In a private room by the locked entrance of the intensive care unit, Dilip Sharan is sitting up in bed, a plate of stew in front of him. He navigates his spoon around the breathing tube keeping him alive, every mouthful soundtracked by a discordant symphony of beeps and bongs from multiple monitors keeping tabs on his vital organs.
It is his fifth day in the last chance saloon of Covid care. He gasps for air, barely able to speak.
Sharan, 53, seems shockingly young to be so ill with coronavirus. But he is far from an anomaly in the ICU at Milton Keynes University hospital, where lunchtime passes almost unnoticed by patients being fed through tubes.
This unit currently has no one over 70 and last week cared for a 36-year-old pregnant woman whose twins had to be delivered early by caesarean while she was in a coma. She was employed by a chain of gyms and was working out regularly until her scan showed two babies instead of one.
The desperate picture is repeated in hospitals across the UK as the second wave engulfs a National Health Service that risks becoming overwhelmed within weeks.
Here, the shock of seeing so many people needing treatment is accompanied by surprise at their ages – there is a sense, shared by many medics, that younger and fitter people are ending up in hospital with Covid.
Official figures bear this out, though only to a degree. Under-65s accounted for 39% of hospital admissions at the start of this month compared with 36% in late March, NHS England data shows. Younger people are not dying in greater numbers, however. Under-65s now account for 8.8% of deaths, according to ONS figures, down from more than 10% throughout last April.
Still, some wonder if the emphasis on protecting the oldest and most vulnerable gave others a false sense of security. The government told the nation to take care and “don’t kill granny”. Would we have behaved differently if told not to kill Mum or Dad, or even ourselves?
“You can’t trust Covid,” says Daniyal Rizvi, 36, who is struggling for breath in Milton Keynes’ respiratory higher care unit, which contains critically ill patients not quite sick enough for ICU as well as those who doctors think will not survive being put on a ventilator. “My husband is a highly vulnerable person. Two years ago his lungs failed and he is perfectly fine and yet look at me.”
She is 13 weeks pregnant and believes she caught Covid from Christmas shoppers in Primark, where she works. (Primark said it was in regular contact with the patient and abided by all government guidance and safety measures.) Doctors don’t know why more pregnant women appear to be getting sick this time around, though many hypothesise it is less about the medical vulnerabilities of pregnancy than a reflection of the increasing incidence of the disease nationally.
With the hospital “creaking at the seams” in the words of one consultant – and widespread concerns that the public are still not taking Covid seriously enough – the Guardian was given a rare invitation to spend a day with the sickest coronavirus patients and the staff who are caring for them during this brutal second surge.
In the first wave, most patients on ICU were sedated and unconscious. Now, medics treat mechanical ventilation as a last resort, with statistics showing that intubated patients have a 43% chance of dying, down from 46% in the first wave. But with the second wave in full swing, the data is in flux and many fates still unknown. Dr Joy Halliday, one of the intensive care consultants, said survival for those on ventilators was now actually nearer to 30%.
This Thursday, four out of the nine patients on Milton Keynes’ main ICU ward are awake, among them Sharan. He has type 2 diabetes, but not all of his ward mates have comorbidities that could worsen their prognosis, says Dr Jamie Strachan, a tall and unflappable Scot who is a consultant in critical care and anaesthesia. “There are people on this ICU on ventilators fighting for their lives that have no underlying health conditions. They don’t take any medications for anything. They’ve just got bad coronavirus.”
Answering questions between gulps of air, Sharan says he probably caught Covid from his wife, a secondary school teacher. He is remarkably stoic for someone whose life remains in the balance, saying he thinks schools should “maybe have been closed down a bit earlier” before Christmas.
Yet he blames no one and does not complain. Yes, the tight-fitting Cpap (continuous positive airway pressure) mask he has to wear for all but a few minutes each day is uncomfortable, he concedes, particularly during the many hours he has to spend lying on his front with it digging into his face. But, he says, “you do what you have to do”.
Cpap, which Boris Johnson also endured, is horribly claustrophobic but “also feels like you’re sticking your head out of a car window, because you’re having air blowing at you at the equivalent of driving at about 90 miles an hour,” says Strachan. Patients wearing Cpap masks look like they are in shock, their eyeballs bulging out of grey-tinged skin, their hands tightly gripping their bed rails or a nurse’s hand. Families are only allowed on the ward to say goodbye.
Sharan seems optimistic he will recover, hopeful that the anti-viral drug remdesivir, which was taken by Donald Trump before its approval by pharmaceutical regulators last year, will get him back home with his wife and daughters soon. But Strachan warns there is no “silver bullet” for Covid. “Time and oxygen” remain the main weapons in the intensivist’s armoury.
