to proning.
I tuned-in to the handover.
‘…Fifty-seven year old male, day twenty intubated and ventilated. Invasive pulmonary aspergillosis plus COVID’.
‘It will be fatal’.
‘I’ve prepared the family for non-survival’.

I went into the donning area, got dressed, entered the unit, and started the ward round. Having orientated myself in the unit with the proning team the general setup was familiar, though in this improvised area the patients were banked together at snugger quarters. At the foot of each bed an A1 chart recorded the progression in each patient’s vital signs, neurological observations, the depth of their sedation, and kept track of all their lines and when they were inserted: tracheal tube, arterial line, central line, vascath, nasogastric tube, catheter. Another area of the chart recorded the current drug infusions, fluid balance, arterial blood gas results, and the hourly rate of vasopressor support required to maintain adequate blood pressure.

Each assessment follows a structured format. You assess the patient’s airway, breathing, circulation, bloodwork, fluid balance and kidney function. Markers of infection. Check their lines. Then do FASTHUGS: prescribe feeding and fluids, analgesia, sedation, thromboprophylaxis, ensure they’re positioned head-up at 30-45° to prevent aspiration. Make sure they’re on ulcer prophylaxis. Check their blood sugars. Can they breathe on their own?

I reviewed each patient, performed the structured assessment, then presented the case to the consultant who made the beyond-my-ken decisions about ventilator weaning and rocuronium. It all seemed quite orderly.

A nurse came up to me looking concerned.
‘We just moved him and now he’s crashed’.
I went across to the patient. He was forty-nine years-old. Something bad had happened. I looked at the monitor: blood pressure low, oxygen low, heart rate high. I waited a few seconds as the nurse applied suction and increased the noradrenaline. He didn’t rally. I went to find the registrar.
‘Doug…’
I explained the problem.
'Give him some more rocuronium. We need to re-paralyse him to give the ventilator a chance to work. It’s a temporary measure. Should work in about a minute'.

I went to find the paralytic. The storeroom was a regular pantry. Anaphylaxis kits, propofol, noradrenaline. Your choice of intravenous fluids: Hartmann’s, mannitol, sodium chloride, glucose. Blood tubes, swabs, giving sets, transducers, arterial lines, anaesthetic masks. A medical student rushed past and knocked down four boxes of venturi masks, which scattered over the floor. I picked them up and saw the anaesthetic fridge: atracurium, rocuronium, argipressin, pancuronium. The blood product fridge. The parenteral nutrition fridge. The controlled drug cupboard, locked. I opened the fridge, took out a cool vial of rocuronium, snapped its glass neck, and drew up the correct dose.

He continued to slide. Heart rate jumped to 160. Blood pressure sagged to 60 systolic. Oxygen saturations fell and fell: 90, 85, 79, 68. I grabbed the arrest trolley.

Though unconscious the whole time, his body told its story: sudden desaturation, hypotension and tachycardia immediately after being rolled in an intubated patient with COVID-19. It was a pulmonary embolism. Features of right heart strain on the bedside echo sealed it.

Doug asked for alteplase, a medication used to break up the large blood clot which was obstructing the vessels in his lung. The consultant began to pepper me with questions about the right coronary artery as I skittered around trying to work out the dosing regimen for the thrombolysis. It struck me as odd that he chose to do this in a peri-arrest situation with a young man on the cusp of losing his life. Then it didn’t. It’s not enough to act. Nor is it enough to understand in abstraction around seminar room tables. You have to do both, at the break of the game.

I looked at the registrar and consultant. Difficult to judge their age. Strain had worn deep lines in their faces. Months and months in suffocating gowns, tight masks and sweaty gloves. Facing a single disease and losing frequently.

After the alteplase, the patient stabilised. Though it remained to be seen whether the episode was a life-saving intervention or an acceleration in an inexorable decline.

