In hospitals overloaded by the Covid-19 epidemic, will doctors soon have to sort patients? Some of them give the alert: in a column published by the JDD, AP-HP crisis medical directors (Assistance publique – Hôpitaux de Paris) say they are preparing for it “in order to save as many lives as possible”, while in the world, nine doctors from the AP-HP believe that “by forcing caregivers to decide which patient should live, the government is relinquishing responsibility in a hypocritical way.”
At the center of these warnings, the question of the number of patients in intensive care, a data particularly scrutinized by observers and decisive in the public health decisions taken by the executive. And these figures are worrying: as of Monday, 4,974 Covid-19 patients were hospitalized in critical care (intensive care and intensive care services), more than the 4,903 on November 16, at the peak of the second wave. “On March 25, in Ile-de-France, the available resuscitation beds were torn apart in a few minutes”, summarize the nine doctors who speak in Le Monde.
Carrying, this cry of alarm is qualified as “counterproductive” by other health professionals contacted by Le Parisien. According to them, these data do not allow us to say that such a triage of patients is inevitable.
“We always had to make choices”
Benjamin Davido, infectious disease specialist in Garches, signed the column published in the JDD on Friday evening. The same day, the 25 intensive care beds available at the Raymond-Poincaré hospital, where he works, were occupied. “A 26th and what would we have done?” In conventional hospitalization, patients are refused. We are at the maximum of our capacities. When a patient dies, that leaves a free space: we are there, it is the musical chairs, ”he laments.
“In this situation of disaster medicine, where there will be a glaring mismatch between needs and available resources, we will be forced to triage patients in order to save as many lives as possible”, write the medical directors of the AP-HP in their gallery. This sorting will favor patients “who have the longest life expectancy”, also explains Benjamin Davido, to the Parisian.
In medicine, “we have always had to make choices,” he admits. “Normally, we do it upstream. It is first and foremost the emergency department staff who assess the severity of an individual’s state of health and decide whether or not to be hospitalized. “They look at the history, the age of the patients”, specifies the infectious disease specialist. This sorting is also decided in the other departments of the hospital, “between responsible doctors and resuscitators”, in order to estimate “which patient will have more or less benefits in resuscitation”.
Repercussions on the quality of care
The current choices, point out the whistleblowers, can have other repercussions than in normal times. “The urgency is such that we risk ending up with a degraded quality of care,” said Benjamin Davido. For lack of space, patients can be “accommodated” in other services which would not be sufficiently adapted: “Take a Covid patient who would have been moved in rheumatology: the nurse, who is specialized in dressings and corsets , will have to practice oxygen therapy? But it cannot be improvised! “
“The triage of patients has already started since major medical and surgical deprogramming have been imposed on us”, warn the authors of the column published in the JDD. However, the fact of “postponing scheduled operations which are already in a certain emergency can impact the vital prognosis of patients”, underlines Benjamin Davido.
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For the moment, “the difficult choice of waiting 24 hours before operating on a young accident victim to take care of a Covid patient does not arise”. What will it be in two weeks? “Since mid-March, the sick have been piling up,” he worries. “We don’t know how far it will go! It’s a never-ending day. “
“There will be no abandonment”
On the side of emergency doctors or resuscitators, some do not approve of the warnings published this weekend. Tribunes “alarmists”, “blows of communication” … tackle Patrick Pelloux, president of Amuf, association of emergency doctors in France. “We are on a high plateau, our activity is constant with a small increase but, roughly speaking, we are getting there,” he assures us. “The situation is serious, but it is not catastrophic,” confirms his colleague Christophe Prudhomme, doctor at the Samu in Seine-Saint-Denis and spokesperson for Amuf. In intensive care units, “we are not yet sorting it out,” also notes Eric Maury, president of the French-language intensive care company, who works at Saint-Antoine hospital (AP-HP). “The situation is very tense, but it is heterogeneous. “
How then to explain these divergent analyzes? The number of patients in critical care must be looked at in detail, underlines Patrick Pelloux. Of the nearly 5,000 people cared for in these services, “only 25% are in intensive care, with intubation and ventilator. All the others are in continuing care units which depend on resuscitators, but these are not resuscitations, ”says the emergency physician. And to assure: “There will always be a doctor at the foot of the patient. There will be no abandonment. “
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Sorting patients is the daily lot of emergency physicians, also recalls Christophe Prudhomme, who is annoyed to see AP-HP crisis medical directors are alarmed at this time about a situation that his union describes for fifteen years “. “Yes, the situation is tense and we are increasing the number of beds over time. But above all, we lack personnel. If they (Editor’s note: the editors of the JDD forum) had doubled the number of interns trained in intensive care, if we had opened these positions to young people in November, as we had requested, things would be better, ”he retorts.
Eric Maury, the resuscitation teacher, fears above all that these warnings “worry the public”. “I don’t think it’s very wise,” he blurted out. “The situation is difficult enough not to add more,” says Christophe Prudhomme. For the emergency physician of Seine-Saint-Denis, we must be careful not to further stress the population. “There is an increase in heart attacks. Last night, I had more heart disease than Covid, ”he notes.
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