Coronavirus in Scotland: A 'difficult day' on the Covid frontline
The BBC has been granted exclusive access to University Hospital Monklands in Airdrie, North Lanarkshire, including the intensive care unit which has been at the centre of the struggle to save lives in the coronavirus pandemic.
Day and night in intensive care the lights blaze, the monitors beep and the machines buzz.
It is bright and it is noisy but for the patients this is the twilight world, a place where the darkness deepens.
No-one wants to be here, far less to return, but nor do they have a choice.
Looking gaunt and ashen, John Houston is being wheeled back in to the unit he left four days ago.
His kidneys are struggling to cope with Covid-19 and he needs filtration treatment.
"Can't breathe," he mumbles as a nurse hooks him up to a jumble of clear plastic tubes and red, yellow and green cables.
A few minutes later John manages a few words, telling us how he was admitted to the hospital three weeks ago and had hoped to be back home with his beloved border collie, Cody, by now.
The medication John has been given makes him hallucinate, he says, a common experience for patients in intensive care and one he describes as "a bit scary".
Doctors here at Monklands say the ubiquitous public health advice - to stay home, protect the NHS and save lives - has worked but they also warn that the first wave of infection to hit Scotland is still washing ashore.
The number of coronavirus patients here has fallen sharply in the past couple of weeks but the average length of a stay in intensive care has risen during the pandemic.
Many of those who remain are extremely sick and cases like John's, where patients need to be readmitted to the intensive care unit, are common.
On the day we filmed in Monklands - Friday 1 May - seven coronavirus patients died, the highest number the hospital had seen in any 24-hour period since the outbreak began.
In intensive care, we met senior nurse Abigail McSherry as she was putting together a pack of memories for the family of one patient who had just died.
Among the items were a diary of the patient's time in the unit, a drawing of a tree based on his handprint and a pair of knitted hearts - one to go with the body, the other to be sent out to the man's family.
Partners of patients are only allowed in the hospital under very limited circumstances, essentially for births and deaths. Even then, to enter a Covid ward, visitors have to don the same personal protective equipment (PPE) as staff - gloves, aprons, masks and visors.
"His wife was here," says Ms McSherry of the man who had just died. "It was very important because they'd spent their whole life together, from primary school right through. So, it was very important that we let her in."
"I got his wife to give his wee heart a kiss," she adds.
Medical staff are used to dealing with death but that doesn't mean they don't feel its sting.
"The staff have had a difficult day today," says senior charge nurse Donna Marie McGroarty.
"We had a death this morning and then another death there, and that gentleman in particular has got no family," she says. "So that's hard for them."
As a gesture of compassion for a deceased patient who has no-one to mourn for them, she says, staff stand in respectful silence while the body is taken from the ward. "That's just something that helps the staff get through this," she tells us.
"We are exhausted," adds Ms McGroarty, "we've been at this from maybe the second week, the third week of January."
The coronavirus known as SARS-CoV-2 and the disease it causes, Covid-19, came early to Monklands because the hospital houses one of Scotland's four regional infectious diseases units, with some of the first suspected cases in the country arriving in special ambulance transfers in early February, according to Dr Nick Kennedy, a consultant in the unit.
The hospital's first positive case was confirmed early the following month.
"It's a strange illness, the likes of which we've never seen before," he says.
The unusual virus prompted an unprecedented response, a wholesale transformation of this ageing district general hospital with one aim above all - increasing critical care capacity.
In just three weeks in February and March, says chief nurse Karen Goudie, Monklands was fundamentally redesigned and restructured to handle Covid-19.
Ms Goudie points out new walls, new barriers and new rooms as she explains how the entire building was divided into two separate pathways in an attempt to stop the coronavirus spreading - red for Covid patients and the staff dealing with them; green for non-Covid.
"Monklands is 40 years old," says chief of medical services Dr Rory Mackenzie. "We have advanced plans for a new hospital. The lack of single rooms is a real challenge for us in terms of managing some of these issues. So having a new hospital would have made this so much easier to deal with."
Instead, Dr Mackenzie and his team had to be creative. As one of the few areas with a plentiful supply of high-pressure oxygen, the infectious diseases unit was selected to become a high dependency unit (HDU) while the original HDU became an intensive care facility. Operating theatres were converted to house intensive care beds.
Before the pandemic Monklands had the ability to ventilate five patients at any one time. At the peak, a few weeks ago, 15 patients were on ventilators and Dr Mackenzie says the hospital could now provide 20 ventilated beds if necessary.
For a while the hospital was running three separate intensive care units instead of one. It is now down to two: one red, one green.
"This is not the health service we had two months ago. This is a different health service," says lead intensive care consultant Dr Sanjiv Chohan.
