French Pandemic Resistance

To rapidly communicate short reports of innovative responses to Covid-19 around the world, along with a range of current thinking on policy and strategy relevant to the pandemic, the Journal has initiated the Covid-19 Notes series.

“It is as if we have transformed the hospital to prepare for a kind of siege. The only certainty is that the wave is coming,” Jean-Paul Fontaine says. He is the head of the emergency department (ED) at Hôpital Saint Louis in Paris. In November 2015, the hospital’s ED and intensive care unit (ICU) were inundated with victims of the terrorist attack that happened here (www.nejm.org/doi/full/10.1056/NEJMp1515229). Now, they are inundated with patients attacked by a different kind of enemy: SARS-CoV-2.

Fontaine’s role is to prepare for the arrival of patients with Covid-19 while overseeing care for the ED’s other patients. This task has required making architectural modifications, training personnel in procedures to prevent disease transmission, and establishing new roles and workflows. Crisis meetings take place daily at several levels — including meetings at the hospital and for the entire APHP (Assistance Publique–Hôpitaux de Paris, the network of 39 public hospitals in Paris). “An important task was to respond to requests for tripling of intensive care beds, but also relocation of several services,” Fontaine says.

Carl Ogereau was in charge of the ED on November 13, 2015, and managed care for the flood of severely wounded patients that arrived that Friday night. His current role is to quickly assess patients with Covid-19 and determine whether they need to be admitted to the ICU, while also overseeing the usual stream of referrals to the ED. During the early stage of the pandemic, everything in the ED was slowed down by the complexity of the necessary procedures and by the staff’s lack of experience with them. “At the same time, we were facing the unknown, about the disease, but also about the impact this unprecedented outbreak would have on any of us, including our colleagues, and the health care system at large,” Ogereau says. “For most of us, this has led to an unforeseen amount of stress, anxiety, and fear.” In 2015, the hospital was fully staffed within hours of the attack. Doctors on call and department heads had to come up with immediate solutions. The guiding principle was resilience. In 2020, the key word is creativity. “We literally had to create new departments, new roles, and new workflows. Although we had more time than in 2015, the changes had to happen at a much larger scale,” Ogereau says.

The number of surgical beds at Hôpital Saint Louis has been dramatically reduced, and the postoperative care room has been transformed into an ICU for patients with Covid-19. A surgical committee has to assess each procedure’s degree of urgency because only 2 of 14 operating rooms are available. All operations that are considered nonurgent are postponed indefinitely. Surgeon Paul Meria worries about the waiting list. “It is dramatically increasing and will cause problems after the pandemic,” he says.

Nevertheless, Meria is struck by a similarity between the events of 2015 and 2020: the outstanding solidarity of hospital employees. “All members of medical and nonmedical teams were involved in the management of the patients in 2015, and all of them are currently present to fight the epidemic,” he says.

Ogereau agrees. “Former trainees and colleagues are volunteering to help in our department,” he says. “Clinicians from all medical specialties are taking night shifts in the ED. Everybody wants to be a part of this, because it reminds us that we are a piece of something bigger than our department, bigger than our hospital: the health care of all.”

Ogereau is encouraged to see France’s shelter-in-place order starting to flatten the curve of new infections, and he hopes the burden will soon be bearable for the health care system. “However,” he says, “I am still very fearful about the coming weeks and months. This state of chronic anxiety is very different from what we experienced back in 2015. In 2015, there was stupefaction but no fear.” After the terrorist attack, he explains, the motto in Paris was “Tous en terrasse!” Social gatherings, including those in cafés and bars, helped people move forward after the crisis. Nowadays, the motto is “Stay home!” That is a much more depressing way to fight.

This note was published on April 22, 2020, at NEJM.org.