An interview rich in polemical little phrases. In his long interview with the readers of Parisian, Tuesday January 4, Emmanuel Macron first declared that he had “very want” “to piss off” “the unvaccinated”. The head of state also taxed “antivax” to be irresponsible, adding that“an irresponsible person is no longer a citizen”. A third statement by the President of the Republic on the subject of the Covid-19 epidemic attracted the attention of franceinfo.
The head of state said that despite the influx of patients, hospitals had not had to sort patients since the start of the health crisis. “Sorting makes sense. It means that someone arrives at the emergency room and we say: ‘No, we are not taking it’. It’s a red line for me”, said Emmanuel Macron, assuring : “We have never been confronted with this. Today, there is no sorting.” But is he saying true or fake?
“Sorting” is a word in medical vocabulary which refers to a common practice which caregivers point out that it does not have the same meaning as in everyday language. It is above all a question of defining who are the priority patients, by evaluating the benefit of a treatment, as explained by Jean-Michel Constantin, head of the anesthesia-intensive care unit at the Pitié-Salpêtrière hospital. “There is always some sorting in intensive care, because resuscitation is very trying. It is only worth it if there is hope of a return to a satisfactory state. bet.”
For Jean-Michel Constantin, it is above all a question of not going against the interests of the patient. “We are more willing to bet on a 15-year-old than on an 80-year-old with a metastasis. Medically, we can call it ‘sorting’. But to get out of medical jargon, we can call it ‘prioritization’. “
“I think it’s not a chance to come and die in intensive care. I sometimes turn away patients, even though I have four free places, because there is no chance of improvement.”
Jean-Michel Constantin, head of the anesthesia-intensive care unit at Pitié-Salpêtrièreto franceinfo
The triage of patients in the hospital is based on medical criteria, in order to make the best decision for each case. Bruno Megarbane, head of the medical intensive care unit at Lariboisière hospital, reminds us of the importance of not practicing harsh therapy. “Historically, in intensive care, we have made a sorting based on medical criteria. We have very powerful medical means. But they should only be applied to people who have a chance of survival in good condition. , some could survive, but bedridden or amputee. “
Even before the start of the Covid-19 epidemic, the reduction in the number of hospital beds was already forcing the intensive care services to sort their patients, recalls Djillali Annane, head of the intensive care unit at the Raymond-Poincaré hospital. from Garches. “It’s everyday life, it’s something that we manage outside of the pandemic. In winter, in Ile-de-France, when there are very severe flu, we are often confronted with situations or more requests than available beds. So we spend our time, as resuscitators, to rationalize the admission in intensive care, because it is a scarce resource. “
“When you have a bed available for three resuscitation contenders, you have to choose. If the resource is scarce, you have to choose.”
Djillali Annane, head of the intensive care unit at Raymond-Poincaré hospital in Garchesto franceinfo
The influx of patients caused by the health crisis has put pressure on the resuscitation services and led doctors to triage even more strictly. From the start of the epidemic, in March 2020, recommendations were issued by Ile-de-France Regional Health Agency (ARS), through the French Society of Anesthesia-Resuscitation and the Army Health Service, over there National health conference (PDF) or by the National Consultative Ethics Committee (PDF).
“The medical criteria for admission to intensive care were a little more stringent than usual, relates Bruno Megarbane. The patients who were refused had extremely high risk of mortality and instead received palliative care. Normally they might have been taken to intensive care. “
At Pitié-Salpêtrière, Jean-Michel Constantin assures us, however, that, since the start of the epidemic, no patient for whom resuscitation represented a medical benefit has been ruled out. “I think we can say that we never needed to sort outside of medical criteria for the benefit of resuscitation”, he assures.
“In all honesty, I was able to treat all those who had to go to intensive care. There was no triage in the sense that people who should have had the chance to be resuscitated but were unable to do so. ‘to be.”
