Prior to 2020, if you didn’t work in a hospital, and if you were lucky and you and your loved ones were healthy and well, you might not have known very much about how an Intensive Care Unit (ICU) works. You might not have known very much about the teams of specially trained staff – the nurses, doctors, pharmacists, physiotherapists, dieticians and microbiologists – who work around the clock to provide care to the sickest and most vulnerable patients in our hospitals. Last year, as the Covid-19 crisis engulfed the globe, we all got a crash course. Words like “ventilator” and “intubated” entered our day-to-day vocabulary as the horror of the pandemic unfolded. Images of ICU medics, with welts and rashes caused by their PPE, were a regular reminder of the gravity of the situation we all faced.

Even so, as we enter into what looks to be another challenging year, when hospitals and the people who work in them face further challenges, there remains a lack of understanding among the general public about the logistics and specifics of the ICU. When the National Public Health Emergency Team (NPHET) warns of the healthcare system being overwhelmed, it can seem at odds with the number of Covid patients being treated in ICUs in Ireland – for the month of December, this figure hovered between 30 and 40, which, to the average person, might not sound like cause for alarm. As of now this number has risen to more than 100 – and our hospitals are nearing breaking point.

Professor Gerard Curley, who is Professor of Anaesthesia and Critical Care at the RCSI and a Consultant in Anaesthesia and Intensive Care in Beaumont Hospital, believes that even the words we use when talking about ICUs have the potential to confuse. Take, for example, the term “bed”.

“There is an unclear understanding of what an Intensive Care Unit bed actually is,” he says. “It’s an unfortunate term – to just describe it as a ‘bed’. It’s much more than that.” Of course, an actual bed is required – as well as monitoring equipment and ventilators and other specialist machines – but a “hospital bed” is a figure of speech and its real meaning encompasses the staff and the infrastructure that is required to provide critical care to each patient.

On average, Covid patients stay in the ICU longer than other patients; the disease is protracted. While there, a Covid patient will need help with their breathing. They may be connected to a ventilator or another type of breathing machine. They may have several tubes going into their veins, delivering HEALTH sedatives, nutrition, pain medication, antibiotics and blood thinners as well as drugs to treat the actual disease. If there is organ failure, other types of machines will be necessary. The patient will need constant monitoring by an ICU nurse and when it is time to “prone” them (the practice of turning the patient onto their front, which is a key Covid therapy), as many as eight medics may be required to help.

“Intensive care means one-to-one nursing; it means all the care the patients receive from a multidisciplinary team,” explains Professor Curley. Furthermore, each nurse, doctor, physiotherapist or other medical professional working in the ICU will have had specialist training. “To become an Intensive Care Unit nurse requires many months of training and a postgraduate diploma – and even then you’re working alongside a senior nurse who is supervising you,” he points out.

Last spring, when the crisis was at its initial peak and the health system was on the verge of being overwhelmed, medics from other departments stepped up to support their colleagues in the ICU. “There was fantastic teamwork and collegiality across the board,” says Professor Curley, praising people who “didn’t have to do it – they didn’t have to take on the responsibility of a very different job with higher stakes.” However, he says, “with staff who are well-meaning but are not experienced in the ongoing care of critically ill patients, patients suffer.”

So, when we heard there were 30 Covid patients in ICUs around Ireland, it did not sound like the entire system was close to being overwhelmed. Thirty might even sound like a small number when we consider the number is now more than three times that. The HSE CEO Paul Reid has warned that the health service is “under real threat”. In the worst case scenario, he says, 400 people may require critical care. Current capacity is 286, with the system being able to scale up to 350 using surge capacity. But here’s an even smaller number: six. That’s the number of ICU beds per 100,000 inhabitants in Ireland, which compares unfavourably to the European average of 11.5.

“In Ireland, we have a fairly low ratio of ICU beds per 100,000 of the population,” says Professor Curley plainly. “And for a long time, it has been noted by the ICU community that this is inadequate to provide critical care.”

That low number means that, even before the pandemic, ICUs in Ireland were operating at 90 per cent capacity. “A system that acts at 90 per cent capacity doesn’t allow for an extra thing,” Professor Curley says. “People think it’s OK if you’re not at 100 per cent. No, it’s not; your occupancy should be at 75 per cent. That allows you to admit that head injury or the patient with meningitis or sepsis or respiratory failure.”

We must begin to understand that if the ICU is at risk of being overwhelmed, we are all at risk. The entire ecosystem of the health system is undermined and unsteadied when ICU capacity reaches 100 per cent. As Professor Curley says: “The figures might look small but when there isn’t much leeway, it really counts.”

It’s worth remembering that last spring, ICU capacity was freed up by cancelling scheduled operations for non-Covid patients who would have required intensive care after surgery. Many hospitals have have had to take the decision once again to postpone non-urgent surgeries.

Professor Curley warns against complacency. The fate of the health system – and its staff and patients – is in our hands again. There is hope on the horizon; commencement of the vaccine rollout is encouraging. We can all look forward to a brighter 2021 but we are not quite there yet. The country’s ICUs rely on us – just as we have always relied on them.

Main featured image: From the sketchbook of the late Portuguese artist Professor Eduardo Salavisa.