‘All of life is in ICU,’ Jim Down writes. And over the course of around 230 pages, he absolutely proves the point. Life in the Balance offers a rare glimpse inside hospital wards where some of the most challenging medicine takes place, the most contentious medical decisions are made, and the most vulnerable patients’ lives are on the line.

Here, perhaps more than anywhere, split-second decisions truly make the difference between life and death. Dr Down, a consultant in critical care and anaesthesia at University College London Hospitals, shares the stories that have made up his career from life as a trainee with ‘an iota of respect’ on the wards, through his experiences as a consultant in intensive care and, ultimately, to a reckoning with mental health struggles as working and personal life became too much to handle. All life is no exaggeration.

In the book Dr Down gives readers an often vivid and harrowing insight into the treatment and fallout around the Alexander Litvinenko case, the graphic and horrendous aftermath of the London bombings and the Hatfield rail crash, and the relentlessness of the COVID-19 pandemic for staff on the absolute front line.

But he also tells the more every-day stories of patients and families in intensive care, and their relationships with the staff who hold their fragile lives in their hands.

On the pandemic, he says: ‘We saw such a lot [of death] in such a short space of time that it certainly affects people and particularly because it was a new disease. We were all running into this thing a little bit blind and there were other anxieties about our own health and about our own families. I think a lot of people are affected by the fact that they were looking after people without their families there, too, which is totally alien.’

While there are stories that revolve around major national events the threads that make up the narratives in Life in the Balance remain steadfastly about the patients. Their characters, charms and worries are given every bit as much importance as their medical conditions.

Equally important are Dr Down’s relationships with them, what he learns from each experience along the way, and also, sometimes, the questions about whether intensive care is actually the right course of action for them.

Speaking to The Doctor he says: ‘You see the best of people. And the thing that always strikes me is when I break bad news to a family and the reaction is so often extraordinary. Sometimes they say, “Oh god, this must be awful for you”.

You see the best of humanity. But also, as I get older, I’m sort of aware how tough it is for patients being there. I’m constantly aware of that – that balance between the burden of what they’re going through and the chance of benefit and what the benefit would be. Those are unanswerable questions…but that’s what takes up my headspace.’

A theme running through the book, too, is the fascinating question of just how much doctors can afford to care.

Dr Down says: ‘I used to think that I would just want the best technical doctor – the one with the lowest complication rates or the surgeon with the best hands. Obviously, I do want that but more recently it’s really struck me how important it is to feel that someone cares. More and more I think the interactions are so important. When my mum was dying the staff were visibly upset and I loved that. I thought this is what matters to me. It’s a really difficult balance – and I don’t have the answer. I want people looking after me to care and to have emotions about it, but I don’t want their lives to be ruined. It’s tough.’

That phrase ‘all life is in ICU’ is as relevant to Dr Down as it is to his patients. This book is deeply personal – it is a rare and privileged insight into person and doctor. The beautiful and the mundane of personal, family life are juxtaposed with the immense challenges and rewards of working life.

Before Life in the Balance went to press Jim Down stood before his intensive care colleagues at University College Hospital, London and read one of the most hard-hitting chapters of the book out loud. Entitled ‘Crash’, it tells the story of a patient – Linda – who was incredibly unwell but whose condition had stumped doctors, with test after test returning results which did not explain her worsening state.

By the time Dr Down and colleagues had got to the bottom of her worsening ill health, Linda was unfit for surgery, and she died a few days later.

It was an episode that tipped Dr Down into a spiral of anxiety, negative and intrusive thoughts and a questioning of his own professional competence and confidence. He writes about this extensively and emotively. (See excerpt opposite)

‘I thought if I’m going to publish this, I’ve got to be able to read it to my colleagues. It was a daunting moment, but a few people came up after and said thank you.’

Dr Down is incredibly willing to discuss his own fragilities and fallibilities. In this book he dispels the mythical perception – a perception he had himself as a young doctor – of the God-like intensive care consultant. But perhaps what his stories do, more than anything, is offer lessons about how the NHS can be better amidst the enormous challenges of demographic change, enormous waiting lists and a workforce so beleaguered by the last decade.

The truth is that life is not just fragile for patients in hospitals but for doctors too. Dr Down’s experiences show the importance of support systems for when doctors need them most.

Even more poignantly, perhaps, the final pages hint at the importance of compassionate leadership – of doctors like Dr Down feeling able to share their experiences and make those  sorts of vulnerabilities normal and understandable for colleagues yet to experience their lowest moments.

Reflecting, he says: ‘I think it is the best shot we have got. ‘If we can create an atmosphere where people feel they can confess to feeling bad or feeling vulnerable then maybe we are really getting there.’ If this book is about anything – it is about compassion.

What it means to be a compassionate doctor, but also what it means to be a compassionate friend and colleague. And in the NHS of 2023 staff need compassion as much as their patients do. 

During an interview with The Doctor, Jim Down takes a moment to support junior doctor colleagues who, just days before the conversation, had voted overwhelmingly in favour of industrial action.

‘I think it’s very tough for them, if I’m honest,’ he says. ‘When I came out…30 years ago it was hard, some of the hours were ridiculous, but we didn’t leave medical school with £100,000 worth of debt, we were relatively better paid, and we had a kind of knowledge that it will be OK in the end. I think for junior doctors now it is very different.

‘I support them in taking action because I think we’ve got to look after them a bit better than we do now.’

In this extract from his book, Dr Down describes his profound anguish at the death of a patient

‘When I’d expressed my condolences to Linda’s family I found myself loitering, looking for something more that I could do for them. ‘Anything to make it better, to make amends for what I’d failed to do three nights previously.

‘‘‘Thank you for trying,”’ they said. I went and reviewed a couple of other patients who might need to come to the ICU and then at 5 a.m. I went home. But I was not all right. I felt guilty, anxious and stupid. I was convinced that I was responsible for Linda’s death. I had the strong impression that one of the senior nurses thought I could have done better on the first night and, although I tried to persuade myself that it wouldn’t have changed the outcome, a part of me agreed with her.

‘Had I lost my clinical acumen? I’d certainly lost my confidence. Over the next few weeks, the events of that first night went round and round in my head. I tried to blame the Australian radiologists, but I had asked them to look for the wrong things.

‘Over and over again I kept asking myself why I didn’t think of Boerhaave. I pictured Linda with her sly smile, making pithy remarks the year before, and as I did so, the guilt and self-loathing welled up in me. I could think about nothing else. I couldn’t sleep, I didn’t know what to say to my children and I couldn’t see the point of anything. I couldn’t remember how to enjoy things. I didn’t think I deserved happiness. I kept imagining what her brother and son were doing now. How were they feeling? Were they coping? When I went for a walk and saw people laughing and messing about, I felt angry. Why were they happy? Did they not know that she was dead?

‘My anxiety level rose and fell and rose again. For a while it would feel manageable, but then something would remind me of what had happened and it would start to build, a knot ratcheting tighter and tighter in my stomach.

‘I felt sick as intrusive negative thoughts bombarded my consciousness. I could explain to Tish what was happening quite rationally, but I couldn’t stop it.

‘The terrible thoughts just kept coming and, with them, panic. You are not good enough. You should have done better. You’ve been getting away with it for years. You need to work harder, or give up. It’s time to face it, you’re just not up to the job.’