UCL Minds


Transcript: Episode 1

What happens to you in intensive care

Vivienne Parry  0:08 

You're listening to Coronavirus the whole story, a new podcast from UCL. My name is Vivienne Parry. I'm a writer and broadcaster and yes, UCL alumna myself, and indeed all our team here. Each week we'll be looking at Coronavirus through a different lens, seeing it from the multiple perspectives of UCL researchers. And that's why we're calling this ‘the whole story’. Because stopping a disease in its tracks is never about medical research alone. It's about history, psychology, social sciences, arts, engineering, economics, law, even politics too. UCL or University College London to give it its full title is uniquely placed to give us that whole story. UCL is known the world over not just for the extraordinary breadth, depth and range of its research on the quality of its researchers, but also for the way they work together to solve the world's challenges.

We're going to start today on the frontline in intensive care. And we're joined by intensivist professors Hugh Montgomery and Mervyn Singer to understand what happens to you in intensive care and how UCL is tackling the ventilator problem. And be assured this interview is being recorded remotely.

Let's begin by talking to Hugh Montgomery about why COVID-19 is putting such a huge strain on intensive care units. Hugh is a professor of intensive care at UCL. He's a man with an extraordinary range, I think both personal from ultra marathons and writing thrillers, but also scientific and he's particularly interested in the so called ‘fitness gene’ and in how the body deals with extreme environments. That might be up Mt Everest, but it definitely also includes critical care environments. I'm so grateful to you for coming on, but to both of you come into today because I'm I know just how manic you are at the moment. But can you tell me first of all, why is it that COVID-19 makes people so sick that they need intensive care?

Hugh Montgomery  2:13 

Well, that's a very good question. And it comes in two parts. The first bit is really a question of numbers, because for the majority of people, it doesn't make them very sick. So we don't quite know the incidence of infection out there, because it's likely that the majority of people and it could even be as high as 80% of people contract the virus and don't even know they've got it, or get a slight runny nose, and really don't get very sick. But some do. And the some do become very poorly or can do. And we don't know why we know that they're much more likely to be men. We know that they're much more likely to be older, so children can contract this virus can become sick and can die. But that's very, very unusual indeed. But as age rises, particularly for the men, it becomes more and more of a hazard to get very severely unwell. So we know that men are very much more likely to suffer from this disease severely. We know that advancing age is a risk factor. But we also know that there are other conditions too. So pre existing, even well controlled high blood pressure, existing coronary disease, diabetes, these are all risk factors for severe disease. And we don't know why, but it could be that those diseases have damaged linings of blood vessels, for instance, that make them more susceptible to viral attack. But it couldn't be that the genetics of those individuals is predisposing them, for instance, high blood pressure, but also to viral infection, and infection and bad response to it is highly heritable. If you had a grandparent who had a heart attack and died of it, your risk of dying that way is elevated twofold. But if you have a grandparent who died of sepsis, in particular bacteria infection, your risk of dying of the same diseases elevated seven-fold. So that's a long winded way of saying we don't quite know why some people suffer more than others, but the ones that do get acutely unwell, firstly presented to us, usually with bad oxygen levels in the blood due to effects on the lung, that particularly we think in the blood vessels of the lung, and then can cascade on to getting severe failure of other organs. So we see a lot of inflamed muscles, we see a lot of inflamed, or at least measures of heart damage. And kidneys failing is very common as well. So once these people hit intensive care, they're often very, very poorly with multiple systems failing.

Vivienne Parry  4:51 

So Hugh, what point in a person's illness is the decision made that they need intensive care and how do you decide who admitted?

