Luca, thirty years old
Cause of death: Covid
Cause of life: Words have power
We have two lives. The second begins when you realise you have one. For Luca, a 30-year-old Italian pharmacist living in Wales, this realisation came in 2020 when he died from Covid.
Luca grew up in an apartment tucked away in southern Rome. His mum was a teacher and his dad a banker, born the same year as intensive care was invented. Luca’s childhood was spent hanging out with friends, going to the cinema and being teased for not following the national religion of football. He loved science as a kid, although regularly missed school with a stream of childhood illnesses. What his friends would brush off as a minor cough or cold would make Luca seriously unwell and take him much longer to recover. It was his frustration with ill health that led Luca to qualify as a pharmacist.
Although he loved his job, even before his brush with death, Luca knew there was more to life than just his own beautiful but familiar city. By 2011, he had booked airline tickets to swap his Apennine mountains of Italy for the green hills of Wales. His bags lay packed on his bedroom floor when a chance encounter at a party led him to meet his future partner, Aria. Luca soon realised he would be leaving behind someone very special but, given the many plans that were already in place, the new couple exchanged Skype usernames and left their future to chance, kissing goodbye after one final trip to Venice.
In life, timing is as crucial as the choices we make. Understanding this explains why Luca was right to fly away. This is vividly illustrated by the viral image of an elderly couple sleeping in a gondola on Venice’s Grand Canal, where Luca and Aria spent their last day together. The photo shows a couple in their seventies sprawled over each other, both fast asleep with the gondolier smiling in amusement to himself. Perhaps they had dreamed of visiting Venice for decades, saving enough until the time was just right, the bank balance enough, the kids settled. When that day came, they found themselves too tired and too old to fully enjoy it. Their peaceful slumber during a once-in-a-lifetime experience serves as a visual reminder of the importance of seizing the right time.
The book Four Thousand Weeks, by the self-confessed productivity junkie Oliver Burkeman, reminds us that our time on Earth is limited – averaging around 4,000 weeks, just 28,000 days. This finite span means prioritisation is key, making sure what truly matters is grasped when the timing is right. Waiting for that ‘perfect’ moment often results in missed opportunities. Yes, Luca could have delayed his move abroad, but would this change ever be possible again?
Instead, the right time is often now, rather than in some distant, uncertain future. Or at least, there are activities where the time must be now to fully embrace them. Starting a family, pursuing a dream job, travelling to new places. Each requires not just the right choice but also the right timing. Delaying these decisions can mean losing out on the experiences and growth they offer. And being sad after making a decision doesn’t mean it was the wrong decision.
In essence, timing and choice are intertwined threads in the fabric of a well-lived life. And certain things are best done at predictable, specific times in life. Bill Perkins, in Die with Zero, argues that the greatest fulfilment comes from experiences that match the right timing of our lives. Ski when you are young even if you can’t afford it because when you are rich and seventy, your knees will not forgive you. Take adventurous trips in youth, invest in relationships throughout your middle years and savour reflective moments in older age. This approach ensures we extract the most value and joy from our life’s timeline, aligning our actions with our stage of life.
Two years after leaving Aria in Italy, after countless phone calls, video messages, flights to meet for birthdays and holidays, Luca proposed in Sardinia. They married in Rome during summer 2016, and after a tough pregnancy, their beautiful daughter, Sofia, was born in May 2019. Just a year after Luca’s life was turned upside down by becoming a dad, another tiny life-form would do it once again.
Luca had been working overtime as a hospital pharmacist during April 2020, handing out medicines to help patients with Covid-19. On a rare day off, pushing his daughter’s pram along the River Taff close to his house felt unusually difficult. After getting home, Luca’s skin started heating up. His temperature climbed higher at night and soon came a dry, annoying cough. Struggling on for the next few days, he took his own professional advice by drinking plenty of water, taking paracetamol to help his temperature and the banging headache. But as the next Sunday came around, Luca’s temperature hit 40 degrees, his cough stopped him sleeping and his breathing sounded like an old church organ.
Luca drove himself to my hospital, passing his pharmacy colleagues in the corridors as his bed was quickly pushed to a Covid ward because his breathing was so fast. By midnight Luca’s oxygen levels plummeted to levels lower than in climbers at the top of Mount Everest. He needed to go to the Intensive Care Unit for extra oxygen to be pushed under pressure into his lungs.
‘I was actually relieved to go to intensive care,’ he told me. ‘I rang Aria and said not to worry, everything would be okay.’
An hour later, Luca was tired, the extra oxygen still wasn’t enough. Not wanting to wake her, he sent Aria a text message saying he was going to be put on to a life support machine. The message ended simply with ‘I love you x.’ Then he sent a message to his boss: ‘I won’t be in work tomorrow.’
That night, I also rang Aria. Everything was not okay.
