When hospitals are faced with an influx of patients, caregivers must make choices, in particular to filter access to resuscitation. A very supervised decision-making, but which can be trying.
Prioritizing patients, as is currently the case in Guadeloupe, strongly affected by Covid-19, is not a new practice. “As an intensive care anesthesiologist, from the start of our training, we are used to having to make choices when we have an intensive care unit where all the beds are full.“, indicates Julien Cabaton, general secretary of the national union of anesthesiologists and resuscitators of France (Snarf). But with the Covid pandemic, this prioritization of patients has intensified. “In intensive care, a number of criteria allow us to assess the balance between the benefit of being admitted to intensive care and the risk of being exposed to this stay and of undergoing heavy treatments., explains Professor Djillali Annane, president of the union of resuscitators (SMR). But here, it is very different, insofar as a priori, the benefit-risk balance of admission to intensive care is the same, it is simply that there is a place for two and that we must choose between the two.“
Mulhouse was confronted with this situation in the spring of 2020. Currently, it is in Guadeloupe and Martinique that caregivers have to face this alarming situation, which is akin to disaster medicine. “When there is a death, there are already at least two or three patients who would require resuscitation who are waiting, so we will choose the youngest or the one with the fewest comorbidities.“, tells a Guadeloupean anesthetist-intensive care practitioner, who prefers to remain anonymous. In his university hospital, the capacity of resuscitation beds has been pushed to its maximum: “refusing people of 60 years old just because they already have too many comorbidities, little hope of getting out, it’s really specialShe said.
The pandemic has revealed that our initial training, for us caregivers, absolutely does not prepare us for this type of crisis which leads to having to make choices between patients.
“We are very rarely faced with an ethical decision for lack of space», Analyzes Sébastien Rubin, nephrologist at Bordeaux University Hospital, who came to assist in intensive care in Martinique. “In metropolitan France, we have enough flexibility to be able to find a bed“. Professionals had to deal with a lack of resources, with a saturation of resuscitation capacities. “In Guadeloupe, the current situation is very difficult because we all see a lack of material resources that weigh heavily on the care of patients.», Deplores Justine, a 21-year-old intensive care nurse, present on the island since August 13. “It’s catastrophic medicine, 40-year-olds die when they shouldn’t“, Breaths half-word Karim Mameri, nurse manager of health in Rouen, in charge of the coordination of the medical reinforcements in Guadeloupe during the last three weeks of August.
Lack of initial training
This prioritization of patients is all the more difficult to manage as almost all caregivers have never been prepared, during their training, for this possibility. Only a few university degrees dealing with disaster medicine mention this sorting aspect. “The pandemic has revealed that our initial training, for us caregivers, absolutely does not prepare us for this type of crisis which leads to having to make choices between patients.», Concedes Professor Djillali Annane.
To support decisions, which often have to be taken more quickly than usual, caregivers have benefited from the advice of their international colleagues, and ethical guides have been published. “In March 2020 the Italians were among the first to be confronted with the need to practice prioritization, analysis Emmanuel Hirsch, director of the space for ethical reflection in the Île-de-France region and professor of medical ethics at the University of Paris-Saclay. They shared their expertise and also benefited from the advice of their European colleagues.“. From April 2020, the French Society of Anesthesia-Resuscitation publishes a guide on the prioritization of resuscitation treatments in a Covid-19 epidemic situation, followed in October 2020 by the national health conference, which publishes a point of vigilance concerning the “patient triage practices“. Ethical observatories have also been created, as in Île-de-France, with a specific mission: to contribute to the reflection of professionals “by sharing with them useful knowledge in the field of ethics“, explains Emmanuel Hirsch. “In difficult contexts we can contribute to the argumentation and arbitration of their decisions“, he adds.
An experience acquired throughout the pandemic and which was useful in the management of the crisis in the Antilles. “In the event of a disaster situation, it is necessary to take a lot of caregivers, to lighten the professional burden of those who are confronted with these patients, considers Marc Gentili, anesthesiologist-resuscitator treasurer of Snarf, who arrived in Guadeloupe as reinforcement at the beginning of September. I believe that the organization set up in France is very good“. Despite this, Karim Mameri was able to observe that some members of the nursing staff who had come as reinforcements had not had “the necessary preparation“Despite their”great motivation to help“. In these periods of epidemic wave, caregivers from other services come to lend a hand in the face of Covid and must confront practices to which they are not used. “Resuscitation is a pretty tough world, you sometimes have to make choices, know how to let a patient go and it is not easy», Develops our Guadeloupean anesthetist-resuscitator.
Necessary psychological support
Prioritizing patients is never a trivial practice for caregivers. “It’s an emotional baggage that you have to manage with time and your conscience, it’s part of the job but it’s not always very easy to carry“, says Sébastien Couraud, head of the pneumology department at the Lyon Sud hospital, who has gone to Martinique as a reinforcement. Psychological support was therefore offered to caregivers who left for the West Indies. Medico-psychological emergency units (CUMP), made up of around ten professionals specializing in crisis and disaster management, psychologists and psychiatrists are deployed on site to support caregivers. “The CUMP is very present and intervenes very regularly with us, confirms Justine. We have a number that works everyday, if we feel the need to talk. ” Daily debriefings are also set up. “It’s essential, that’s how we manage to hold on», Considers Karim Mameri.
On a human level, it is a big hit and it changes us. We come back to France, not quite the same person as when we left.
Faced with this situation and this strong influx of Covid patients, returning to mainland France can be particularly difficult. “On a human level, it’s a big hit and it changes us, confirms Sébastien Rubin. We come back to the metropolis not quite the same person as when we left“. “We will all come back with images, sadness, vivid memories for us without this calling into question the decision.», Adds Sébastien Couraud. “There is a clear risk of post-traumatic stress», Estimates Karim Mameri. A reality already known by the first medical reinforcements sent there, and returned since in metropolitan France. “There, I was able to do things correctly, even though I cried a lot when I left the hospital. When I arrived in France, I was completely lost in the face of the world, the noise. I dread the resumption of my work», Testifies a nurse member of the medico-psychological emergency unit (CUMP).
A national listening cell has been set up by the CUMP of the SAMU de Paris, available by phone 7 days a week from 6 a.m. to 6 p.m. The General Directorate of Health also indicates that “the ARS are responsible for transmitting the contact details of the reinforcements in their regions upon their return to the departmental CUMPs who contact each of them to debrief their mission and offer appropriate support if necessary“. The association Care for health professionals (SPS) also ensures that it is taking care of some of the caregivers returning from the overseas departments and territories. “We will also set up a communication campaign there to communicate the association number (0805232336), the prevention actions and workshops that we will organize.», Specifies Pauline Dubar, spokesperson for the association.
Finally, vigilance indices must be taken into account to measure the mental health of the caregiver. “Sleep disturbances, loss of weight or appetite, repeated nightmares, startle response at least noise, loss of caregiving, listlessness or a feeling of guilt“Should alert, explains Michel Lejoyeux, psychiatrist at AP-HP and Psycovid referent. For Professor Djillali Annane, support for caregivers who have faced this pandemic must be long-term and special attention must be paid to caregivers in training in order to avoid “imperatively that they do not develop anti-health crisis antibodies“. After the first wave, caregivers turned away from intensive care units, never wishing to have to deal with these situations of saturation and choice among patients again.