Hugh Montgomery  5:01 

Well, it's a difficult one. Patients present sometimes very early in their disease. But most commonly people contract in the illness are asymptomatic and not spreading for a couple of days. Then spreading the disease without knowing they've got it for about four more and then become ill. And the majority of patients we're seeing attending hospital are falling acutely and seriously unwell sometime around eight to 10 days into that illness, and then they're getting worse and presenting hospital. The way we manage them, we're still not quite sure what the right way is we give them supplemental oxygen. We sometimes get them to lie on their tummies, which for various reasons, helps distribute blood in the lungs better and improves oxygen levels. Some of us, Mervyn and I fall into this group will then support patients with tighter fitting oxygen masks under a bit of pressure if the oxygen levels in the blood are particularly low. But if they remain very low, will often end up having to put people on a ventilator or a breathing machine. And it's fair to say that thresholds for doing that are very different in different parts of the world. And indeed, in different hospitals. There are hospitals in the United Kingdom that almost immediately put people on a breathing machine. And there are others such as myself, perhaps, and Mervyn, who would perhaps not do that. And it's a dark art. We don't really know yet what the best management is for these patients, but we judge it based on the oxygen levels, the work of breathing, and then I suppose the mark one eyeball of just how sick people look.

Vivienne Parry  6:40 

Let me turn to Mervyn now because I want to find out a bit more about the machinery that's used in ICU because I guess we all imagine that, you know, it's everyone is on ventilators. From what you've said so far. It's clear that that's not the case. Now Mervyn is known for his work on sepsis but also for the his work on the development of technology used in intensive care. For example machine he developed a monitor heamodynamics is is now news all over the world. And he's one of the clinicians who's been working with Mercedes Formula One to develop c pap to help these COVID-19 patients. But before we go into the whole c pap project, what is CPAP, Merv?

Mervyn Singer  7:27 

Yeah, so thanks Vivian. So CPAP is an acronym for continuous positive airway is pressure. So essentially you and I, when we're breathing, start off with atmospheric pressure, we then suck air into our lungs causing a negative pressure to bring air into the lungs and then we exhale and the air gets pushed out and we go back essentially to atmospheric pressure. With continuous positive airways pressure there's a tight fitting oxygen mask and there’s a valve at the end so the oxygen’s delivered under the pressure. And that valve that we breathe out against, keeps the lung splinted open. And so usually atmospheric pressure essentially is about zero centimetres of water. Here we're breathing out against a valve a resistance of 10 centimetres of water. So it's like blowing out through a straw inserted to a depth of 10 centimetres in a bottle of water, for example. And that helps not only open up the air sacs, the alveoli in the lungs, but as Hugh was mentioning in this particular illness COVID-19 the blood flow distribution in the lungs is very abnormal. And so it helps match the blood flow to the alveoli, the air sacs that are being ventilated.

Vivienne Parry  8:56 

Now is a CPAP machine the same as the thing that people who snore sometimes get?

Mervyn Singer  9:02 

Yeap, very similar that those are the sorts of low end machines where they're driven mainly off air, though you can bleed some oxygen into them. But those are the very low end machines and there are more sophisticated machines. So some people can be ventilated at home with machines that can offer CPAP and also additional support when they breathe in. So there are a range of commercially available machines. A lot of them are the low end devices for sleep apnea. But there are some which are more sophisticated and the intensive care machines we use for ventilating patients as Hugh described earlier, can also offer CPAP as a mode. But the big problem and that's when COVID-19 came along, we looked in our Trust and we had enough for our intensive care units. These are the normal intensive care ventilators. We could augment those with a few other ventilators, we beg borrowed, borrowed scrounged, we could add in anaesthetic ventilators. So these are the ventilators used for patients having operations, but they're not best suited for keeping people asleep for a long time for days or weeks, especially if you've got really bad lungs. And we only had 12 standalone CPAP devices in the whole Trust. So there was an identified need for more of these machines.

Vivienne Parry  10:31 

So is it true that all of this started with you sending a note to Tim Baker, Professor of Mechanical Engineering at UCL that just said we need more of these?

Mervyn Singer  10:42 

Well it was actually the other way round in that when Boris Johnson announced a call that we need more ventilators, my reaction - I think Hugh also spontaneously was having similar thoughts was, well, it's all very well having new ventilators, but by the time they engineer these quite complicated machines, even a simple ventilator, it's going to take weeks and weeks and weeks and then they've got to go through regulatory approval. So by the time these devices come out, the Coronavirus pandemic or crisis may be largely over. And I can, as you explained, I think, probably patients benefit if you can try and keep them off the ventilator, because once a COVID-19 patient ends up on a ventilator to survive, you're looking on average at at least 10 to 14 days. And there are other complications that can arise from being on mechanical ventilation. So therefore, I think the view was that you needed a better way of trying a halfway house to try and keep people off of a ventilator. And these were in short supply. And so I was approached by Tim Baker and Becky Shipley, who's a professor of healthcare engineering. Because UCL engineering were invited to be one of the hubs that were trying to coordinate these different companies – Airbus, Rolls Royce, Dyson, etc, to be able to come up with new ventilators and when they contacted me and I think, again Hugh had similar responses, well, we don't really want ventilators. We want to keep people off ventilators and perhaps CPAP could be the answer.