Intensive care doesn’t really have outpatient clinics or waiting lists. If a patient needs to wait even an hour for life-saving treatment, then that is too long. And so I seldom write letters that are posted to GPs or sent to the patient’s home. Instead, most of the words I use are written directly in hospital notes. These entries used to take a formulaic, structured style, full of bullet points, lists and strange symbols. Even if my doctor’s handwriting was neat (which it is not), my notes would still look more like hieroglyphs than English, incomprehensible to patients themselves. But the pandemic changed that.
The whole world wanted to make sense of the story that was unfolding. And so my notes changed from reading like an academic textbook to like the pages of a book found on a coffee shop’s table. I wasn’t trying to pen a thriller or crime drama, but a biography of the patient I was caring for, weaving the science with the human, the worry with the hope. I wanted to make my notes understandable to all, not knowing who may read them in the future. After all, medicine should and must be a humane science, a scientific expression of the human condition. My long lists and strange symbols morphed into narrative, a tightly constructed paragraph to explain to other doctors, to me, and to the families of those who couldn’t be there, what was going on. Using bullet points did allow me to take aim at diseases, but they would often miss the heart of the matter. So now I tried to make sense of each story through words. I still wrote prescriptions to heal bodies but now narratives to heal minds.
After I made this change, something else seemed odd. We try as doctors to put patients at the centre of all that we do. Yet the perpetual record of clinical encounters excludes patients from their own story. Medical notes are addressed to other doctors, written about patients. Not to them. After speaking with Luca’s wife that night, I did something I had never done before. I’m not sure why or if I even thought about it. Despite Luca being unconscious and dying, I addressed my notes to him, like I was writing a letter just as I had done to my Aunty Win for her funeral. I desperately hoped this wouldn’t be a eulogy.
Hi Luca, I had a long chat with your wife, Aria, by phone tonight and could hear your young daughter, Sofia, in the background. I explained that you were critically unwell, needing all the oxygen that we could give you through our life support machines. We have turned you to lie on your front, but this is not helping. I told Aria that you are sick enough to die. I’m very sorry that hearing this made her cry, but I wanted to be honest.
But there is hope. We wouldn’t keep you alive like this if there was not. The reason I come to work every day is to get people like you back to the people who love them, like your wife and your daughter, Sofia. I said to Aria that I’ve asked a specialist team in London for one final treatment called ECMO. This could add oxygen directly to your blood, bypassing your lungs, which are full of fluid and infection. It might not work, and if it doesn’t, you will die. But there is hope. It might work. And then you might live.
Words have power. Reading and writing have long affected me deeply. They seem to bypass an emotional electric fence that keeps me strong when talking to relatives or speaking to large audiences on stage. I also often write what is difficult to say and read what is difficult for me to hear to sneak through a gap in my own emotional perimeter. After I wrote these words to Luca, there was something extra left on the page in front of me, a tear from my own eye.
It is easier to find tears in hospital than water to drink. But collecting them all together still wouldn’t cry enough for a river. It would need everyone on Earth to cry at least fifty tears to fill the equivalent 2.5 million litres of an Olympic swimming pool.
Only humans cry because of emotions. Tears can spring forth from the simplest stimuli – a poignant memory, a piece of music or the joy of a reunion. They cleanse the eyes of irritants, but emotional tears serve a deeper, more mysterious purpose. They are the body’s way of releasing stress, a silent language that speaks our inner turmoil or joy.
The act of crying is not just a release but also a form of communication. It signals distress, asks for empathy and support from those around us. Crying can strengthen bonds and foster community, ensuring that we are not alone in our moments of greatest vulnerability. This is why crying in response to emotional pain, such as grief or loss, can be profoundly therapeutic.
The theory that crying helps us deal with loss is supported by both psychological and physiological evidence. Emotional tears are known to contain higher levels of stress hormones like cortisol. By shedding these tears, we may be physically ridding our bodies of stress, leading to a calming effect. Psychologically, crying can act as a cathartic release, helping to process and accept grief. It allows us to confront and express our deepest emotions, facilitating a path towards healing.
Are we the only animals that cry? The short answer is no, but with caveats. Many animals produce tears for physiological reasons, like keeping their eyes moist or clearing debris. However, the phenomenon of crying in response to emotional stimuli seems uniquely human.
Human tears, therefore, remain one of our defining traits, a blend of the primal and the profoundly human. They are both a biological necessity and a profound statement of our emotional complexity. Through our tears, we connect, heal and express what words often cannot. That single tear I left on the page landed directly on the word hope. It blurred my blue ink but made it clearer than ever.
A few hours after my call for help, the team from London arrived. They drove on quiet streets, past closed shops and pubs as life had been put on pause by the government. Even the churches were closed on that Sunday. Perhaps this was the first time that organised religion had ever really listened to science.
