‘This man knows he’s dying as surely as I do’: a doctor’s dispatches from the NHS frontline

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As lockdown is relaxed, many in the NHS are left reeling. Palliative care doctor Rachel Clarke shares her experience working with coronavirus patients, and her fears of a second wave

Death has been headline news for so long now, I am beginning to feel like a plague doctor. My next patient, an 89-year-old from a care home, is perilously ill. Despite the highest flow of oxygen we can deliver through his face mask, he is gasping for air at a rate of 40 breaths per minute, two or three times the norm. Swiftly, I search his hospital record for a glimpse of the man he used to be before coronavirus so violently reduced him.

In my mind, the voices from this morning’s car radio linger. Listening to the politicians and journalists talk – loftily, from afar, an Olympian perspective – coronavirus can feel like a mathematical abstraction, an intellectual exercise played out in curves and peaks and troughs and modelling. But here in the hospital, the pandemic is a matter of flesh and blood. It unfolds one human being at a time. And when the statistics threaten to throw me off balance – the unprecedented number of deaths for peacetime – I try to keep things as small as I can. Winston used to work in the local glass factory. His wife died three years ago. He has two sons called Michael and Robert.

Usually I work in a hospice as a palliative care doctor. But now, with the wards of my local hospital filling with patients dying from coronavirus, the need is there instead. I’m already wearing my mask. I’ve pressed the metal strip down hard on to my nose and cheekbones, endeavouring to make it airtight. Now I layer on more protection. Apron, gloves and visor, the minimum with which we approach our patients these days.

In PPE, everything is sticky and stifling. Voices are muffled and smiles obscured. Sweat starts trickling into your underwear. Even breathing takes more effort. Behind our masks, we strain to hear each other speak and are forced to second guess our colleagues’ expressions. Being protected entails being dehumanised.

Entering the antechamber to Winston’s side room, I’m dismayed to discover his sons are here. Someone has helped them into their own protection, but one mask, I can see, is on inside out and both men look limp and bewildered. “We don’t know how close we’re allowed to get to him,” says one. “Can you tell us how long he has?” asks the other, in a voice made hard by fear.

I fight for a second to maintain my composure. The sons have been permitted to visit only because their father is dying. I am a doctor with neither a name nor a face. My hospital badge is hidden from view and my eyes – the only part of my face still visible – are obscured by a layer of Perspex. So much for the healing presence of the bedside physician. I scarcely look human.

All those arcs and sweeps and projections and opinions – the endless, esoteric, disorientating debates about whether flattening or crushing the curve is more desirable – arrive, in the end, at precisely this point, this moment of cold simplicity. Six feet away, a father, a man I am yet to lay eyes on, is dying of a disease only named a month ago.

“Hello Michael, Robert,” I say warmly, though doubtful any warmth will carry. “My name is Rachel. I’m one of the doctors caring for your father. Forgive me for not knowing which of you is which.”

“I’m Michael,” says the brother with the stony edge to his voice. “No one’s told us anything. Can he even hear us?”

Everything about this is wrong. The physical barriers between us. The harsh and jarring words that conceal rising panic. The glaring need – that can’t be met – to rip off the masks and gloves and shake hands, sit down, read each other’s expressions and begin, inch by inch, to cross the gulf that divides us.

The sons step aside to allow me in closer. And there, palms turned upwards, chest heaving and trembling, is their father, spreadeagled in tangled cotton. Winston’s mask clamps down on skin slick with sweat. His lips are grey, fingertips the colour of bruises. An intravenous line drips antibiotics into one arm. A catheter drains urine the colour of mud into a bag left lying on the bedclothes. His arms and legs, barely more than bones, are twitching and scything. The only part of his body not in motion, I realise, are his eyes, white-rimmed and fixed on the ceiling.

The radio programme crosses my mind again. The language of war has been rife during the pandemic but never more so than when the prime minister was rushed to intensive care. Since then, battle tropes have dominated the national conversation. Cabinet members assured us Boris Johnson would beat the disease because he’s a fighter, as though survival is somehow a test of character, a matter primarily of valour. The reality, of course, is more banal. People do not die from this illness – or from any other – because they lack grit. Nor do they live by sheer pugnaciousness.

I look down at the bedsheets, stained with sweat, and the coil of limbs squirming in fear. It could not be plainer to anyone here that Winston is no participant in a battle. He is, instead, merely the battlefield. His body, worn out to begin with, is being methodically disposed of by a virus so primitive it scarcely qualifies as life. Character has precisely nothing to do with it. It never does in the real world of the hospital where the good, the bad, the brave and the timid all kneel alike before cancers and microbes.

I move closer. Speaking sufficiently loudly to be audible above the thrum of the oxygen, I say his name. Nothing. No flicker of response. Still closer. Again, almost shouting: “Winston.” His eyes remain locked on the ceiling. I can feel those of his sons fixed on mine.

