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They were prepared, having reorganized the departments, studied the curves, and taken containment measures, but 15 days later, Benjamin Davido, MD, an infectious disease specialist at Raymond-Poincaré Hospital in Garches, Paris, and his team find themselves facing a catastrophe.
More than the lack of equipment or space in intensive care, it is the exhaustion of the staff, as well as the unexpected severity of the disease, that make them fear the worst.
What is the situation now?
It’s difficult, but for the moment we’re holding on. We are helped by colleagues whose workload is reduced due to the crisis, like surgeons or those who work in day services, but the difficulty of managing the growing influx of patients remains. We are lacking nurses, care assistants, doctors trained in resuscitation….
Are the “new” caregivers sufficiently trained?
No, and I find it hard to understand. It should have been done earlier. In Paris, there is a center that is supposed to do accelerated training for nurses, but I find it hard to imagine that in 3 or 4 days, you can train a nurse to be specialized in intensive care.
Of course, between having no one and caregivers who do the best they can, for sure it is better to be helped, but we are heading towards a gap in the quality of care as the crisis accelerates. The reality today is that we are reaching the saturation point with intensive care beds.
#COVID19 #coronavirus Audrey, interne, impliquée dans l’activité particulièrement importante ces dernières semaines du Samu 92. Elle participe à la régulation des appels au 15 et aux interventions de secours. Merci à l’ensemble des équipes mobilisées 24h/24 et 7j/7 ! pic.twitter.com/sQqBPioO8H
— Hôpitaux Ambroise-Paré et Raymond-Poincaré AP-HP (@Pare_Poincare) March 28, 2020
Did you not expect such a rapid saturation of the services?
Honestly, no. A month ago, I think that no one would have believed that this situation could happen in France. Now, all my colleagues are facing a daily increase in intensive care patients of 20%, and everyone has realized that we will inexorably reach saturation, given the average length of stay.
It has therefore become a disease of intensive care, no longer of infectious disease specialists or pulmonologists. And the intensive care specialists must decide who lives and who dies. This is a disease for which the treatment is the respirator.
What proportion of your patients go to intensive care?
In fact, you must be ready to determine whether the patient is very severe straight away. You should perhaps not admit them [to another unit] if there is a risk of them going to intensive care and they should not be moved. You should ask the question: Is this patient destined for intensive care on arrival? This is something we have never done with any other disease. We never decided, the moment the patients set foot in hospital, whether they were heading for intensive care or not.
When the patient arrives, even if there is a two in three chance that it will turn out well, we nevertheless immediately ask the family: “If they get worse and potentially die, do we resuscitate?” And the families of patients I have had on the telephone this week have fully understood the issue, that this is a serious illness.
Much has been said of it being “flu-like,” but once they are in hospital, patients are well aware of the reality. It is clearly a viral pneumonia, but with a degree of severity that we have never seen before and that spares no one. The day before yesterday, I brought a 35-year-old man to intensive care who, after 36 hours of hospitalization, required ventilatory assistance.
What about the belief that the young are not at risk, that it’s only older people and the frail who are vulnerable?
It was the interpretation at the time to reassure us. Obviously, nature abhors a vacuum, and overall, it’s the elderly and the frail who pay the price of this disease, like any other disease (cancer, etc). It is obvious, and we get the same advice for the flu, which kills vulnerable people more easily.
But at a certain point, once the disease has decimated the most vulnerable, it will affect the young, as there is no herd immunity. They are a little more durable, but some (probably due to a cytokinetic storm, like a severe lightning strike) will not be spared. The lethality is clearly much less in those aged less than 40 years (0.1%), but one in 1000 in people under 40 is not at all consistent with a benign disease!
The whole spectrum of age ranges in the population is affected, to different extents. And that is something that we cannot absorb in terms of the flow of patients. Especially as the mortality rate in intensive care is 40%.
What worries you the most as the crisis unfolds?
Beyond the number of beds and the lack of equipment — I expect some colleagues will do what was done in Italy and use one respirator for two patients — at a certain point we will not have enough human resources. Because resuscitation, the care of severely ill patients, dialysis, and monitoring the ventilation machine cannot be left to chance. It requires several years of training.
Professionals also fall ill. For now, the cases among the caregivers are more benign, but that creates absenteeism. The medical staff are not invulnerable to this disease, and you can imagine, in a catastrophic scenario, the more the epidemic advances, the more we will have some among the reserve of caregivers who will say, “I don’t want to come because I’m scared.” We hear that already a little.
Physically we can, in intensive care, admit more patients. But to open these beds, we need not only the machines but also the human resources. If I am told that we are capable of doubling or tripling the capacity, I’m not sure that we are capable of tripling the human capacity without considering the fatigue of caregivers, some of whom work almost 1 day in 3, day and night.
I witnessed terrible scenes in the hallway of a patient who was being resuscitated and another who had just died. For intensive care specialists, it’s very hard on their morale. We know very well that we still have several weeks, maybe months. I am therefore worried for our team and for the teams of colleagues in intensive care at the end of the epidemic.
So the models and projections for organizing the fight against COVID-19 do not match up to reality?
Exactly. A team from Rennes published estimates of the number of severe patients who will need critical care in mid-April based on mathematical models. But already we are not very far from those figures, maybe several days ahead of the projections.
We thought that, thanks to the lockdown, we would probably be in the optimistic scenario for the epidemic — because this is how we think in mathematics: a catastrophic scenario and an optimistic one. But now I think we are very close to the catastrophic scenario.
We are still only at the beginning of the wave, and mathematics cannot tell us everything, but the latest estimates for Île de France [the region around Paris] were 4000 cases at the peak of the epidemic. And today we are at almost 1500 severe cases, while the capacity in Île de France is estimated at around 1600 critical care beds. If we end up in this catastrophic scenario, we wonder how we will manage the delta of 2000 patients….
We were told we should flatten the curve to prepare, but unfortunately, the preparations were not enough, the equipment is not there. We are starting to recover the stock of masks, but we find that we no longer have enough swabs to do screening, that we have no more scrubs….
On the other hand, what we do have is a little more ingenuity; we reflect daily on the situation. That’s my hope. And that’s also why we should make more therapies available that could be used upstream, whether hydroxychloroquine and azithromycin or another treatment.
Translated and adapted from Medscape’s French edition.