Vivienne Parry  12:30 

And how did Formula One come into this?

Mervyn Singer  12:33 

Well, Tim has had in fact, he used to work for Mercedes Formula One. So this is a company based in Northhampton, who are bankrolled by Mercedes, but they make the powertrain, the engine for the Formula One machines, the formulary machines and so forth. So he had a long standing relationship and he then came to UCL as an academic and there still is a very close relationship. So many of the postgraduate student in UCL engineering do projects alongside Mercedes, Formula One. And so there was already this long established, very amicable very productive relationship. And so my idea was, you want something simple, which didn't rely on lots of clever electronics that could be very quickly developed, and mass produced. And there was something years ago that had been abandoned because obviously, machines became more sophisticated and obviously more expensive. But there were very simple basic devices that had been around in the 1990s, the early 2000s that had essentially been abandoned, but the job and one of these was called the whisper flow, which I think first came into being in 1992. And this was a very simple device that plugged into the oxygen supply, which is standard by every bed. And you could when you switched it on in train air. And so you could get an air oxygen mix and you could twiddle a button to get the desired oxygen concentration, you could change the flow rate to get the flow rate that would suit the patient's breathing. And that was all there was to it. And we found one of these in the anaesthetic department Museum, and basically handed it over to Becky and Tim in engineering. And the following day, they handed it over to the Mercedes Formula One team, and literally within the following day, they CT scan it done metalography. So they knew the metallic component of constituents of each component. And a day later, they'd actually got a beautiful working model that myself and one of my clinical colleagues, Dr. David Brealey, we tried on ourselves and it worked. And so we were very impressed with the speed and the quality have what they produced. And then we did some bench testing and some human volunteer testing. And then that gave us within a few days, the technical dossier to go to the MHRA the medicines healthcare regulatory agency that approved drugs and devices in the UK. And they were brilliant, extremely helpful. Within 36 hours they approved it. And a day later we trialled it on our first patients at UCH.

Vivienne Parry  15:33 

Fantastic! So how many of you now got in your department?

Mervyn Singer  15:36 

Well, we've got in the hospital because our respiratory physicians have taken this on board and they're using it to try and save patients from coming to the intensive care unit. And so I think we've now got about 15 around the hospital.  And Mercedes - so this is a month ago -came up with the thought and yesterday they produced the 10,000 machines. So this is quite amazing in literally four weeks to make 10,000 machines.


Vivienne Parry  16:12 

You're listening to Coronavirus, the whole story, a podcast brought to you by UCL Minds. And if there's a question about Coronavirus that you'd like our researchers to answer please email us at minds@ucl.ac.uk. Let me turn to you both now and ask you how COVID-19 is impacting the hospital? Because it sounds as though it's brutal. Hugh -