But when they arrived, it wasn’t as simple as just adding oxygen directly to Luca’s blood. Luca first needed to be moved from his delicate position, tiptoeing on the shoreline between life and death in the ICU to the operating theatre. The machine that added oxygen needed thick plastic pipes to be inserted in blood vessels deep inside Luca’s groin, fed along the inside of his body like an underground tunnel towards his heart. Plumbing these in safely needed millimetre precision, X-ray guidance and a sterile environment to prevent damaging his blood vessels, to stop Luca bleeding to death.
Even moving Luca was tough as Covid had shut down the theatres close to ICU. Instead, we needed to move him to a distant area normally used for replacing knees and hips. As well as being an intensive care doctor that day, I needed to be a locksmith and search for keys, an electrician to operate banks of light switches and a removal man to bring boxes of equipment. We needed to bring the operating theatre to life so that Luca could be brought back to life.
We delicately pushed Luca down the longest hospital corridor in Europe, still lying on his front attached to the countless leads and pipes of the life support machine. After arriving in the operating theatre, the whole team knew the next hour would mean the difference between life and death. Before any new pipes could be inserted, Luca needed to be returned to lying on his back. But simply doing this caused his oxygen levels to plummet even further. The monitor screamed out as Luca’s blood oxygen saturations counted down from the mid-80s, a life threateningly low number, to the 70s then 60s. Numbers not compatible with life. Luca’s heart struggled, slowed down to a stop. For a brief moment, life had gone, paused, his blue body looked already dead. I mentally prepared for the next conversation with Luca’s wife, imagining her holding his daughter. I planned what words I would say. ‘Died.’ ‘Painless.’ ‘Sorry.’ Then I thought of my own daughter, Evie. It was her birthday. I had promised to be home on time. But it had already been hours since her candles had been blown out.
Then the complex machine that the London team had brought started spinning. Pumps whirled, pipes rattled with the deep blue blood being sucked out from Luca’s body, the colour of azure paint on a delicate porcelain vase, threading an intricate pattern through its surface-like veins in the body. The blue blood from Luca dived through the core of the machine in translucent pipes, ejected the other side like a fast-flowing river of bright red blood. This new blood was the intensity of a roaring fire, its warmth and energy coursing through Luca’s veins like a relentless blaze.
This redness flowed into Luca’s leg, up his body, turning his face from ashen to an ember glow. The monitor’s screaming changed to a new ever rising tone, higher and higher, as his oxygen levels rose to the normal range for the first time in a week. The drugs we had been using to keep Luca alive were spooled down and within minutes all the pumps could be turned off completely. This was the moment between the past and the future. The moment we call life. It was like magic. The team prepared to transport Luca, still attached to their machine, to London.
Luca was the unlucky lucky one in those pandemic years. Many would never make it in time for this treatment and the team had to say ‘no’ far more than ‘yes’ to the phone calls for help coming in from all around the country. I remember Luca because he was rare, but I cannot forget the many patients, old and young, that didn’t make it. Although many of us talk to the dead, they only spoke back to me in my dreams at night. In the years since, the dead have managed to stay with me, and even grow taller. Perhaps, or certainly, this was one reason why in the years that followed, I needed to change my own life.
A year after I cared for Luca, a project was launched by my friend and colleague Jack Parry-Jones to plant a tree for each person we cared for during the pandemic. For the many that didn’t make it, this paired remembrance and hope through new life. On a windy day, in a picturesque town nestling in the beautiful Usk Valley, my youngest daughter and I went to help plant these trees. For every patient cared for over the past year, and every staff member who worked tirelessly, a tree was planted. It was a poignant way to honour their memories and struggles, and it also provided a tangible connection to nature’s healing power.
Jack was inspired to start this project by Viktor E. Frankl’s book, Man’s Search for Meaning. The Austrian neurologist, psychiatrist and Holocaust survivor was well-placed to argue we all need meaning in our lives. It was thanks to meaning that Frankl survived the horrors of his concentration camp. In Luca’s case, meaning came from relationships with his wife and daughter. For others, purpose is found through work or spirituality and religion, perhaps personal growth or even their contribution to society. Others find worth in creativity and expression, experiences and adventure or even legacy. Jack realised that those who thrive after surviving critical care are those with meaning or hope in their lives.
In the wake of Covid, meaning and hope were thinning from people’s lives and deaths. Jack approached the charity Stump Up For Trees as he felt planting trees might be a way to add meaning and commemorate patients and our staff as well as offset some of the carbon footprint from our critical care unit.
There now stands a woodland with 1,400 trees native to the Welsh hillside – hazel, wild cherry, blackthorn, sweet chestnut, oak and hawthorn. ‘We need a world worth living in and biodiversity helps provide value to our lives.’ Jack told me on that windswept day. The ICU is life on overdrive, a high-stakes blur of urgency and intensity. It is nice to think more slowly by immersing oneself in greenery, knowing the trees we planted will take decades not seconds to change. This experience was more than just an act of planting; it was a moving tribute to those we lost and a therapeutic process for those of us left behind.