Maintaining such a high level of critical care capacity is putting enormous demands on staff and resources.
"I don't think it's sustainable," cautions Monklands' head of emergency medicine Dr Fiona Hunter.
These days Dr Hunter oversees, in effect, two accident and emergency departments - again, one red for Covid patients, one green for non-Covid - a situation she believes must persist while the virus remains prevalent in the population.
For now that means two senior consultants on site at all times, rather than one. It means double the number of reception staff. It means more expensive equipment and the cancellation of leave.
For Dr Hunter it even meant postponing her own wedding, which should have taken place on 28 March, when she and her fiance realised the best man would not be able to fly into Scotland from France because of the pandemic. It was a difficult decision, she says, but "the right thing to do".
"It allowed me to be freed up to really help with the fight in this department against Covid," she says.
It's not just the emergency department which is feeling the strain. Elsewhere in the hospital, physiotherapists and nurses who usually work in day surgery, operating theatres and the endoscopy unit have been seconded to intensive care.
At the same time the demand for some of those services has risen. Many Covid-19 patients have intense fatigue and continue to require a great deal of help with rehabilitation, says Kirstin Cleary, a specialist physiotherapist who has been working in intensive care.
"Even though we're past the peak there's going to be a massive impact on physiotherapy services, social care services and services in the community because these patients are going to need a lot of rehab to help them recover from this," she says.
Right now the dilemma for Monklands is that it simply cannot handle its normal patient traffic while it is configured for a pandemic and yet if there is "recrudescence" - another outbreak - intensive care may be overwhelmed again.
"I think we're over the worst of this current outbreak, and undoubtedly we've seen that in terms of the figures that come through the hospital," says Dr Kennedy in the infectious diseases unit.
"The trouble is, of course, we don't have an effective treatment. We don't have a vaccine. And so there is every risk that we could have a second wave," he adds.
It's not just here. Managers across the NHS are now grappling with the challenge of how to maintain critical care at a safe level while also preparing for an expected rise in emergency admissions as the lockdown eases, and the return of patients with other serious illnesses, whose absence during the past couple of months has apparently led to a rise in preventable deaths from heart attacks, strokes and other causes.
"The overall occupancy of the hospital has been down," explains Dr Mackenzie, and while "that has made it easier to cope with the Covid patients, the main concern we've got is there are patients who need health care [who] haven't been attending the hospital."
Matthew Weir from Coatbridge is one of them. He is being treated in the infectious diseases unit for a lung infection. It's a fate that Matthew, 34, could probably have avoided had he not put off seeking medical help because of his fears about catching the coronavirus.
"If I'm honest I probably left it a little bit too long, which is why I ended up staying here rather than it just being treated with antibiotics in the first place," he says.
Dr Hunter, in the emergency department, says the pandemic is forcing a rapid reassessment of the balance between providing services in hospital and in the community.
She says the hospital has set up a line for paramedics to seek "advice and perhaps a bit of back-up" from consultants on when a patient can safely be cared for in the community, perhaps in a clinic, rather than in hospital.
"That's something that they didn't have access to before Covid but a lesson I would be keen to continue on after Covid," she says, adding, "I think it's made a big difference for patient care, by reducing unnecessary admissions to hospital".
When it comes to cases that do require hospital treatment though, Dr Hunter is keen to stress that "we are open for business".
That's the message in intensive care too where coach driver John Johnston is struggling with the effects of Covid-19.
John has underlying kidney issues and has developed a lung infection. He is conscious but on a ventilator which helps him to breathe but leaves him unable to talk.
Instead he communicates, with great effort, by writing on a small plastic board.
I ask him if he can sum up his message to the staff here.
"There are too many words to say to them," he manages to write before stopping to wipe away tears.
This pandemic has clearly brought immense and painful challenges for patients and staff alike.
Hope, though, springs eternal.
Irene Norwood, a 51-year-old housewife from Cumbernauld, is back in the intensive care unit — but only to say thank you. After a brush with death she is on the mend.
She tells us she only has fragments of memory about her time being treated in here for Covid-19.
"I remember lying in bed at night thinking the machines were talking to each other. I think I must have been hallucinating," she says.
Irene also recalls a doctor telling her that she was being put on a ventilator and that she should telephone her loved ones because she might not survive.
"I remember everything was happening really quickly and they said, 'we need to get her to call her family'.
"I spoke to my husband and my sons. You can only say what's in your heart," she recalls. "If you don't say it you might never have got the chance."
Irene is hoping to leave hospital today and has a simple message for the public.
"I don't think people understand the severity of this illness and that's what people need to learn. They do not say 'stay at home' for no reason."