Jean-Michel Constantin, head of the anesthesia-intensive care unit at the Pitié-Salpêtrière hospitalto franceinfo
The Civil Hospitals of Lyon also told franceinfo that no sorting of patients with chances of survival in good condition has been carried out there. “There has never been any sorting out of patients, whatever the waves, whether in critical care, medicine or emergency. In intensive care, we have always had beds ahead in the region, allowing us to cope. “
At national scale, Emmanuelle Durand, doctor in the anesthesia and intensive care unit of the University Hospital of Reims, estimate that “sorting has been reduced to a minimum” and that“‘there was very limited damage”. If a drastic sorting could be avoided, it is thanks to “a very, very strong mobilization of the hospital from the first wave”, judge the vice-president of the National Union of hospital anesthetists and resuscitators extended to other specialties (SNPHARE). The caregivers did not count their hours and gave up their leave, the students and reservists were called in as reinforcements, others working in areas more spared by the epidemic went to lend a hand to their colleagues in the lesser regions. most affected … In addition to this considerable effort, “a huge deployment” of means and a “large organization” at national scale.
Resuscitation places were created from scratch, converting hospital services. From 5,080 intensive care beds at the end of 2019, the public hospital rose to 10,705 at the peak of the first wave on April 15, 2020, according to a Senate information report (PDF). Transfers of patients by TGV or by plane have enabled hundreds of patients hospitalized in saturated hospitals to be cared for in intensive care units in other regions.
Overseas patients have been transferred to France from Reunion Island (in March 2021) or Polynesia (in September 2021). French caregivers also responded by dozens to the call for national solidarity, leaving to lend a hand to their ultra-marine colleagues, in August 2021 in particular. Several hospital practitioners interviewed by franceinfo believe, however, that the situation has been even more critical overseas.
“We are no longer saving people in a disaster medicine, except what is savable”, “with a sorting of patients”, told in August 2021 on franceinfo the emergency physician Olivier Bertet from the CHU of Fort-de-France (Martinique). The influx of patients was “so huge” that caregivers had to “install up to 17 people on stretchers outside, without oxygen because we had no more bottles”. The doctor also explained that the “age limit for access to intensive care (…) goes down more and more”, “to 60” year.
Same tension at the same period in Pointe-à-Pitre (Guadeloupe). Marc Valette, head of the intensive care unit at the University Hospital Center, told Franceinfo the “prioritization of patients”. “We are forced to do so, it is part of the disaster medicine that we are obliged to practice, because we no longer have places available in the territory, despite the fact that we have tripled our places in intensive care.” The doctor confided in trying with his colleagues to “take the least bad decisions, which remain inhumane, since they lead us to prioritize the patients who are most likely to come out”.
To cope with the epidemic, the hospital has for two years been forced to carry out another form of sorting: a selection between Covid-19 patients and others. Wave after wave, the health authorities had to decide to deprogram consultations and operations deemed non-urgent, in order to free up space in the services. “If the hospital holds, it is at the cost of numerous deprogramming”, underlined at the end of December on franceinfo Frédéric Valletoux, president of the Hospital Federation of France and Agir mayor of Fontainebleau (Seine-et-Marne).
In March 2020, while France was undergoing its first wave, the Ministry of Health ordered the first deprogramming. A year later, in March 2021, faced with the third wave, the ARS of Ile-de-France decided to deprogram 40% of the interventions, then 80%. The scenario is repeated with the fifth wave, in Marseille. “Deprogramming is the only way to accommodate people with Covid-19, and especially those with serious Covid who go to intensive care”, explains to franceinfo Jean-Luc Jouve, president of the medical commission of establishment of the Public Assistance-Hospitals of Marseille (AP-HM). “For very serious and vital pathologies, for the moment, we manage to operate on things that are urgent, that is to say, accidents, trauma, oncology, heart problems or acute neurosurgeons. has patients who will not be able to wait all the month of January for an operation. “
Delays in cancer diagnosis and treatment, postponement of orthopedic surgery operations … These deprogramming will not be without consequences on the health of the patients concerned, warn hospital practitioners. There are “inevitably, for some of these people, risks of loss of real chances that one does not measure well, but which nevertheless will weigh and which are in the daily newspaper of many French”, recognizes Frédéric Valletoux. “We now find ourselves confronted with a situation where we are unable to resume the course of things and we have patients whose state of health is worsening and that we are not able to take care of in the right ones. time limit”, confirms Emmanuelle Durand.
A British study published in November 2020 in the British Medical Journal (in English), analyzing some thirty published works, had calculated that each month of delay between the diagnosis and the start of treatment led to an increase in the risk of mortality of 6 to 8%, depending on the type of cancer. The president of the National League against cancer, Axel Kahn, had estimated, in view of the work, that in France, this represented an excess mortality of at least 13,500 deaths in the next five to six years.