Planting trees has long been associated with physical and mental health benefits. I met the wonderful James Wong, a British ethnobotanist who trained at London’s Kew Gardens with both Welsh and Malaysian human roots. We were fellow panellists at the Hay Festival, a vibrant celebration of literature that transforms the town of Hay-on-Wye into a bustling hub of creativity and thought. Often dubbed ‘the Woodstock of the mind’, this ten-day event, beginning in late May, draws writers, thinkers and book lovers from all over the world.
James and I appeared together on a live BBC radio comedy show where guests argued over what was the world’s ‘best medicine’. I claimed that animals were healthcare’s most powerful treatment after writing my book One Medicine, which explored the profound connections between human and animal health. I was sure I would win, not least because I was armed with facts like the kangaroo has three vaginas and a whale’s penis is actually called a ‘pink floyd’.
James, however, swept in with a brilliant alternative, won over the crowd and took home the trophy. He showed how nature plays a crucial role in our emotional and physical well-being. Horticulture, he said, was clearly the best medicine. Being surrounded by greenery helps lower stress levels, reduce blood pressure and improve overall mood. This connection to nature is especially vital during times of crisis, like the pandemic, when many people turned to green spaces for solace and rejuvenation as we did in the forest. Perhaps the reason I was so happy that day at the Hay Festival was not because of the books that surrounded me, or the green room filled with my favourite literary celebrities, or even the overpriced ice cream. I was happy, James argued, because we were deep within the lush nature of mid-Wales, where the grass really is greener.
The human eye has even evolved to detect many more shades of green than any other colour. This evolutionary trait allowed our ancestors to distinguish between toxic and tasty plants, and now it enhances our appreciation of the natural world. James shared a fascinating study where participants on treadmills viewed different scenes while their stress levels were measured. Those who saw green environments found the exercise easier, felt better and had improved self-esteem compared to those who saw black and white or red-filtered views. This highlights how green spaces are somehow hardwired into positively affecting our perception and mood.
It is no wonder then that community gardens significantly combat loneliness and isolation, key factors in poor mental health. Engaging in gardening fosters social interactions, even for introverts. Of course, these benefits of horticulture are complex and individualised. What matters most is finding a personal connection to nature. Whether it’s through a lush garden or a simple plant on a windowsill. Or for me and my daughter, planting trees to remember the lost from my past, to think about hope for the future and to plan the next birthday cake, which I hoped to make it home in time for.
So, although James won, my loss was worth me realising that our time making a new woodland was not just about planting trees. It was a therapeutic journey. The act of planting, feeling the soil, and working alongside others who shared our grief and hope was deeply healing. The trees we planted will stand as a testament to resilience and recovery, offering a peaceful spot for reflection for this lifetime and the next. As they grow over decades and generations, they will also contribute to a healthier environment, supporting local ecosystems and providing cleaner air. This initiative underscores the dual benefits of such projects: honouring those we’ve lost while promoting mental and environmental health. Moreover, the initiative aligns with broader findings that urban greenery can significantly improve public health. Studies indicate that increased tree canopy cover in urban areas correlates with reduced stress, lower crime rates and better overall mental health. This project in Wales is a step towards creating a more sustainable and mentally supportive community. In the end, the windy day spent with my daughter planting trees was a day of connection – to nature, to each other and to the memories of those we lost. I found myself discussing difficult topics from those dark Covid days and nights with colleagues, made easier, less intimidating because I wasn’t facing them. I couldn’t see their eyes; they couldn’t see mine. The movement and surroundings provided a comforting backdrop, making it easier to open up. It reminded us that from grief can come growth, and from loss, new life.
We wanted to give our woodland a name that would resonate deeply with its purpose and spirit. The decision to choose a name in Welsh was a tribute to our heritage and the local community. We believed that the right name could encapsulate the memory, peace and gratitude we wished to express through this woodland. After much deliberation, we narrowed our choices down to four names: Coed Cofio (Trees to Remember), Llecyn Llonydd (Peaceful Spot), Dail Diolch (Leaves of Thanks) and the eventual winner. A skilled local woodworker, Mick, battled through long Covid by carving a bench made from local beech and sweet chestnut. It sits proudly at the top of the site, overlooking the growing forest. I recently sat there, next to the plaque set deeply into its wooden layers translated into the many languages spoken by our diverse staff, including Spanish, Urdu, Polish and Portuguese. ‘As well as the biodiversity in this wood, human diversity is as important to us,’ Jack told me as I sat looking at the plaque that reads Gwreiddiau Gobaith, or Roots of Hope.
