It was a bright, unseasonably warm day in late February this year and the critical care consultant Jim Down had just finished a 12-hour night shift at University College Hospital in north London. He had been struck by the contrast between his intensive care unit (ICU) ward, where more than 50 desperately sick Covid patients were teetering on the edge of death, and the mood in the streets of the capital, where people were milling around in the sunshine with takeaway coffees and life went on.
Overnight, several patients who had appeared to be recovering had suddenly crashed, and his team had fought to restabilise them. We met for coffee in his garden a few hours after his shift had ended, and he told me how difficult it can feel knowing that while doctors have learned a lot over the past year about how to treat Covid, there is still no cure. The illness is strange and unpredictable. Sometimes a patient would recover quite rapidly and unexpectedly, and Down could not stop himself from hoping that this would miraculously happen to all of his patients. His pandemic anxiety and horror came in waves. “I’ve had some moments when I’ve felt pretty desperate about it,” he said.
Down has recently published his first book, Life Support, which documents his experience on the Covid front line last spring, when the hospital more than doubled the size of its ICU in two weeks, scrambled to develop new treatment protocols for this unknown disease, and confronted problems that would have been unthinkable only days earlier, such as: would they run out of oxygen? The writing had been “cathartic”, he told me, but he had also wanted people to know what was happening inside British hospitals as the death toll surged. He wanted the public to better understand his medical specialism: what it means to keep bodies alive even as one by one their organs shut down; the ethical dilemmas intensivists encounter daily as they decide how far to push the limits of natural biology and when to allow someone to die.
Down’s instinct is to want to admit every critically ill patient to the ICU, to try to save everyone. But that’s not always the right approach. “It’s not a pleasant way to die, to put it starkly,” he said. “You might be putting someone through misery when there’s no realistic hope.” Before they are approved for use by the NHS in England, expensive new treatments are evaluated by the National Institute of Clinical Excellence (Nice), which must weigh up the cost against the possible improvements in the quality or duration of a person’s life. But Nice has never evaluated ICU care, which costs around £1,700 per person, per day.
Last spring, Down implemented a “three wise people” system, so that no ICU doctor would be required to make life-or-death decisions without support and input from two colleagues. He was appointed the ethics lead for the University College London Hospitals trust, convening a group of experts that would set and review guidelines for when to withdraw treatment from coronavirus patients, and for how, if medical staff were completely overwhelmed, they would prioritise patients. Usually, if an ICU doctor determines that ongoing treatment is futile, they would consult with the patient’s family; the process of reaching consensus might take weeks. Down understood by early March last year that, based on the number of Covid patients the hospital was expecting to admit, staff would be forced to make these fraught decisions at high speed, and that they would be making such decisions many, many times a day.
The novelist Edward Docx documented one of Down’s night shifts in mid-April, then one of the deadliest days of the pandemic, in a powerful and evocative New Statesman cover story. That night, Down was in charge of around 70 desperately sick ICU patients on a hastily expanded ward. Reading Docx’s feature I found it hard to imagine that the situation inside the ICU ward could ever be more tragic or more urgent. And yet, in the early weeks of 2021, Down and his colleagues were treating well over 100 ICU patients.
His patients were often alone, and so the nurses set up iPads to enable relatives at home to speak to their loved ones. “Initially I was so stupid, I thought that’s just weird” – his patients are usually unconscious, after all – but Down soon realised his mistake. Now he finds it both moving and life-affirming to overhear snippets of conversation as he moves between beds and machinery. The families talk about the same things that people have always talked about at hospital bedsides. “They talk about how people are doing, how the kids are, all the things the person would be interested in. How much they are loved. Sometimes there’d be a recording of a child – ” Down must have noticed something pass across my face, because he stopped abruptly. “Yes, it’s very hard,” he said. “There’s been a lot of the best of humanity,” he began, and then he trailed off. “It’s a bit weird, generally, thinking about it,” he said after a moment.
