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How is the sorting of intensive care patients carried out, so dreaded by caregivers?

Caregivers, who are facing a very violent third wave, fear that they will soon be forced to sort through eligible patients for intensive care. – Eric Dessons / JDD / SIPA

  • With hospitals on the verge of saturation, more and more caregivers fear they will not have the capacity to accommodate all the patients who would need to be admitted to intensive care.
  • Many are already preparing to perform a “triage” between patients and fear it.
  • But how is this “sorting” carried out, on what criteria and with what consequences?

Will it be necessary to go through new restrictive measures to stem the third wave of Covid-19 which is currently unfolding? While the Head of State is expected to pronounce this week on the issue, many caregivers fear that they will very soon be forced to “sort” eligible patients in intensive care, as the pressure of the epidemic is strong and saturated hospitals.

The highest medical officials of the AP-HP alerted Sunday to the growing risk of “overflow” of Paris hospitals, where doctors are preparing to no longer be able to practice “disaster medicine” and “to sort out Between patients. 20 Minutes explains what it would consist of.

Sorting between all patients, Covid and non-Covid

“This sorting will concern all patients, Covid and non-Covid, in particular for the access of adult patients to critical care”, indicate in a column published by the Sunday newspaper 41 AP-HP crisis medical directors. This prioritization “consists, when there is only one resuscitation bed available, but two patients can benefit from it, to decide which one will be admitted”, supports in The world a group of nine resuscitators.

“The purpose of this forum is not to panic the populations, but to inform about the reality of our daily life: we are today in a third wave different from the two previous ones, with patients much younger and without comorbidities, and a fairly aggressive disease, ”explains 20 Minutes Prof. Elie Azoulay, head of the intensive care unit at Saint-Louis hospital, in Paris. If in normal times, “the prioritization is already in the identity of the resuscitators, it is a medical decision taken in the best interest of the patient. There are several factors, age is one, but it is not the only one: we have 80-year-old patients in good health. There are also the co-morbidities, the patient’s autonomy and his life expectancy in good health at the end of his passage in sheave. We have the duty not to do harsh therapy on a patient at the end of his life for whom resuscitation has nothing to offer ”.

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On the other hand, “to have two patients eligible for intensive care and to arrive at a” sorting “ordered by the sole lack of beds, that, the caregivers die psychologically at the idea of ​​having to do it, breathes the resuscitator. Without forgetting that in reality, it is not only the Covid-19: they are also heart attacks, strokes, road accidents: patients who must be taken care of, recalls the resuscitator. Fortunately, for the time being, we have not had to do this in my hospital since the start of the pandemic, and that is precisely what we want to avoid. But how long will we get there? “

“Sorting has already started”

But in practice, “the sorting of patients has already started apart from resuscitation with the massive surgical deprogramming which has been decreed, underlines Dr Benjamin Davido, infectious disease specialist at Raymond-Poincaré hospital in Garches (Hauts-de-Seine) and signatory of the platform. And it will intensify: in the hospital where I work, there was a crisis meeting to discuss the closure of one or even two operating theaters, which would amount to deprogramming all of the planned surgical interventions. This means a loss of opportunity for the other patients who are forgotten in this pandemic, with a stake in their prognosis. And that is a sorting, where we can no longer treat life-saving emergencies, and it’s disturbing, ”regrets the infectious disease specialist. “Non-Covid patients are therefore also the victims of this health crisis,” says Prof. Azoulay. Cardiovascular diseases, cancers, infectious and inflammatory diseases: we are missing out on all of this and falling behind schedule for the months and years to come. Today, we allow the emergence of diseases for which we will still have repercussions in five years ”.

And in Garches, “the hospital pressure is increasingly strong and extremely distressing,” says Dr. Davido to 20 Minutes. Because we are no longer in the situation of the first wave, with a strictly confined country, and spared regions which send us caregivers as reinforcements. Today, the virus is everywhere ”. And press a little more on the reception capacities. “In my department, the 25 beds are all occupied, so I can no longer accommodate other patients. And I am already observing my resuscitator colleagues making choices between patients ”.

“We have almost no room for maneuver”

And the next few days do not bode well. “Contamination continues and accelerates, with nearly 42,000 new cases as of March 26. When we know that up to 5% of Covid patients end up in intensive care, we can imagine that hospital pressure will increase, insists the infectious disease specialist. With a hospital saturation rate well beyond 100% in Ile-de-France, how are we going to manage the patients who flock to the emergency room? Because in practice, if tomorrow, we have a 30-year-old victim of a road accident, a 45-year-old patient with a myocardial infarction and a 40-year-old Covid patient: if we don’t have any left – like today – only one resuscitation bed, which one will we choose among the three? Will we be able to find another bed in another hospital 10 or 100 kilometers away? And when you no longer have room for a myocardial infarction because the cardiology department has been transformed into a Covid unit, in fact, this leads to a loss of opportunity for other patients. The quality of care is necessarily impacted! We have almost no room for maneuver ”.

Because in one year of the pandemic, “the hospital system has not developed further: we have not recruited more nurses and doctors, reinforcements are less available, patients are more transferred, and we find ourselves in a much more constrained situation, notes Professor Azoulay. If we arrived at the figures for last April, it would be very hard, and that would be accompanied by an undue number of deaths, ”he fears.

Sorting, “a red line” for Bruno Le Maire

This fear of caregivers, the government claims to hear it. “We are all touched, overwhelmed by what we see as testimonies of caregivers, doctors, in front of the difficulties which are theirs, in front of the increase in the number of cases in intensive care (…). There is an absolute red line, it is the sorting of the sick, ”said Tuesday the Minister of the Economy Bruno Le Maire on RCJ radio. “We certainly do not want to reach a point where hospital staff would be forced to sort out the sick,” he insisted.

But with more than 4,970 patients in intensive care on Monday, the peak of the second wave has been exceeded in France and President Macron could announce a new turn of the screw this week. “We caregivers and signatories, what we want is not a strict containment, it is that people contaminate themselves as little as possible, whatever the measures in force, because it is clear that those that are valid today are not effective, ”insists Dr Davido. “A drug has a risk-benefit ratio, and a political decision too,” adds Professor Azoulay. The caregivers do not intend to influence the political decision: we are whistleblowers ”.

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