in intensive care, the fear of sorting between patients

On the crisp white sheets, someone has placed a skein of pipes, a nasal mask, a digital sensor, which, installed at the tip of the finger, will allow the oxygen level in the blood to be measured. On the left, a respirator and syringe pumps. On the right, control screens. And a great silence. Like the calm before the storm.

Empty beds like this one, equipped and ready to receive patients in intensive care, there are five left, this morning of November 10, at the Grenoble University Hospital. Five boards of salvation, to continue to stem this second wave which does not weaken. Normally, the service, located in front of the mountain, at 9e floor of the CHU, specializes in “cardio thoracic and vascular” resuscitation, but the coronavirus pandemic “Turned everyone into covidologists”, notes Pierre Albaladejo, deputy head of the anesthesia-intensive care unit at Grenoble University Hospital. While a peak of patients is expected for November 15, a fear already hovers: not being able to welcome everyone, being forced to choose between patients. Sort, as on a field of war, or in disaster medicine.

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These painful arbitrations must have already been carried out in the spring in certain hospitals in the Grand Est and Île-de-France, submerged by the first wave. Within the hospital system, the injury remains acute. ” I’d rather not talk about it “, entrusted to The cross caregivers having been confronted with it.

Choose: the intensive care routine

Today, it is in Auvergne-Rhône-Alpes that some doctors are holding their breath. Refusing patients, choosing who will be accepted or not: this is however the daily life of resuscitators. “I have the impression that during this crisis, the general public is discovering our profession and these ethical dilemmas, says Professor Albaladejo. We refuse sick people every day, Covid pandemic or not. »

It tells about the ethical reflection carried out before any admission to intensive care and which is essentially based on a question: what is the benefit / risk ratio for the patient? “A passage in intensive care is a heavy procedure, explains the practitioner. The devices that surround the patient are invasive. At such times, the body struggles to survive. “ Not everyone is able to endure the ordeal.

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Standing in a corridor, in front of a patient’s room, Deborah, nurse’s aide and Julie, nurse, confirm. They who know the sick closely, touch them, accompany them on a daily basis, whether they are conscious or not, know that“We do not come out of resuscitation unscathed”.

The sequelae can be physical: muscle loss, difficulty walking, undernutrition, neurological damage. They can be psychic too: many patients suffer from post-traumatic stress disorder – anxiety, feeling of abandonment, feeling of black hole. The recovery is never a given. “Leaving the sheave does not mean going home. It takes several weeks of rehabilitation and re-education ”, assures Deborah. “Entering intensive care is only the start of a long marathon”, summarizes Pierre Albaladejo.

The fear of being overwhelmed

What has the Covid changed? “It weakened a system that was already subject to strong constraints”, continues the doctor. This Tuesday in November, 18 of the 25 beds occupied are occupied by Covid-19 patients, who, on average, stay three weeks in intensive care. Among them, two men, 72 and 73, in an artificial coma, admitted ten days ago. Or a patient, in her fifties, lying on her stomach. A position, the prone position, which aims to improve oxygenation of the lungs and must be renewed every 16 hours and can mobilize up to six people. “Last week was… complicated, soberly tells Deborah. We had a lot of entries, a lot of deaths. “

“So far we are holding, assures Professor Albaladejo. But the question is: what will happen in the event of overflows? ” It is not so much the lack of material that worries him. “The stock of respirators has been built up. The hospital is able to push the walls. Five new beds, in addition to the existing ones, are ready to be rearmed if necessary. The limiting factor will be the staff. Resuscitation requires specific skills. However, the teams are exhausted. “

Move from clinical criteria to logistics criteria

What he fears is having to select patients not only on clinical but also logistical criteria.. The question then becomes: who will the available resources benefit the most? An alternative that undermines equitable access to care. Concretely, the refused patients will be directed to other services, where they can receive oxygen and corticosteroids. The most serious cases could be referred to palliative care. Choices badly experienced by doctors because they constitute a loss of opportunity for patients who, under other circumstances, could have been admitted to intensive care.

Ethical conflicts that Bertrand Guidet, head of the intensive medicine-intensive care unit at Saint-Antoine hospital, in Paris, understands well, and who, in March, wrote recommendations for good practice. “We can favor two approaches. The first is said to be egalitarian: a life equals a life, there is no reason to favor one person over another. ” So much for the general principles. Except that…. “In a context of shortage, how do we do it? constate Bertrand Guidet. You only have one bed and a mother of three and an 85-year-old man arrive. Are you going to draw lots to respect the principle of equality? Obviously no. You will admit the young woman! Not because her life is worth more, but because she is the one who will benefit the most. “ It is the “utilitarian” approach: to allow the greatest good to the greatest number, by saving those having the greatest chance of survival.

Criteria on which to rely

What are the criteria? Age? “He cannot be the only factor”, defends Bertrand Guidet. To help the decision, the learned societies invite to weigh in the balance three ethical principles: the collection of the patient’s wishes (what does he want? Has he drafted advance directives?); the seriousness of his situation (is his vital prognosis engaged?); and his history (does he have any other disease?).

The decision is always taken collegially, by at least two doctors. And each case can be reassessed over time. “A patient admitted to the sheave can leave it and a patient who was initially refused can finally be admitted”, specifies Doctor Potard, the regulatory doctor at the Grenoble University Hospital. Which does not prevent doubts. “We never know if our decision was the right one”, he nuances.

At Grenoble University Hospital, we hope not to have to come to this. But the noose is tightening. “We are surrounded by Savoie and Loire, two departments where the virus circulates a lot”, specifies Pierre Albaladejo. Who is worried about the morale of his troops: ” We are at the maximum of what we can do, respecting the standard. If the service was forced into difficult arbitrations, it will have an impact on the teams. There will be resignations. “

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The “sheave” in France

4,803 patients with Covid-19 were, as of November 11, in intensive care, intensive care or in a continuous monitoring unit.

2,906 new hospitalizations in intensive care were recorded over the last seven days.

5,800 intensive care beds are officially available in France. There were 5,100 before the start of the pandemic, increased by 700 since the spring. Each hospital is able to increase its reception capacity. On October 28, Emmanuel Macron announced his intention to carry the capacity ” over 10,000 beds ”, without specifying a timetable.

The intensive care occupancy rate is 94.7%. This rate is calculated on the basis of the initial capacity of the beds, that is to say before an increase in resuscitation capacities.

The deprogramming rate of operations currently stands at 40% at the national level.

Sources: Public Health France, Ministry of Health, Fédération hospitalière de France.

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