LONDON — The moment of reckoning British officials have warned about for months has arrived.
Hospitals across the country are stretched to the brink with COVID-19 patients, medical staff are at their breaking point, and the death toll is soaring.
Decisions about who dies and who is given a chance at survival through intensive care grow more challenging by the day. The amount of oxygen being given to severely ill patients has been reduced in a few hospitals to prevent a “catastrophic failure” of overstressed infrastructure. Some institutions are moving COVID-19 patients to hotels to free up beds. Ambulance crews frequently wait hours to offload patients. And medical workers on the front lines are reporting levels of emotional trauma that outstrip even those of combat veterans.
The number of hospitalized COVID-19 patients in England has risen sharply since Christmas and now dwarfs the spring peak by 70%, with almost 14,000 more patients in hospitals than on April 12.
Prime Minister Boris Johnson warned this past week that there was a “very substantial” risk that many hospitals will soon run out of beds in intensive care units, even as the nation continues to set daily records for fatalities. And as the strain on hospitals grows, death follows.
“Every region has more COVID patients in hospital than they did in the first wave,” said Christina Pagel, director of the Clinical Operational Research Unit at University College London.
Pagel was co-author of a study on the impact of overcrowding at hospitals during the first wave of the pandemic in the spring and found that mortality rates rose some 20% at the height of the pandemic as compared with recent years. While her team has yet to publish a more recent survey from December, she said it had found similar outcomes.
The situation is growing more dire by the day in the worst-affected hospitals. Eleven National Health Service trusts in England now have more than half of their beds occupied by COVID-19 patients. Whittington Health in north London has 66% of beds occupied by COVID-19 patients, the highest proportion of any NHS trust in England. An NHS trust is made up of multiple hospitals and clinics in a local area.
The data includes most hospitals’ beds excluding those in intensive care.
While the health service in London is under the most immediate pressure, hospitals in other areas are starting to see a sharp rise in COVID-19 patients. In north Cumbria, COVID patients occupied 12% of beds on Dec. 25, but that has since risen to 42%.
Even as the number of new infections in England starts to show signs of slowing — with nearly 43,000 new cases reported Wednesday, compared with the recent high of more than 60,000 daily cases — the consequences of weeks of raging spread are being felt across the country.
Neil Ferguson, a public health researcher at Imperial College London whose modeling led to the first lockdown in March, said there were signs that restrictions might finally be starting to have a significant impact.
“It has to be said this is not seen everywhere — both case numbers and hospital admissions are going up in many other areas — but overall, at a national level, we are seeing the rate of growth slow,” he told BBC Radio 4’s Today program Thursday.
Johnson’s Cabinet is considering even tighter restrictions. The country is not only trying to contain a more contagious variant of the virus first seen in England in the fall, but also to fend off other highly infectious variants — one first detected in South Africa, and two in Brazil.
It has been three months since Britain introduced a tiered system of restrictions in mid-October, and a second national lockdown was put in place in early November. That was briefly lifted after four weeks, but then more restrictions were put in place after the discovery of the highly contagious variant, and a third national lockdown was announced Jan. 4.
Throughout most of that time, however, infections continued to rise.
Like a wave that builds in open waters, months of surging infections led to unprecedented levels of illness that are now cresting and slamming into the intensive care units run by an exhausted cadre of health care workers.
Dr. Neil Greenberg, a forensic psychiatrist based at King’s College London, released a report this past week that showed nearly half of the staff treating the most seriously ill patients reported symptoms of post-traumatic stress disorder, severe anxiety and depression.
The results are based on a survey of workers in intensive care units at nine hospitals and “pulse surveys” being conducted every six weeks that show that the situation now is as bad or worse than any time in the pandemic.
By way of comparison, a similar survey of military veterans who had recently served in combat roles in Iraq or Afghanistan had a PTSD rate of 17%.
Greenberg, who spent more than two decades in the British military and now advises the defense department, said the results should serve as a wake-up call.
One of the greatest immediate challenges, he said in an interview, was dealing with “moral injury,” which results from having to make terrible choices regarding who lives and who dies.
“‘I tried my very best to save lives and do my best, but it was not enough,’” medical workers tell researchers, according to Greenberg. “And because of that, people died,” he added.
“ICU staff are used to death, but this is different,” he said.
It is clear that England’s hospitals are under considerably more strain than during other recent winters. On Jan. 10, there were more than 4,600 patients in critical care beds, 40% more than was typical on that day over the last four winters.
Pagel, who has also done extensive research on the operation of intensive care units during the pandemic, said that the public perception that only very old people were filling hospital beds was wrong.
Britain has a much higher bar than the United States for who should be given intensive intervention, making it less likely that people over 80 will be given a slot given the odds stacked against them when they reach a critical level of illness.
“Seventy-five percent of patients in ICU are under the age of 70,” she said.
Pagel said that staff members were faced with almost impossible choices every day. It is a problem that is being compounded by what she said were years of underfunding the system and a failure to address some of the issues that arose during the first wave of the pandemic.
Perhaps the most troubling example, she said, was the failure to improve the systems that deliver oxygen to patients. COVID is a respiratory illness and it often attacks the lungs aggressively. So getting oxygen to patients is critical.
In a healthy person, the amount of oxygen carried by red blood cells exceeds 96%. Medical staff would normally aim to bring sick patients’ levels up to 95%. But in many hospitals, Pagel said that has been reduced to 90% because of fear of a catastrophic failure of the system.
It is an engineering problem: To bring oxygen to patients, liquid oxygen needs to be piped into the ward and then converted to gas at the bedside. But the system was never designed to treat so many people at once or run around the clock for so long.
“Staff are literally pouring warm water on the pipes as they go so they don’t freeze and crack,” she said. “Then the system fails.”
While doctors have reported to her that 90% is sufficient for patients, she said, it leaves little room for reacting if someone’s condition worsens.
“It is OK, but you are on a tightrope,” she said. And for a staff already facing unimaginable burdens, she said, this was one that could have been avoided.
A spokesperson for the NHS said that there was little evidence to support an ideal target oxygen saturation for COVID-19 patients, and that national guidance indicated a target of 90% to 93%. The official, who was not authorized to be quoted by name, said that roughly $20 million was spent on upgrades to oxygen delivery infrastructure in preparation for the winter.
Still, the NHS has told hospitals they need to “carefully manage their oxygen flow and infrastructure.”
Pagel said that even when new admissions begin to fall — which experts hope will happen in the next few weeks — it will be slow and grueling.
“It takes a long time for the system to decompress,” she said. “You are not going to have dead bodies in the street. But you are going to have more illness and death.”