Oxygen is the big problem for the 235 Covid patients currently in hospital in Milton Keynes – more than twice the number on the worst day of the first wave – as well as the army of staff caring for them. No one seems to have enough of it, neither the patients’ lungs nor the pipes that supply the gas from canisters in another part of the building.
On this Thursday, consultants are worried that the oxygen to the respiratory wards will run out. Supply is less of a problem than delivery. “The oxygen comes via pipes and the pipes have a flow rate, so that pipes can only allow a certain amount of oxygen per minute to flow in them,” says Dr Hamid Manji, a consultant in critical care and anaesthesia who is also clinical director of the surgical division.
“And so it doesn’t matter really how much oxygen you have in the reservoir. If the pipes can’t deliver it per minute, to all the places that require it, then you have an oxygen shortage.”
So many patients are requiring near round-the-clock support from Cpap masks that doctors have decided to repurpose yet another part of the hospital to care for their sickest patients, opening up new pipelines into what was the day surgery unit.
Two other Covid wards have already been fashioned out of other parts of the hospital complex, with 60% of all adult beds and 10 out of 14 wards taken up by coronavirus patients.
“We’re definitely creaking at the seams in the hospital, and the next four to six weeks I think is going to be even worse,” says Halliday, a smiley and reassuring redhead from Ireland. “All these people that we’re seeing here are people that were already sick on Christmas Day. They’re about 10 to 12 days into their illness.” The hospital expects to see an influx of patients from next week as a result of Christmas mixing.
When the Guardian visits, Halliday is in charge of ward 15, a respiratory higher care unit for patients extremely ill with Covid. It is the next step down from ICU but patients are dying there every day, sometimes people in their 30s and 40s.
“People are terrified of being ventilated this time round,” she says. “Nobody wants to go on it because they think it’s a death sentence. They think that last time around, it was bad – this time is even worse. So there’s a lot of people that are saying ‘don’t don’t put me on a ventilator’, even knowing that they have no other chance.”
Critical care use graph
Deciding who gets what treatment is tough, she says. “We know that there are some people that just will not survive no matter what treatment we have.” All of the staff have “decision-making fatigue”.
Everyone in the hospital is exasperated with Covid deniers. Darren Gregory, 53, a project manager for a construction firm who is attempting his first day without Cpap since being admitted five days previously, says he has been on Facebook to warn others. “You know, I don’t normally post stuff on Facebook, but I said: this is real, guys. You know, I’m never ill. I’m not. I’m not a sick person. So for me to get this … ”
He seems astonished to have ended up in hospital. In the run-up to Christmas he was doing five miles four times a week using Nordic walking poles. “He was a very fit and well gentleman,” says Halliday, his consultant. Patients have been dying around him every day. “You see them coming in and they’re not too dissimilar to yourself. And then you wake up in the morning and you look over and you can see how limp they are, and lifeless.”
Covid patients can deteriorate fast and doctors cannot always predict which ones: one patient on Cpap, in their early 60s, was well enough to be interviewed by the Guardian, only to be sent to ICU hours later and intubated the following morning.
Staff are struggling with the amount of death they are encountering, says Halliday. “We’ve already had intensive care nurses giving in their notice because they just cannot deal with the fact that every single shift they do someone dies. And it is tiring. You know, as doctors, we are fairly privileged, because we can get out of PPE after a couple of hours and leave and come back later: the nurses are here at the bedside, for their entire shift. They come up out of PPE for a break in the morning and break in the afternoon. You get dehydrated, you get exhausted. It is really, really, really tough.”
She says she has almost fainted countless times after not having time to eat or drink during a long shift. When Strachan shows the Guardian around ICU it is 11.30am and he has been on call since 5pm on Wednesday night.
Anna Hunt, one of the ICU nurses, was working in London when the 7/7 terrorist attack happened. What makes Covid so difficult is the relentlessness, she says. With the London attacks, “it was very intense, but it was for a short period of time. And you could pull in resources from outside. This is completely different, this is that on a different scale, because it doesn’t stop after a week or a month, it just continues.” The team are amazing, she says, “but oh, my God, it’s tiring.”
In normal times, ICU nurses get to know their patients by talking to relatives at the bedside. “We have that rapport with them and they bring in pictures, but we’re not getting that now, which means that it’s difficult to build a relationship with a sedated patient,” Hunt says. Nurses do their very best but families struggle to understand what is going on via daily, sometimes hourly, reports from the unit. Many families are understandably distressed and some times turn up at the locked ward, demanding to be let in.
All of the staff are nervous about the weeks ahead, particularly the anticipated post-Christmas surge. “I genuinely don’t know what we’re going to do. We’re already bursting,” says Halliday.
“Yesterday we transferred someone to another hospital because we didn’t have any beds left in intensive care and that’s happening everywhere in the country. But there will come a time where there’s no beds in the country to transfer them to and we are going to have to deal with it ourselves.”
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