In this alien time when even breathing the same air as your patient is heavy with risk, physical contact is permitted only when strictly necessary. I observe the muscles on Winston’s neck bulging to drag a little more air into his waterlogged lungs, and reach forwards, inching nearer.

Gently, I take his hand in both of mine. His pulse flutters so faintly, it is barely there. No warmth from his flesh creeps through my gloves. I am holding the hand of a man who is dying and who knows it as surely as I do. Behind closed doors, with neither fanfare nor drama, he has been quietly drowning all night.

I squeeze Winston’s fingers, repeat his name once again, and now, at last, his eyelids flicker. Our gazes meet for the first time. “Are you in any pain?” I ask. A barely perceptible shake of his head. But when I ask if his breathing is distressing, he manages to nod. “In just a moment, we’ll help your breathing,” I promise. I go on, a vital question. “Are you afraid?” He nods a second time and in turn I make a second promise. “I’m going to ask the nurses now to bring you an injection which will help you relax and help your breathing.” A final nod and then, just before turning to his sons, I lean closer still: “Winston, Michael and Robert are here. They’re going to sit with you now until the nurse comes.” I straighten up from the bedside. I note the glint of tears beneath the brothers’ visors. “Would you like to pull up these chairs?” I ask them. “You can sit as close as you want, you can hold hands, you can say anything.”

Later, when Winston has all the medications he needs and has finally lost that look of undisguised horror, his sons and I converse in low voices. I explain that yes, time is short, yes, he is probably in his last few hours of his life. Suddenly Michael interjects, his voice abrasive. “I don’t want him to be a statistic.” He knows full well – each of us in the room does – that tomorrow’s death toll and its televised dissection will include, in all likelihood, his father. I see through his eyes the colossal affront of someone you love – of all that your beloved has been and meant to the world – being reduced to a numerical bit part in tomorrow’s headlines. “He is not a statistic,” Michael repeats. Then he pauses. And in the bleakness and tenderness of the next four words, I think I understand for the first time the true cost of a pandemic. “He’s my best friend.”

There was a moment in mid-March when the mood at work, the newspaper headlines and even the heavens themselves aligned in mutinous harmony. A couple of nursing colleagues and I had just arrived at the local hospital to be trained in how to take our PPE on and off. We squinted up at the glowering sky, dark and steely with the threat of thunder, and laughed at the aptness of the weather.

The evening before, Boris Johnson had delivered an unexpectedly jaunty press conference in which he assured an anxious nation we would “turn the tide within the next 12 weeks” and “send coronavirus packing in this country”, like some unwanted door-to-door salesman. He made the comments on the same day the number of Britons known to have died from the disease rose by 40% to 144. The deaths, of course, were just getting started.

For NHS staff, the speech felt a little like prime ministerial gaslighting. At this point in the pandemic, the Cheltenham races had just been allowed to go ahead, some 250,000 people jamming into the stands over four days, and schools were still open. Government discussions about abandoning community testing for herd immunity had just been leaked, to great consternation. And PPE guidance for frontline staff had just been mysteriously downgraded so that most of us now were (indeed, still are) advised to wear equipment that fell short of World Health Organisation and EU standards. Meanwhile, friends working in intensive care in London were describing unfolding horrors in their ICUs. “I don’t know how much longer I can take it without lockdown,” one of my colleagues murmured as we walked towards the hospital. “I mean, have they actually decided to just ignore what’s going on in Italy?”

We passed a security guard who took one look at our faces and told us to bloody well cheer up. We laughed and I asked him what the mood was like in the hospital. He pointed up at the thunderclouds above. “See that?” he told us. “That’s what it feels like. It’s not like London here yet. But it will be. It hasn’t arrived yet but it’s coming for us. We’re waiting for it to hit.”

When the hit finally came – those daily hospital death tolls nearing a thousand – the population was, at last, in lockdown. Time, the one commodity we tend to crave more than anything, stretched out in enforced, unnerving abundance. The quarantined population tried to manage its fears and listlessness using the unconventional strategies of baking bread and stockpiling toilet rolls.

Doctors, nurses and allied health professionals, on the other hand, were reeling. From top to bottom, with dizzying alacrity, the NHS had transformed itself into a single-minded, pandemic-focused, pared-down field service. For armchair critics of the “lumbering”, “monolithic”, “bureaucratic” NHS, it was a stunning example of local teams working with fearlessness, urgency and vision to deliver high quality pandemic medicine. Operating theatres, recovery areas, normal wards and even conference rooms were transformed into makeshift ICUs. Psychiatrists, surgeons, dermatologists and medical students were co-opted from their day jobs to staff them day and night. In nine days, a London conference hall mutated into a 4,000-bed hospital. Everyone, everywhere threw themselves into action. We were proud and eager to do our part. We tried not to think about catching coronavirus. The trickle of dead colleagues began.

