Maria works as a senior ICU (intensive care unit) consultant in a university teaching hospital. Daily work involves assessment, resuscitation and ongoing treatment of critically ill patients, including application of life support equipment (e.g., ventilator, dialysis machine etc) and medications. Duties include training and mentorship of undergraduate and postgraduate medical and nursing personnel. How did events unfold for her? Maria is a senior philosophy student in Dublin.
ICU Physician during COVID
Maria Donnelly, Dublin
When COVID struck I was due to retire but knew as a senior staff member it was my duty to contribute to the COVID effort. I also instinctively knew that years of practical philosophy training would stand me in good stead for what was ahead.
In early Dec 2019 when news was filtering through that coronavirus19 (COVID19) was sweeping Wuhan, the problem seemed rather abstract. However, as we live in a highly connected world, by the end of January 2020 the threat was no longer theoretical.
Surge planning for ICU
It was time to review our ICU (Intensive Care Unit) surge plan which comes out 6-yearly, the usual frequency of a pandemic threat. Up to now threats did not require full scale activation. This was a first.
Surge planning refers to the ability to increase ICU capacity quickly –logistically complex when it comes to critical care. Few locations in a hospital have the services required to support an ICU-grade ventilator. It takes around 10 yrs to train an ICU doctor or nurse; it can’t be done in a couple of weeks. To supplement staff numbers, staff worked in teams containing a skill mix of trained professionals together with less experienced staff.
We needed multiple meetings and intense negotiations to implement the details of the plan. Staff training and upskilling was provided for all staff who undertook tasks not normally done.
ICU Operations Room
A vast amount of preparation, including setting up an operations room needed to be done within a short time frame. The operations room, something like the ‘war room’ was crucial to the success of the effort. Everything was orchestrated from there. Daily executive meetings followed a rolling agenda, updating our position regarding supplies of patient equipment, PPE (Personal Protective Equipment) and staff issues.
A real time census of all covid and non-covid patients was displayed on screen here, giving oversight of all patients at a glance. The patient areas were divided into Pods but at shift change, staff hand overs and debriefs took place in the operations room.
The above preparations started in earnest in early February. In early March a meeting of all departmental consultants was called to discuss changes in work practices and rosters. This was required to sustain us through a pandemic of unknown size and duration.
Italy
As some still did not fully comprehend the gravity of the situation, I forwarded a translation of a news broadcast from Italy, by Professor Antonio Pesenti. He is a well-known and respected intensivist from Lombardy – publicly praised as one of the best Italian men of science. Professor Pesenti was the coordinator of the Lombardy region crisis Unit for Intensive Care .
He spoke with a broken voice after 17 days of nonstop work. Pesenti said, ‘If the population does not understand that they must stay at home the situation will become catastrophic.’ At that point the emergency system was unable to guarantee ordinary standards.
He added ‘By profession we are used to dealing with any situation in cold blood but only those who are living in the front line can understand the drama of the events.’ The picture was of such gravity as to require an increase in resuscitation places up to 10 times their current availability. They were clearly overwhelmed; the system and staff were breaking down and they were running out of essential supplies. Their surge capacity was exceeded. The high death toll included healthcare workers.
St Patrick’s Day
Meanwhile at home ICU specialists were extremely worried that the same thing was going to happen to us especially if the planned St Patricks Day (17th March) celebrations were to go ahead.
We were metaphorically biting our nails until the news came through that it was to be cancelled. And quarantining and other measures were introduced to enable us to stay in the containment phase for as long as possible.
Most ICU doctors were emotional when the news came through – this was the most frightening time of all. The measures introduced prevented hospitals from being totally overwhelmed, although when we were at peak COVID intake we had exhausted all our surge capacity. As Wellington said after the battle of Waterloo – ‘It was a damn close-run thing.’
Communication not isolation
At this stage the ICU community had set up a Whatsapp group – ‘ICU docs Ireland’. Doctors working in ICU all over the country used it to communicate medical information and to prevent isolation. Our Italian and UK colleagues were constantly sharing information with us in the form of Zoom lectures, publications, Whatsapp messages etc. We were all learning from each other as no one had experience of treating COVID.
Once the preparations were complete and patients started coming in, everything proceeded calmly. In fact, you might be excused for thinking that there was nothing unusual happening.
That’s not to say that there were no issues. There were multiple daily issues, but these were hammered out in the operations room away from the patient areas. Some meetings were emotionally charged. Fear and tiredness led to anxiety and anger. Tempers often ran high and small events could trigger an angry outburst. Philosophy practices such as ‘What would the wise person do?’, and the awareness exercise were of great benefit.
Life changed for everyone. Bedside staff encountered many challenges. Isolation was acutely felt, as only essential staff could enter the COVID ICU. Prolonged wearing of PPE was intolerable due to sweating and dehydration. Goggles hurt the face especially for those wearing glasses and it was hard to hear and recognize others. Fogging of glasses and visors were common; performing procedures was more difficult in full PPE.
Fear
Apart from their concern over patients, psychological challenges for staff included fear of contracting the disease themselves and dying from it. Or of bringing it home to their families. Some staff stayed remote from their families for prolonged periods leading to isolation and loneliness. Fear of running out of PPE was constantly in the background, as was fear of working outside of their scope of practice.
Patients and Relatives in ICU
Life changed for patients too. They were often sedated heavily by necessity, sometimes for weeks. This had to be withdrawn when the patient improved. Delirium and nightmares were common as with most ICU patients. But it was compounded in this setting by the difficulty in recognizing and hearing fully donned staff who looked like ‘aliens’ to a patient in a delirious state. Human touch was very abnormal through 2 layers of plastic gloves. There were no familiar faces to help orientate them as relatives were not allowed to visit. ‘Aliens’ were woven into the fabric of their nightmares as we discovered at the post ICU clinic.
Many patients developed Post Traumatic Stress Disorder (PTSD). To minimize this – nurses kept patient diaries where possible, detailing events in ICU for the patient to read later to help fill in the memory gap.
Relatives were very hard hit by not being able to visit their loved ones. Daily life revolved around a phone call from the hospital, always dreading the worst. A patient dying without the presence of a loved one was particularly troubling for everyone.
And from my point of view…
The psychological demands were huge and because of this, to stay mentally healthy myself, I knew I would need the battery recharge of daily meditation and weekly philosophy class (on zoom). Our class tutor has compassion instilled in her being. This together with the support of the group was much needed.
What I have taken away from all this is that in spite of all the difficulties encountered, people are intrinsically good. As Shantananda Sarasvati says, ‘When good thoughts and emotions arise, mankind develops.’
I saw evidence of this in the countless small deeds performed by unknown people at many levels starting with the local community. We welcomed food, goodies and warm wishes sent throughout the year.
Inner resources
Sometimes when people ask me what I learn at philosophy I can hardly say, yet I know it has deeply affected me. My inner resources like calmness, patience, ego control and wisdom have built up over time. Rebecca Neuberger Goldstein’s words best express my feelings about it.
‘Philosophical progress is invisible – over time it becomes incorporated into our points of view, and we forget its origin. We don’t see it because we see with it.’
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