Hugh Montgomery  16:43 

Yeah, so it's been it's has actually had some positives as well as some negatives. So, the first thing is everything changed as Mervyn pointed out earlier on,  six or eight weeks ago, there was a routine cancer surgery going on orthopaedic surgery, all the routine working as of a hospital, and now virtually nothing is happening in that hospital anywhere that isn't to do with Coronavirus. The second thing is that we've had to change what people's roles are and where we care for patients. So these tight fitting CPAP systems that Mervyn's been describing, six weeks ago, if I'd had someone requiring one of those machines, with a very high respiratory rate from a severe viral illness, requiring an awful lot of oxygen and monitoring, they would definitely have been in the intensive care unit with one to one wants to nursing and these now nurses on open boards being supervised by General Medical colleagues or respiratory colleagues and ordinary ward nurses on the intensive care unit itself, and Mervyn can speak to his expansion which has been very substantially greater than ours in North London. We've moved up from a smaller unit with 10 ventilated beds and five others to in the mid 20s, have ventilated beds, with perhaps another 30 of these patients with CPAP on a ward. And that's meant that instead of having one intensive care nurse to every patient, we've had to move to one intensive care nurse to every six patients with helpers, looking after the others, which will be physiotherapist from the community, or even dental technicians. So we've had to change the staffing and the way we work and we've had to change the consultant ratios. So we now work with more than one of us on at once. Someone else outside doing the helicopter view of how to run the service and so forth. And we've had to change the machinery. We didn't have enough of the ventilators, the machines that blow air in and out and we're having to use the anaesthetic machines which would normally be used for healthy lungs for short term operation and not really been designed for critically ill patients. And we've run out of drugs of various sorts. We've had to adapt what we're using for sedation. And we've had to deploy teams in ways they never would have been before. We often have to have patients on their tummies and on their backs. And actually that move is very difficult because there are lots of tubes connected to patients, which, if they were dislodged, would be very harmful. So we as I'm sure Mervyn will have too have teams in our case of orthopaedic surgeons, who instead of operating on hips and knees are coming to help lift and turn our patients on a regular basis. So pretty much everything about the way we practice the equipment, the deployment of where patients are the roles of staff, and the access to facilities and equipment that we use have all changed dramatically.

Vivienne Parry  19:51 

And is UCL at peak now. Or have you still got capacity?

Hugh Montgomery  19:58 

Well Mervyn's, best place to answer that. So Mervyn, how are you now? You've actually been sort of supersurge hospital. You've taken a lot of our patients for us.

Mervyn Singer  20:06 

No indeed, well, we had the capacity to go up to about 70 beds. So we normally have a 35 bed in intensive care unit. So essentially, we've doubled our capacity using operating theatre space and recovery room space. And so we still have 61 patients across the site, we we've managed to help hospitals that are a bit smaller taking, I think we've taken about 54 transfers from hospitals mainly in the north central London area, and obviously to try and relieve the burden on them. And as Hugh said, it has been incredibly hard and I'd add to that there's a huge physical and psychological strain. These are often young, fit healthy people who are getting incredibly sick and you have to nurse them. And obviously the medical input as well, but especially on the nurses, it's a huge strain because they have to wear this horrible PPE this personal protective equipment where it you get hot, sweaty, dehydrated, and you have to wear this for four hours at a time. And you can't even during that time, scratch your nose, rub your eyes because potentially that's a risk of transmitting infection. So on top of the burden that Hugh was describing accurately of a very reduced nurse-patient ratio, you now have all of the added burdens of looking after these patients in a very alien, abnormal environment.

Vivienne Parry  21:42 

And who's looking after all of you and your nurses?

Mervyn Singer  21:46 

Well, there's a lot of multidisciplinary collegiate collegiality collegiateness, I'm not quite sure what the noun is… collegiality, I think is that right? And You know, there's psychological support. And there's a lot of team bonding, you know, we have, you know, a bit of alcohol if people wanted at the end of a shift, and sometimes that helps people unwind, actually in the running joke is to have Corona beers because for some reason, the popularity

Vivienne Parry  22:21 

everyone else is drinking them

Mervyn Singer  22:22 

exactly that way. You know, I think they've walked down well with the staff and people actually have been incredibly generous and I think Hugh at the Whittington hospital will attest to there's been incredible generosity from people donating food, drink, clothes, you name it, people have been remarkably good. So it's a very nice way of keeping up morale. I've not had to buy any food at work for the last three weeks. And there's my right to thank you.

Vivienne Parry  22:52 

Quite right too!

Let me just turn now to Hugh and talk a little bit about what life is like for patients after they leave ICU because I think people have this idea that, you know, the minute you come out of ICU, that's it, you're better. But it there's a very long road to recovery for these folks, isn’t there?