Down has been worried since writing the book that people would think he had done something “heroic” when all of his work was a team effort. The ICU nurses have the hardest time. The consultants’ case-loads were just about manageable even during the second wave, but the nurses might sometimes be looking after three patients so helpless that they cannot even blink themselves. Down was worried, too, that readers might conclude he’d had a more difficult pandemic than most. In fact, his job had given him a sense of purpose, and he was grateful neither he nor his family had been sick. Down has always been a worrier; his wife thought his anxiety had got worse. “She’s probably right,” he conceded.
Down is 50, tall, slim, blond, affable, at times excruciatingly embarrassed by the very un-British enterprise of talking at length about himself. He is married to the actress Patricia Potter, whom he met on the set of the BBC drama Holby City. She played a surgeon; he was a medical adviser. It tickles him that occasionally when they have been out and someone has been in medical distress they want Potter, the doctor they know from the telly, to come to their aid. They have 11-year-old twins.
When Down needs to unwind he likes to go for runs across Hampstead Heath, listening to comedy podcasts. When other teenagers were obsessed with music, Down was obsessed with comedy. During a “midlife crisis” he had even done stand-up for six months (“terrible”, he mutters). Growing up in Dorset, he had wanted to do something creative, perhaps something on TV – almost anything except becoming a doctor like his dad. Then, when he was 17, his father set him up with some medical work experience. “It was a really weird week because something made me think: ‘Oh yeah, I’d like to do this,’ but I also kept passing out all over the place – for really benign things,” he said. His father was mortified.
Squeamishness might seem an obvious reason not to go to medical school, but Down thought it was something he would learn to cope with, the same way medical students must learn to cope with death. He fainted occasionally as a medical student at Bristol and some things still discomfort him – “I couldn’t watch someone take off a fingernail, I don’t know why!” he said – but mostly he was right about learning to cope. In contrast, while he was able to “bluster through” the dissection classes that upset some of his classmates, he has found that as he has grown older he’s become more empathetic. He feels his patients’ pain more keenly now they are usually closer in age.
Down had thought he wanted to be a GP and live somewhere sedate on the coast, but he found it hard to deal with the uncertainty of general practice – the “necessity for calculated risks” – the knowledge that you might send a patient home having diagnosed them with something harmless when in fact they have cancer. He likes the machinery of the ICU, that he can run any test or scan he wants and get the results almost instantly, that he can consult with any hospital specialist he needs. He works with different kinds of uncertainty. He is used to making difficult trade-offs. Sedating a patient more deeply might improve their oxygen levels but drive their carbon dioxide levels too high. Conversely, fixing the carbon dioxide levels may cause their oxygen to plummet. Ventilating a patient earlier might stop them from becoming dangerously exhausted while attempting to breathe for themselves, but it subjects them to other potentially fatal risks.
Most of his intensivist colleagues have developed firm views on what kinds of treatments they would consent to, but not Down. “I don’t think I know my future self that well,” he said. “It’s awful being in the ICU; generally the recovery takes a year or so if you’ve been in there a long time, and you might be left with all sorts of symptoms. So some people feel that if they were at a certain stage in their life they wouldn’t go through with that… But I’m not sure I would want to pin my colours to the mast.” He paused. “Maybe I’m avoiding the issue a bit, maybe I should think about it.”
After everything he has witnessed, I wondered what Down now thought of the government’s pandemic response. “I’m going to dodge that,” he said. “I didn’t vote for the government, and I am vehemently anti-Brexit so I’m not an impartial observer of these people.” He felt underqualified to comment on measures for lifting restrictions. “I’m always amazed by what incredibly strong opinions everyone has on this when it’s such a specialist, difficult, complex subject.” If his career has taught him anything it’s the importance of embracing complexity and accepting equivocacy. “Most medical books are pretty confident. But I’m a massive fan of doubt. I love people who doubt. I don’t get people who are so sure of everything”.
This article appears in the 17 Mar 2021 issue of the New Statesman, The system cannot hold