I stepped away. Around was the cross-talk of the handheld radios, nurses washing a patient, the FY1 running bloods, students restocking a cupboard, the registrar arranging transfers, the microbiologist relaying culture results from the lab, the consultant anaesthetist breaking dread news over the phone.
'I just need to give you a bit of an update…’
‘He’s okay now?’
'He’s very, very, very sick now'.
Outside fat white flakes of snow fell and lay on the redbrick houses leading to Gospel Oak. The winter finery soft and waving in the air.
A transfer team arrived with a patient. Across the city, hospitals were working together to make space for patients wherever possible. We found room.
I went to find a slide sheet. Over the radio, an old ‘Faces’ song played.

‘I wish that I knew what I know now 
When I was younger’.

I rejoined the consultant, who was deciding what to do with another gentleman. He wasn’t doing well: symptoms started at the turn of the year, admitted to ICU two weeks later, intubated and ventilated, proned five times. An updated chest CT suggested an organising pneumonia. Now his kidneys had failed and he’d progressed to multi-organ failure. The question was whether he should go onto haemofiltration, a dialysis machine to take over the functioning of his kidneys. He called the patient’s wife. In the quietness of the room, you could not but hear her grief.
He learned about the man’s life, his family, the things he loved.
‘I think we must continue to struggle to get him through this. But you should come and see him. If he takes even one step in the wrong direction today, he may die’.
We put him on the filter.

Those who survive intensive care are frequently left with disabling lung fibrosis, pulmonary hypertension, profound and potentially irreversible critical illness neuropathy. 

The consultant explained.
‘When you come out of ICU, it can take two years to return to baseline function. About twenty percent end up with post-traumatic stress disorder’.

I got on with my jobs. Arranging scans, line changes, rewriting drug charts, checking the weekly fungal markers had been requested. Then I went to see the last patient.

She’d been in intensive care for a month. The front of her neck had been cut and a tube placed in her windpipe. The tracheostomy meant she didn’t have to be sedated for the ventilator to work. Her eyes followed you around the room, and sometimes she smiled if you waved. She couldn’t speak though. That requires the passage of air through the larynx. The tracheostomy bypassed that. She’s been proned many times and was someone I’d expected to do badly: quite old, high BMI. But it seemed she might pull through.
She had another fever, so I went to take blood cultures. This was bad but not surprising. Ventilators and central lines are open highways for bacteria, viruses and fungi to breeze past the normal lines of defense into bodies already reeling from critical illness. We needed to grow whatever was causing the infection so we could treat her in a focused way.

I crouched beside her, and saw she was crying. Tears gleamed in her eyes and ran down to her bed. She couldn’t communicate why. I asked her to blink if she was in pain, and explained what the blood test was for in a way I hoped she would understand. But the water was dark and deep, and we were both out past the shelf now. Her personhood had been smothered by her illness, by sedatives, paralytics, and the massed contraptions of organ support. Now she was coming back, but I couldn’t make out how far, nor could she tell me the meaning of her tears. Was she fearful? Was something irritating her eye? Was it a human pain she felt, or some unfathomable animal sadness?

I took her blood anyway and walked through the unit. The whoosh of ventilators, the pad of rubber soles on linoleum, and the rustle of gowns was all I could hear. A proning team assembled around a body, sheets in hand. A technician hurried past with an arterial gas for the analyser. The nurse in charge bringing new syringes of Fentanyl to last the night. In the muffled, over-bright hall, I thought of a passage from Frederick Manning:

'One by one they realised that each must go alone, and that each of them already was alone with himself, helping the others perhaps, but looking at them with strange eyes, while the world became unreal and empty, and they moved in a mystery, where no help was’.

After, I ate a stale cheese sandwich from the fridge in the reception area. I changed out of my scrubs and left. I took a longer walk home through the heath. Red lights lit tall buildings to the south. Otherwise it was dark. Walking down through Tufnell Park the moving people seemed unfamiliar. Leaving grocers, driving cars, preparing kebabs. None of them had tubes running down their throat. Their hair was neither wild nor matted. No lines fed into their neck.
Streetlights and storefront windowpanes illumined the fogged air of my breath. I pulled my hat down to cover my ears. Kept walking.