You never forget certain patients or families. Perhaps they are those ones that are most like you at that time. When my daughter was three I cared for a little girl who died in a fire when she was three. The same week Aunty Win died, the first family I broke bad news to lived in the same village, one street away from Win. Often, I have a strong inbuilt desire to find out what happened next in their lives.
A month went by after Luca was taken to London and hundreds more patients passed through the Intensive Care Unit. I would often think about Luca, his wife and his daughter. He was one of those that we as healthcare workers carry along with us. I kept meaning to call London, to find out how Luca was doing, if he had stayed alive. But the endless patients, the pandemic and my life got in the way. Or perhaps I didn’t want to know the answer. Many say that it is not the despair that gets them, but the hope that’s unbearable. I disagree. For me there is power in uncertainty, because uncertainty contains hope.
I still remember the first time I uttered those three little words. Growing up in a loving Welsh family, I’d heard them countless times. But saying them yourself for the first time is unique. You try to pick the right moment, but sometimes the words come out unexpectedly, catching both you and the listener off guard.
If ‘I love you’ are the three most important words in life, then ‘I don’t know’ are the most crucial in medicine. Despite their significance, they’re seldom used. Their strength lies in acknowledging that doctors don’t, and can’t, know everything. For me, the first time I confessed my uncertainty to a patient’s family was after caring for a young man who died from sepsis. As an ICU doctor surrounded by advanced tests and scans, I still couldn’t answer his family’s simplest and most important question. Trying to grasp the situation, his mother asked, ‘Why him? Why has he died?’
Medical encounters often revolve around unknowns. Patients and families frequently challenge us to predict the future, asking, ‘Will she survive?’ or ‘When can I go home?’ Like skilled meteorologists, we blend science, history and intuition to estimate a possibility we hope aligns with the truth.
Consider a weather forecast predicting a 90 per cent chance of rain. If the sky remains clear, the prediction wasn’t wrong – truth just resided in that smaller 10 per cent. Being open about uncertainty fosters understanding: a 90 per cent chance of rain may prompt you to take an umbrella, but ‘I don’t know’ initiates deeper, more nuanced conversations.
Looking a patient or relative in the eye and saying ‘I don’t know’ is challenging. These words are hard to say. It’s difficult to admit the limits of our knowledge, and sometimes it means hinting at the boundaries of medical understanding. Patients and families often expect doctors to have definite answers, assuming modern medicine can cure them. It can be surprising when we don’t and can’t.
These words also carry risks. Standing on the solid ground of reason, it can become slippery when uncertainty melts that foundation. You can falter, become unsteady, and lose your grip. Admitting ‘I don’t know’ can be a disorienting experience for doctors, leading to more profound self-questioning.
Yet these words also hold immense power: the power of hope, suggesting a chance for recovery. They also inspire the pursuit of a better understanding of the unknown. Even when hope fades and answers remain elusive, perhaps honesty with yourself and those you care for is valuable in itself – though I’m not entirely certain. I don’t know.
The guessing would soon end. It was at the end of another busy Friday afternoon when a new patient was wheeled into my area of ICU. Arriving by ambulance, they looked thin, weak but were breathing for themselves. Bad timing I thought, right at the end of the day, a new patient, another day when I’ll be home late. I caught a glimpse of the back of the patient’s head as I walked down the corridor for a handover. I couldn’t believe it. It was Luca. Back from London. Back from his death. Even writing these words now makes me smile.
Luca was completely off all life support machines, his eyes open, darting around, trying to make sense of where he was and now who he was. He spoke in Italian then in English. He tried to tell me about the crazy dreams he had been having, first where he was surrounded by lifeless mannequins, another with wasps biting his legs. But the scariest memory was not a dream or delusion at all. It was seeing Big Ben as he was driven back to Cardiff, not knowing why on earth he had been in London or what had happened.
Luca was right to fear the famous clock tower. Officially called the Elizabeth Tower, it lies next to the seat of government, which was the most dangerous place in the UK during the pandemic. Not for those inside, expelling political chicanery and privilege, but dangerous for the safety of the nation after its litany of poor decisions and poor leadership. Luca showed me the last text on his phone from one month ago that still read, ‘I won’t be in work tomorrow.’ Unlike the politicians’ messages, this one hadn’t been deleted.
As Luca settled into his new temporary hospital home in Cardiff, he rekindled a long-distance relationship with his wife, Aria, like they had years before. This time they weren’t separated by an ocean, but by pandemic restrictions keeping the hospital doors closed to relatives. Instead, Luca spoke by video in Italian to Aria, saying he was now much closer to home. As the conversation started to end, I asked if I could borrow Luca’s phone. Perhaps for selfish reasons, I wanted to speak with Aria, to help make sense of the story for her and for me. It was a much better conversation than the last time. She cried once again, but this time for all the right reasons. After talking to Aria, I flicked back through Luca’s old medical notes on my lap, found the page from a month ago where my tear-smudged word ‘hope’ still lay. I wondered if I now write not to communicate but to preserve. I turned to a new crisp page and wrote:
Hi Luca, I spoke to your wife Aria again today. I said how pleased I was that you were back from London after having the life-saving treatment where oxygen was added directly to your blood. You were no longer sick enough to die. There is still a long and winding road to recovery ahead. But for today, you have your life back, your wife has her husband back and your daughter has her daddy back. And I have my hope back.
