Nick's story

A staff member in PPE with a lung xray in the background
  • Introduction

    • Professor Nick Hart
    Joint Critical Care Director

    “There were rows of patients on ventilators. I will never forget that sight. The severity of illness was extraordinary.”
    Professor Nick Hart

    “I was in Beijing on 8 January when I heard what was happening in Wuhan. I flew back the next day. We admitted our first patient to the High Consequence Infectious Diseases Unit (HCID) unit on 6 February. By then it was obvious this was going to be a pandemic, from what was happening in Italy. I remember thinking that people out there on skiing holidays were all going to be bringing it back. 

    On 9 March, we were instructed by NHS England to provide 300 ICU beds. Our baseline is 50 ICU and 24 HDU beds – 74 in total. My response was: Oh gosh – we have got a challenge now.

    But it was smart of them. That pushed the agenda for London. Other trusts realised the seriousness of the situation.

    The plan was to stop surgery in 3 weeks. But we knew cases were doubling every 3 days. I said by Monday there would be 1,000 cases and by Thursday 2,000. We needed to shut down surgery next week or we would be behind the curve. I know some colleagues felt I was being hysterical. 

    Normally we are planned, strategic, we know what we are doing, we have a vision. Here plans were changing daily. We had to be agile. We had to get going and adapt as we went along. We had a team around us that was amazing. That was what gave me reassurance. We built new ICU units in a matter of weeks.

    Staff with equipment in an empty unit with beds

    Staff prepared to set up new critical care units to meet demand

    Staff prepared to set up new critical care units to meet demand

    But it meant lots of people were going to have their surgery delayed. We had to talk to the surgeons who were obviously really worried their patients were being de-prioritised while we were prioritising patients with COVID-19. I found those 10 days incredibly tough.

    We came up with a plan to get cancer ops at the [private] London Bridge hospital. That was a master stroke. It meant staff who had diabetes or were pregnant, who really wanted to contribute but were high risk, could be re-deployed. That was genius. 

    In the end, surgery stopped and we had an empty hospital. It was the lull before the storm.

    “Italy was 3 weeks ahead of us – I was on calls with them and it was like getting an update on the future.”

    We had to slot extra beds in so there was less space between them. I remember looking down one of the units and there were rows of patients on ventilators. I will never forget that sight. The level of illness was extraordinary.

    a wide view of a crowded intensive care unit

    Extra beds were needed to increase capacity

    Extra beds were needed to increase capacity

    The hardest point was where mortality was getting worse. This is a virally-triggered, multi-system, inflammatory disease that is catastrophic. The more organs that are failing the more muscle wasting you get – over 10 days you lose 20% of your muscle mass. If you start with not so much, that is a big loss. We had to take some very difficult decisions about which patients, particularly if already frail, would benefit from escalation to ICU. In Italy, in the first wave, they all went to ICU and they had massive mortality.

    Italy was 3 weeks ahead of us – I was on calls with them and it was like getting an update on the future. I was walking round one weekend – there were a lot of patients dying. Two patients died within 20 minutes of each other and I gave the research nurse caring for them a hug. Patients who looked alright and were recovering would suddenly die. Some aged 50 or 55.

    I thought perhaps we are doing the wrong thing? That was when we started to think about the thrombotic element – blood clots. We began using more anti-coagulation treatments and steroids.

    We had to protect the patients and protect the staff. We made sure we were never short of PPE and we gave staff a break every 2 to 4 hours. People were battered and bruised from the masks. The dermatologists set up treatment sessions for them – they did a brilliant job.

    But the changing early messages on PPE made it very hard and the requirements were then downgraded. This was not Ebola. I found myself explaining to colleagues that you can wash the virus off, just don’t put your hands in your mouth. We needed to be clear what was needed and what was adequate. 

    How do you reassure people? By doing it yourself. You need to lead from the front. 

    What made me angry? The Nightingale Hospital was difficult for us. They wanted us to provide senior staff, and then, when they were ready to receive patients, we still had capacity. We felt we had a really good understanding of what was going on, and we were coping. Later, we took patients in from the Nightingale who were referred for ECMO, but thankfully we avoided the need to send patients there.

    The scale of the investment in the Nightingale – 4,000 ICU beds to treat this bloody awful condition – that undoubtedly helped push people inside when lockdown was announced. The streets were empty. London was really struggling in early April. One Friday [3 April] we were intubating a patient every 2 hours.

    Staff member in critical care unwrapping syringe
    Housekeeper removing waste from critical care
    Two staff caring for an adult patient in Evelina London Children's Hospital
    Two staff at a patient's bedside in critical care
    Two staff at a patient's bedside in critical care
    Staff looking into a doorway of the high dependency unit
    A team of staff talking in a huddle
    Staff putting on PPE before going into the ward
    Nurse preparing medication
    A group of nurses in a huddle
    Staff member putting on PPE
    A staff member in critical care making a phone call
    Two critical care staff at a patient's bedside
    Item 1 of 13
    Staff member in critical care unwrapping syringe
    Housekeeper removing waste from critical care
    Two staff caring for an adult patient in Evelina London Children's Hospital
    Two staff at a patient's bedside in critical care
    Two staff at a patient's bedside in critical care
    Staff looking into a doorway of the high dependency unit
    A team of staff talking in a huddle
    Staff putting on PPE before going into the ward
    Nurse preparing medication
    A group of nurses in a huddle
    Staff member putting on PPE
    A staff member in critical care making a phone call
    Two critical care staff at a patient's bedside

    Our survival rate was high and our patients were very similar to those admitted across England and Wales. It’s a tribute to the team’s amazing skills, and the process. We now have a system that is much better organised. Although a 2nd wave would be challenging in terms of how exhausted everyone is, the infrastructure is in place. We need to consolidate the treatment pathways.

    “There was a feeling of can do, must do. I was in meetings asking people to do things and normally you would go back later to check they were done. I didn’t go back to check – things were moving too fast.”

    One thing I am really proud of is the way the trusts in south London came together. There are always gripes in the competitive environment we work in. But we took patients from other trusts and we transferred patients between trusts to help. We became a very tight knit system which will be helpful in the future.

    I am wholly data driven. I was constantly walking round ensuring we had the right capability. What kept me awake at night was our oxygen supply. It could only deliver 3,500 litres a minute – nothing like enough. Thanks to a huge amount of work by many colleagues, we got a new oxygen tank installed along with 1.2 kms of new piping.

    There was a feeling of can do, must do. I was in meetings asking people to do things and normally you would go back later to check they were done. I didn’t go back to check – things were moving too fast. But they were done. It was fantastic.

    I am pretty convinced I had the virus around Christmas. I had done so much travelling. I was really breathless and went to bed on Christmas Day afternoon. There have been moments balancing work and home life with my wife and three children. But what had to be done had to be done.

    Now [the peak is over] I have had periods feeling flat about the whole experience. Could we have done better?

    In the early days I described COVID-19 as the new polio. It was mild, moderate or severe and would require a long period of rehabilitation. We have launched a research initiative with UK Research and Innovation to follow up these patients for 25 years. It’s our responsibility to look after them.”

    The photographs in this story were taken at different stages of the COVID-19 response with varying guidance for personal protective equipment (PPE) and social distancing.

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