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Dr. Xavier PUECHAL
Internal Medicine, Cochin Hospital
At the hospital, it's become very difficult, I won't hide it from you.
I understood early in the afternoon of Sunday, 15 March that the French health system had just exploded in Mulhouse and Colmar, from where we received the first distress messages. Insurmountable choices had to be made concerning COVID-19 infected patients, to decide who would or would not be accepted for resuscitation. There were no more vacant beds to accommodate patients, caregivers were totally overwhelmed, equipment was lacking, and minimum care could no longer be provided. A war situation was developing. The dedication of the teams was tremendous, but the wave was too violent, too sudden and took everything away.
The reacting team, whose mission is to prepare and coordinate research to deal with epidemics, already had this information. It took another 48 hours for the official start of confinement on March 17 at noon.
So, we knew that the wave was coming to Paris. We worked hard to prepare to receive COVID-19 patients requiring hospitalisation, i.e. the most seriously affected. It was also at this time that we began to admit COVID-19 patients into the department.
Our department is a very large Internal Medicine unit with five wards of approximately 18 beds each. We usually take care of complex pathologies (systemic diseases affecting several organs) in patients who are often immunocompromised by disease and treatments. We also provide support for emergencies. We are extremely well equipped medically, with about fifteen senior staff members of an exceptional level of competence, and as many interns.
The arrival of the first patients was accompanied by a steep learning curve. This is a new and highly contagious pathology, which requires great rigour in order not to risk contracting the disease. The patient must be isolated in a dedicated unit, from which the other patients must be evacuated. To enter an infected patient's room, it takes almost ten minutes to get dressed (in addition to the paper pyjamas we wear), cover our head and hands, put on glasses, a smock, etc. Above all, on leaving, we must not contaminate the whole unit or our colleagues. We have created and posted a video on clothing for colleagues so that everyone can save time in learning. There is a need for specific equipment to be left in the rooms, which becomes exclusively for individual use (which therefore requires being present in large numbers) such as devices to measure the oxygen saturation of the blood, reflecting the efficiency of the lungs to properly oxygenate the organs.
The monitoring of patients must be rigorous because this disease is characterised by a very speedy degradation that can, in only a few hours, impose resuscitation (to be able to be ventilated) for a patient who was well only a few hours before. This monitoring requires a large number of staff, continuous attention from doctors, and the ability to make emergency decisions.
The workload is therefore considerably heavier than the management of regular patients. The medical and para-medical teams must be approximately doubled on a weekly basis.
The increase has been so rapid that crisis meetings are held twice a day to take stock of the number of patients, available staff, equipment to be requisitioned, and schedules. We also quickly had to double and then triple the number of senior staff present at weekends, requisition five interns in other departments and organise ourselves. We plan to create an additional night senior medical guard just for our building and the COVID-19 patients.
From the outset, we had to deal with patients who were in a very serious condition but could not be taken into intensive care, providing end of life support for them and their families. This is difficult enough in all cases, but when patients are isolated, it makes things even more complex. We have to help family members get dressed to go into the room, which is a long process. Theoretically, there can't be more than one person with the patient at a time, but it is very difficult for families not to be together when someone is dying. When time is short sometimes exceptions need to be made.
Patients are very anxious, which is normal, especially since we drastically limit visits. They probably also feel the tension that has invaded the medical, nursing and caregiver teams at the same time. So, support is also at the forefront and we devote a lot of resources to it.
We are having to juggle a rapid increase in the number of COVID positive patients. We decided that part of the service would continue to operate for the patients that we normally serve and that we would gradually open the remaining wards to COVID-19 patients.
It's not easy as a team when you can't physically get together anymore to avoid contamination. It requires computer resources that we didn’t have and that are being installed in an emergency. We currently have two telephone meetings a day where the entire medical team of the department and the interns (about 30 people in all) exchange information. We don't have webcams on our fixed computers and there is a stock shortage in France. These meetings follow the hospital's crisis meetings and the information is then shared immediately. For example, it was necessary to triple the number of resuscitation beds in the hospital by equipping other structures and requisitioning personnel capable of performing resuscitation.
Intensive Care Units are always the first to be saturated because of the large number of patients to be ventilated, but also because patients may need to stay for many weeks, reducing normal turnover that even in viral infectious pathologies such as influenza, rarely exceeds a few days. In the ward, which was full as usual, we had to open 50 COVID beds in less than seven days. We will be one of the services in France to take care of the most infected patients. The situation is evolving at an unimaginable speed and what is true in the morning may have totally changed in the evening. Sharing live information is therefore crucial.
Another difficulty to overcome is that some of us are getting infected despite the precautions we take. We are not particularly afraid of this, but it does reduce the number of medical personnel who are able to care for patients. Already in our department, health professionals have been infected but are doing well. In Parisian hospitals over 350 personnel are COVID positive, with a couple in intensive care.
We have a very high level of stress which is difficult to bear on a daily basis. Our meeting room has been transformed into a relaxation area with mattresses to get some rest if needed, in limited numbers. A team of psychologists is also here for support.
Our usual patients are very understanding: we have had to transform all face-to-face consultations into teleconsultations, even though we are not well equipped.
Schedules went crazy. Our head of department is in at 5 a.m. and leaves at 8 p.m. He has a remarkable sense of organisation. At 7:30 in the morning the medical team has already exchanged about 15 emails. To give you an idea, last Saturday morning the first email from the head of the department to the various hospital services requesting equipment, and anticipating replacements to be made in the teams, was received at 7:30, meaning that he found time for this before the nurses' shift.
We know that the wave is going to become a tsunami in the coming days. All French private and public facilities will be admitting COVID positive patients because there will be no other choice. In Cochin, we have refused COVID-19 patients from other hospitals, explaining that every institution needs to take care of these patients now. We are doing what we can to save lives in the midst of this crisis and would appreciate the message to get through to the public that they must stay at home to help!
It's very tough. We know we will have to hold out for the long term when everyone is already very tired. But the medical teams, nurses and orderlies are wonderful and absolutely dedicated. There is a lot of great solidarity emerging and we can all be proud of that.
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