Amid all this frenetic activity it took time to realise that something glaring – and terrible – had been overlooked. The whole country was repeatedly assured that although efforts to contain the disease were now abandoned, the most vulnerable would be “shielded” from harm. On 11 March, for example, David Halpern, the head of No 10’s “nudge unit”, stated in a BBC interview:

“There’s going to be a point, assuming the epidemic flows and grows as it will do, where you want to cocoon, to protect those at-risk groups so they don’t catch the disease. By the time they come out of their cocooning, herd immunity has been achieved in the rest of the population.”

At the time we knew full well – because the data from China had already told us – that those most at risk from coronavirus were elderly patients, such as Winston, plus those with underlying comorbidities. But far from being cocooned, he and the other 400,000 residents of UK care homes were being quietly incarcerated. No testing. No contact tracing. No proper PPE, even, for care-home staff. Pitiful stories began to circulate of care workers wearing bin bags for protection, while begging local builders and veterinary practices for masks. Worse, care-home residents were being sent to homes from hospitals without knowing they were not infected.

When, therefore, at the end of April I watched the prime minister declare our coronavirus strategy a “success”, I felt physically sick. We had “avoided the tragedy that engulfed other parts of the world”, he insisted, “because at no stage has our NHS been overwhelmed”. How very cheap – how spectacularly expendable – one human life must be, I thought, if the avoidance of tragedy is consistent with the deaths of 27,000 people, as the toll then stood.

Does it matter that 400,000 of our most vulnerable citizens were promised shielding while being effectively abandoned? That for them, even the most basic measures of protection were at best overlooked, at worst deliberately ignored? That the alleged “success” of April came at such stupendous cost to those too elderly, frail or disabled to live in their own homes?

You could argue – indeed, some commentators have essentially done so – that there was little point to a man like Winston. He was 89 years old, after all, and probably hadn’t been economically productive for three decades. He was lucky, frankly, to have had an innings like that. Of course the young must come first. You might even champion another old man’s exploits – the charm and determination and ebullience of Captain Tom – while being secretly at peace with the expendability of certain parts of the herd.

But to those of us up close with this dreadful disease – who see, as we do, the way it suffocates the life from you – such judgments are grotesque. The moment we rank life according to who most “deserves” it, we have crossed into a realm I don’t want to be a part of – and I struggle to believe many other Britons do either. The way out of this pandemic cannot, surely, entail the sacrifice of those deemed less worth saving?

Like many in the NHS just now, I keep my head by looking down – at one patient and then another. I am lucky in this respect: I have focus. Sometimes I fret that most people don’t know how very close the NHS came to being overwhelmed this Easter – how we avoided the hellishness of Lombardy or New York City only by superhuman efforts. I fear, too, that most people are unaware of how exhausted, stunned – shellshocked, even – some NHS staff and care workers are. How daunted we feel as we watch lockdown being relaxed before proper testing, tracing and isolation infrastructure are in place. How incredulous we are as we see government figures breaking the rules they wrote, that so many others have lived and died by.

In my darkest moments, I worry that the televised coronavirus press conferences are increasingly being used to distract us from what is really at stake. That the flood of pseudoscientific statistics is intended to bamboozle – to leave the population dazed and bemused. When you are invited daily to celebrate supersized statistics – 100,000 tests a day, no, make that 250,000 – it is easy to lose sight of what matters.

Sir David Spiegelhalter, professor of the public understanding of risk at Cambridge University, suggested earlier this month that Downing Street is using “number theatre” to manipulate the message rather than actually inform people. The chair of the UK Statistics Authority, Sir David Norgrove, has even been forced to write to the health secretary, Matt Hancock, urging him to improve the “trustworthiness” of the way he presents data on coronavirus testing.

The true metric of success in a pandemic is simple, the overall number of deaths prevented. The point of our response to coronavirus is not to flatten curves, ramp up headlines, protect the NHS or invent mathematically nonsensical equations: it is the prevention of unnecessary dying.

As we reel, punch drunk, from press conference to press conference, we must not allow those standing at their lecterns on the podium to gloss over recent history. It is a fact that a whole swath of our most vulnerable citizens, those residing in care homes, have already been abandoned once to coronavirus. And no matter what any government figure implies – no matter how distracting or persuasive their abstractions – this is entirely and inexcusably wrong. Our society may be endemically unequal, but noone in Britain is expendable. Winston, though vulnerable, was loved and cherished. His death was not inevitable, his time hadn’t come. He was no more disposable than any of us.

Dr Rachel Clarke is the author of Dear Life, published by Little, Brown. Names and other identifying details have been changed to protect anonymity.

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