Hugh Montgomery  23:12 

I think there's going to be and we've moved on. I've spoken about this a lot and have others that we don't know yet particularly for these patients, because we haven't had enough of them. But I think the signal is very clear. Mervyn and I back in the day, used to have patients like this with very severe lung inflammation from other causes, who we had to manage and very much this sort of pattern and way. So I guess our generation knows what the outcomes are. And the outcomes are Savage. This is a very, very, very debilitating environment. One is paralysed often with drugs to let us take over breathing, the muscles aren't moving. This is about like being in space where you don't lose muscle and it wastes away but also the disease itself in this case is damaging muscle quite significantly. The net result of this is that patients are going to be dramatically weak. And we have many on our units at the moment who were waking up two weeks in to find that they can't even lift a hand or a foot off the bed. They can't even lift limbs against gravity. And that's normal from what we used to see before. We know that from those previous studies, up to 80% of people of working age, are significantly physically disabled and unable to work even a year after discharge. And we know that if you measure physical functional capacity and those sorts of patients with what we call odds or acute respiratory distress, even five years later, they haven't returned to normal levels of physical function. Now on top of that, there are dramatic psychological impacts. So it depends how you define these impacts. But in the broadest sense, we could expect up to 82% of patients who survive to have significant psychiatric or psychological morbidity. So anxiety, depression, PTSD, and that relates partly to the drugs we have to give people to the fact that this virus as well seems to affect brains, we're seeing more and more of this, causing delirium or confusion or worse. The fact there's no day or night, alarms going off the entire time, the light exposure is a constant, and many other factors seem to contribute to this. So you're absolutely right. This is not going to be a wake up, get out of bed and walk out two bumps of roses and a champagne party at home. This is going to be very tough, and Mervyn points out very rightly that whilst we're focused on those patients as we should, the impact on the staff that have to look after them Those patients and see this level of suffering is difficult. And we also have to remember this is very, very hard for family members. Often they see their, their family member go to hospital. The next thing they know they're an intensive care unit. They can't talk to that family member because they're on a ventilator. They can't visit them because of the workload we have at the moment. And the next thing they might face is to be told that their loved one is now coming off a ventilator. And then they're going to be needed, there's going to be a lot of social support is going to be required here. And I think sometimes we forget that in time of war, there's a lot of spirit and support. And when the war is over, sometimes people forget that for other people, the war has only just started and that will be in this case, the family members and those survivors.

Vivienne Parry  26:53 

Mervyn, must complete our podcast now but Mervyn, I just wanted a final note from you really about how this period working in intensive care in this extraordinary environment, you know, how it feels to be right in the middle of it?

Mervyn Singer  27:13 

Yeah, I think that's a great question, Vivienne. When it obviously happened in China and then the Lombardy region in around Milan, particularly were affected. So I have lots of friends and colleagues in both in China and in Italy. And I remember one describe when more than one actually Italian describing it to me as a warzone. And that I, I laughed and I actually joked that, you know, this is Italian melodrama. And I actually now eat my words. It is actually sadly, it was only it's a very, very accurate description. It's a desperately busy, desperately tiring, stressful and, you know, it's something I've not experienced in over 30 years of clinical practice, so this is something we've completely, you know, not seen before. And also it's a disease the like of which we've not seen before. So, as with other conditions where there's an evidence base, and we know what to do, we've had to essentially be learning on the job. And we've had the advantage of picking up hints and tips from our Chinese colleagues, our Italian colleagues, but this is very much a learning experience as we work and there is no set guidance as to how best to treat these patients. And so it's very much not quite trial and error, but try and do the best thing you can and and learn what things seem to work and what don't.

Vivienne Parry  28:45 

Well, we're extraordinary grateful to you both for coming today and telling us about life on the front line. You've been listening to Coronavirus: The Whole Story. This episode was presented by myself Vivienne Parry produced by UCL with support from the UCL Health of the Public and edited by Cerys Bradley. Our guests were Professor Hugh Montgomery and Mervyn Singer from the UCL Faculty of Medicine. If you'd like to hear more of these podcasts from UCL Minds, subscribe wherever you download your podcasts, or visit ucl.ac.uk forward slash Coronavirus. This podcast is brought to you by UCL Minds, bringing together UCL knowledge, insights and expertise through events, digital content, and activities open to everyone. Hope to be with you again soon.

Transcribed by https://otter.ai