I hardly recognised Luca as he cycled on to the slatted wooden walkway of the cafe suspended over the water where we met. It had been nearly five years since he nearly died. We exchanged small talk about the weather, ordered coffee, argued about who would pay. And then we talked, for hours.
‘My life now is so different now,’ Luca said. “Very different. Better even. I’m glad it happened.’
Luca described how his life before Covid felt like a daydream. He was a passenger on a train of his own life, with scenes from reality flashing by in a blur like my tear-smudged words. Luca’s touch with death, getting through the tough recovery that followed and being reunited with his family, meant he now lived for now. He climbed through that train window, jumped into his own life. Luca became acutely aware that he was alive.
‘I woke up,’ he smiled.
It had been a slow recovery, discharged home in May and returning to work in October. But work too was different.
‘There is my actual work as a pharmacist, which I still love. But the most important job I have is working on me.’
This was a novel approach to work for me. I realised that life will always have more to do than time allows. All recorded human history fits into just sixty lifetimes of a hundred years each, making it clear how brief our time really is and how we can never do it all. You are really no big deal. Instead of denting the universe, Burkeman towards the end of his book argues, what really matters is ‘making some tiny contribution to the betterment of the environment, or your neighbourhood, or the political culture’.
It struck me that those 4,000 weeks of my life will contain 1,800 weeks in work. Eighteen hundred weeks of work. Boiling your entire career down to these simple numbers may help you to move from last year to the next with a different view of how you relate to time, to people, and to yourself. Not everything that weighs you down is yours to carry. Allow the good days to bring you happiness; the bad ones will bring experience of this short life and even shorter career. The true value of any time-management strategy lies in it helping you to neglect the things that don’t really matter.
Luca now realised this. As soon as he got home from hospital, he started consuming books. ‘The first book I read when I got home was yours – Critical.’
Published just before the pandemic, my first book, Critical, pulled back the hospital curtain to reveal the science and stories of my life in the high-stakes world of intensive care medicine. For Luca, reading my words was hard because he had lived through much of the detail. Lived experience, or perhaps died experience. But Luca needed to understand what his body and mind had gone through. Hearing him speak about this over coffee really got to me. I tried not to show it. I had never imagined that the words I wrote in that first book years ago, after meeting other patients like just Luca, would one day mean so much for my future patients. I pulled out a crumpled sheet from my bag that I had photocopied from Luca’s notes. It felt right to read out to Luca the words that I had written to him when he was too sick to hear them. After all, I wanted to write to patients and not about them.
‘Thank you for writing down my story,’ he said after reading them through from top to bottom.
I was looking at a white church in the distance that reminded me how much another storyteller had improved the lives of millions, including my own children, through his stories. One of my favourite questions to ask junior doctors during ward rounds is about the connection between Cardiff, The BFG and intensive care medicine. Surprisingly, few know that Llandaff, a cathedral village just a mile from our wards, was home to the world-renowned children’s author Roald Dahl. He was born in Cardiff and christened in the Norwegian church in Cardiff Bay where Luca and I were meeting. But Dahl’s legacy extends far beyond his literary achievements. His life, marked by personal tragedies, spurred contributions to medical science that often go unrecognised.
Roald Dahl’s life, though privileged, was interspersed with profound hardships from an early age. At three, his sister succumbed to sepsis from a ruptured appendix. During the Second World War, Dahl narrowly escaped death when his Gloster Gladiator biplane crashed in the Egyptian desert, leaving him with a broken nose, fractured skull and a concussion. The five years between 1960 and 1965 were particularly harrowing. His three-month-old son, Theo, suffered a brain injury after being struck by a taxi in New York. Then, in 1962, a measles outbreak claimed the life of his 7-year-old daughter, Olivia, after the virus spread to her brain, causing encephalitis. Adding to his woes, his wife, the actress Patricia Neal, suffered a massive stroke while pregnant with their fifth child.
Dahl tackled each crisis with remarkable determination. To manage his son’s hydrocephalus, a condition causing fluid accumulation in the brain, Dahl collaborated with hydraulic engineer Stanley Wade and neurosurgeon Kenneth Till. They developed the Wade-Dahl-Till (WDT) valve, a device that significantly improved the treatment of hydrocephalus by preventing blockages in the brain’s fluid drainage pathways. This invention continues to benefit patients worldwide.
