Gérald Kierzek is an emergency physician and health columnist, notably at Coronavirus, how to protect yourself? (Archipelago editions, March 2020).
FIGAROVOX.- Is reconfinement the inevitable result of a lack of resuscitation beds?
Gérald KIERZEK.- The number of intensive care beds is one of the important indicators, but it is not the only one. Why? Because the care of patients has changed, and we know how to treat them earlier. It is therefore a bad indicator. Where the Head of State is right is that we cannot have enough resuscitation beds for all patients. But where we are wrong, it is that we do not only need intensive care beds but also conventional hospital beds, or even patient care capacities before resuscitation! And not only in the hospital, we can also imagine oxygenating patients at home … there are other ways to take care of them, as long as they are treated quickly, at the very beginning of the infection. Emmanuel Macron’s presentation of the hospital situation is therefore biased and loses sight of the overall healthcare capacities that we should put in place to deal with this second wave.
The President of the Republic also explained that we were short of personnel, and that it takes five years to train nurses in intensive care …
It is true that we do not train resuscitation staff in a few months. But we could organize the services differently: rather than putting in the same team five resuscitators, we can split up the service by separating the specialists and placing around them interns or non-specialized nurses, but coached by the resuscitator. The number of resuscitation teams would thus be multiplied accordingly.
We are not taken by surprise, we are simply structurally deprived.
But again, the problem isn’t just resuscitation: the reasoning is wrong. We hide the fact that we could open other beds, with less trained staff, where the only care to be administered would be oxygenation and cortisone. I would not want the debate on resuscitation to obscure the reality of the crisis: it is a crisis in the capacity of our hospitals, as much or more than an epidemic out of control. We are not taken by surprise, we are simply structurally deprived. We are paying the price for a critical shortage of beds and places in our emergency services (including to accommodate patients with other pathologies). The hospital is undersized and to date, it is no longer the non-Covid patients who are a problem for us and have no place in the downstream hospitalization services!
“Our strategy was to control the circulation of the virus by relying on our capacities to test, alert protect” Emmanuel Macron said, adding: “We did everything possible”. Is this your opinion?
The last few months have been a failure, firstly because we have not restored the resources to the hospital. Countries which have never confined their population (South Korea, Japan, etc.) have a number of hospital beds per inhabitant two or three times higher than ours. We cannot overlook this link between hospital capacity and mortality.
We have a diagnostic strategy, but not a preventive screening strategy.
Then the test strategy fails. The president is right when he says that we test more than our European neighbors, but we test very poorly: the labs are clogged, and the test results are too late. We need a “point of care” preventive testing strategy, that is to say in direct proximity to people, in companies, faculties, public places… and rapid tests. This is the only way to detect patients before they infect other people. South Korea and Japan had the right strategy: they implemented efficient and rapid tests across the country. If we do not implement this strategy at the end of this new confinement, we will only have to prepare for a third confinement. These tests exist, they are not used and we are chasing the virus.
We are paying for the lack of a real screening strategy: we have a diagnostic strategy, but not a preventive screening strategy.
What is the difference?
The diagnosis consists in identifying the pathology from which a person is affected who already presents the symptoms and who has already had time to infect all his relatives: it is too late! Ultimately, it does not matter whether an individual is positive or negative once he has been in close contact with other individuals for several days when he already had symptoms. What is needed is to screen positive individuals upstream, with preventive tests carried out on non-symptomatic people before they go to university or to their workplace, this is what should be done. meaning.
Would a strategy based on collective immunity really cause, as the president claims, 400,000 deaths?
It is a mathematical modeling carried out by scientists who make calculations on the basis of fragile assumptions, and who have said everything and the opposite of everything. This figure seems to me to be questionable but above all it is unverifiable: since the confinement will break the chains of contamination, it will be easy then to say that it is thanks to the measures of the government that the disaster was avoided.
The WHO does not recommend confinement as a first measure, on the contrary, emphasizing its major side effects.
What bothers me is that no government study is done to verify the impact of the decisions taken (curfew, confinement), even though interesting models have been designed at the international level. They show that what determines mortality is not first of all the decision to confine the population or not, but the state of health of the population: in France or in the United States, the population is elderly and the cardio risks. -vascular are numerous, hence fragility and therefore a high mortality rate. Moreover, the WHO does not recommend confinement as a first measure, quite the contrary, by emphasizing its major side effects. But it is a measure of last resort, emergency.
Emmanuel Macron has however ruled out a targeted confinement of the most fragile people …
No, not by confining them, but by targeting them with a massive screening strategy, twice a week for example with a rapid test and immediate result. In an nursing home, this would make it possible to isolate a patient before he can contaminate the entire establishment. Ditto in families in which the elderly live. Grandchildren could thus be tested before going to visit their grandparents, for example. But undoubtedly it is too late now: only, we should have implemented this strategy when it was time. These tests exist and are ready in sufficient quantity.
The crisis has suffered from particular prisms, almost from lobbies: doctors-resuscitators, biological analysis laboratories … have demanded to retain the monopoly of the health response to make the means they have implemented profitable, but they are not yet not the only players to be deployed: patient care and the testing strategy could be conducted differently. The challenge now is to organize the next six months to succeed this time with the exit from containment and not to make iterative “stop and go”; rapid tests and hospital capacity are the two essential levers to also give hope to the population.
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