Olivia’s death profoundly affected Dahl, prompting him to advocate passionately for vaccination. The BFG, dedicated to Olivia, was published fourteen years after the introduction of the measles vaccine that could have saved her. In 1986, Dahl penned a heartfelt letter urging widespread vaccination, which public health campaigns still use today to emphasise the importance of immunisation.
Dahl’s commitment to medical advancements didn’t stop there. Frustrated by the inadequate post-stroke care his wife received, he devised an intensive rehabilitation programme that proved instrumental in her recovery. Patricia Neal not only regained her ability to speak and move but also returned to acting, earning an Oscar nomination three years after her stroke. Their innovative approach to stroke rehabilitation laid the groundwork for modern techniques and contributed to the formation of the Stroke Association.
Roald Dahl’s story reminds us that a writer can change the world not only through words but through transformative actions. His medical innovations, born out of personal tragedy, continue to save and improve lives, illustrating the profound impact one individual can have across diverse fields.
Once Luca had made sense of his own story, he could plan where the plot of his own life would take him.
‘After I understood what had happened, I wanted to get better. Better than before.’
After finishing my book, his taste in literature improved greatly. He bought endless self-help books, books on self-development and self-improvement. Books changed not only Luca’s internal voice, making him less shy and more willing to speak his mind, but started to transform his body. Waking at 5 a.m. to exercise is now his superhuman ability, hacking the time restraints of being a busy father to not only Sofia, but now his second daughter, Grazia. Words were a fantastic way to do that. Words have power.
After talking with James Wong at the Hay Festival about the power of greenery, I met another panellist, Professor Neil Frude. As a clinical psychologist obsessed with books, he developed ‘bibliotherapy’ as a powerful tool in mental health treatment. This innovative approach harnessed the transformative power of literature to provide solace, guidance and a sense of connection to those struggling with psychological challenges.
Frude was not the first to transform the power of books into a physical reality. Mexican architect-turned-artist Jorge Méndez Blake turned literature into sculpture with his installation art project The Castle in 2007. At first glance, the piece appears to be a normal brick wall. A closer look reveals a subtle curved bulge in the middle of the 75-foot-long structure. As your eyes move down from the arched top, the cause of this distortion is a single book placed at the wall’s base. Lodged in the mortarless foundation, between the floor and the first layer of bricks, is a copy of Franz Kafka’s The Castle. With his architectural background and a life-long love of books, Blake pays homage to Kafka by placing his novel at the base, warping the monumental red-brick structure. Words really do have power. This is even more poignant as Kafka only ever wrote privately, never intending his work to be published. It was only after his death that The Castle was published by a friend. Blake’s art reveals the power of a single book, how small ideas can have a monumental effect even when the words are whispered using a faint, shy voice. The quietest person in the room often has the most to say.
Frude harnessed the physical effects of books in a different way, not using them for art but as practical help for patients. His ‘Books on Prescription’ project revolutionised how mental health professionals could approach treatment. This government-backed scheme, where doctors could prescribe self-help books instead of pills, was rooted in Frude’s extensive research and clinical experience. It still provides cost-effective, accessible and stigma-free treatments. Patients can delve into narratives and advice that resonate with their experiences, offering practical strategies for managing conditions such as depression, anxiety and stress. The books are as effective as the costly pills for mild to moderate conditions, without the side effects.
I’ve just returned from our annual family trip to Hay Festival. The tradition started when my daughter became obsessed with Julia Donaldson’s The Gruffalo, but the march of time has morphed her tastes into young adult themes of love, sex and murder.
Just as traditional as the trip itself were the accompanying rain showers, prompting a dash to the undercover deckchairs, where we ate and read, and I started writing this. I was surrounded by words: words of hope for the future, pleas for help from war zones, words seeking understanding, and words that made people smile. These were written and spoken at more than 800 events in eleven days, by 700 people from Bonnie Tyler to Theresa May. Thankfully, there was no dancing. Thousands of books were sold and millions of words were read every day by the 300,000 visitors.
Yet these statistics are dwarfed in just a single day in my own hospital. There are more patient encounters where I work daily than there are events at Hay, more clinics than speeches, more words written about patients than visitors like me on those deckchairs. But medicine often forgets the power of simple words, distracted by the importance of verbal communication skills, simulation training workshops, and human factors courses. These things are important, but let’s not forget about the millions of written words that affect patients and staff every day.
I’ve previously collaborated with the Welsh artist Nathan Wyburn to show the harmful impact that words of hate can have on healthcare staff. In his art installation Words Bruise the reddened face of a healthcare worker is formed from hundreds of negative words and phrases sent over social media. But these same staff often use well-intentioned phrases in their everyday work that can hurt patients.
Sadly, familiar terms written in medical notes include ‘housebound’, ‘bed blocker’, and patients ‘complaining of’ things rather than being affected by them. The worst might be ‘poor historian’, meaning patients who can’t give a clear account of their medical history. It is as if we forget that it takes six years of university and a decade of hospital training to become a specialist doctor – and even they struggle to retell a medical history when they’re not seriously ill. It’s almost as if we’re expecting patients to moonlight as a consultant while battling to survive. But my personal nemesis that I’d love to murder (like the plot line of my daughter’s latest book) is the ‘ceiling of care’. For one thing, care should never be limited, even if treatments are. But what really grates is the idea of a hierarchical escalator of interventions. This suggests that lower-level treatments are somehow inferior to those at the top, and near the ceiling are the ‘best’ ones.
The truth is that many patients I care for may be treated with some drugs but not all drugs, many attached to some machines but not all machines. After the complex interplay of wishes and best interests are combined, the conclusion we often reach is that more and more drugs are not better – they would be worse. Similarly, more complex machines wouldn’t be the best choice but the worst. And so, not only is the phrase ‘ceiling of care’ clumsy and poorly formed but it may promote the idea of ‘more is better’. Instead, the Australasian approach of describing ‘goals of care’ is better at describing this complexity, using the same number of words.
Writing a letter to my Aunty Win was not the first time I’d written a letter to someone very dear. When the Covid pandemic gripped the world, I kept hearing in the media sentiments like, ‘Don’t worry, it will only kill the elderly, frail or vulnerable.’ These people are the core of a society. They are my patients, my friends and my family. Should I not worry about them? Should we just forget about them?
After getting home late from hospital after a long, anxiety-inducing meeting planning our ICU pandemic response, I slid on to an old leather sofa in the jumbled-up spare room of our house, the type of space that acts as a dumping ground for spare chairs and old photo albums. Staring through a window without blinds at the dark sky, I thought about my wife’s brother, who is a wheelchair user. I thought about my friends living with cancer. I thought about my parents as they exceed the average life expectancy. I wanted to say something to them, about what the future may hold. I pulled out my laptop, tapped quickly on the keys making countless spelling errors but not stopping. I wrote a letter to them all in just a minute or two, my fingers not lifting once from the keyboard. It was easy to write because it was true and simple and honest. I sent it to my brother-in-law, my parents and my friends by text message before going to bed.
The next morning, I woke to a phone screen filled with missed calls, messages and notifications. My letter addressed to a handful of people had been read by countless more. The world’s media arrived on my doorstep and within a week, my open letter to patients during the pandemic was read by over half a million people worldwide and viewed three million times after featuring on television. Bad words grind. Good words mend.
It read:
To those who are elderly, frail, vulnerable, or with serious underlying health conditions,
We have not forgotten about you.
It must be so hard listening to endless news reports that end with, ‘Don’t worry, this illness mainly affects the elderly, frail, vulnerable, or those with serious underlying health conditions.’ What if that is you?
Our passion as an intensive care community is fixing problems that can be fixed. Yet we often meet patients like you who have problems that cannot simply be fixed. As this virus continues to impact on the world, we will meet many more of you. Although we have fancy machines, powerful medicine and talented staff, none of these things cure every disease. All they do is give us time – time to work out what is wrong, time to hopefully treat it, and time for people to get better. But sometimes we already know what is wrong, we already know that there is no effective treatment. And so sometimes the machines offer little, intensive care offers no fix. But hope is not lost. We have not forgotten about you.
As difficult as this is, we will be honest. We will continue to use all of the treatments that may work and may get you back to being you again. We will use oxygen, fluid into your veins, antibiotics, all of the things that may work. But we won’t use the things that won’t work. We won’t use machines that can cause harm. We won’t press on your chest should your heart stop beating. Because these things won’t work. They won’t get you back to being you.
And if these things are still not enough, we will sit with you and with your family. We will be honest, we will hold your hand, we will be there. We will change our focus from cure but most importantly we will continue to care. We have not forgotten about you.
Signed,
The Intensive Care Unit
After Luca and I had been speaking for hours, I asked him my last question: ‘What would you say to the old Luca, before he was sick enough to die?’
‘I would say two things. Firstly, be present in your life. Life can shoot you in the chest. And like being shot, you feel it before you hear it. Life happens without warning or sound.’
Being present doesn’t mean you have to own all the problems of the world; often it is a case of ‘Not my circus, not my monkey’. But being present allows you to feel your way over uneven ground, as life happens in the cracks.
‘And secondly, choose the words you say and read with as much purpose and care as the drugs I dispense at work. Words matter, especially the ones you say to yourself.’
For me, I still write what is hard for me to speak, but important for others to hear. I am lucky that I can do this through my books. But words do not belong only to authors. Anyone can and should write. Start using more written words. Take them inside and allow them to change you. In my science-obsessed, technology-focused world of medicine, it is important to remember that at our core, we are all made of stories. If you cut me in half, next to my organs and my blood, I am filled with words. So are you.