Containment, psychiatric patients and … a catastrophe that did not take place

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Containment, psychiatric patients and ... a catastrophe that did not take place





© ANNE-CHRISTINE POUJOULAT
Nurses in the Valvert psychiatric hospital in Marseille during the patient lunch on April 16.

They are schizophrenic, bipolar, suffering from severe melancholy, or even suicidal ideas … The philosopher Cynthia Fleury, member of the National Consultative Ethics Committee, worried about their fate at the time of the Covid, by questioning those who support them.

During the first fifteen days of confinement, the doctors at GHU Paris psychiatry & neurosciences imagined the worst for their patients. Their psychiatric complications risked making them terribly vulnerable; they would be unable to maintain barrier gestures and any form of social distancing. Worse: they were going to disappear from the radars. During these two weeks, they feared the tsunami. We had to organize Covid units in twenty-four hours, reinvent the organization, transfer patients to this or that department unless we got her out. “Dantesque”, summarizes Professor Raphaël Gaillard at the head of the hospital-university center of the XVe borough.

However, the disaster never happened. A hypothesis has even emerged, worthy of the highest expectations: possible protection of patients against Covid-19, even when they form a population at risk (overweight, cardiovascular disorders). In Sainte-Anne (but this is true in other psychiatric services), while on average 19% of the medical and nursing staff contracted Covid-19, only 3% of hospital patients were tested positive. Certainly there is the argument of social isolation, and the fact that caregivers have taken a lot of precautions to protect them. Nevertheless the question arises: would there be antiviral effects of chlorpromazine (an antipsychotic usually prescribed against schizophrenia)? Since then, a study has been launched in partnership with the Institut Pasteur. “It would be a superb reversal of history”, allow themselves to dream of Raphaël Gaillard, Raphaël Gourevitch (Pôle CPOA- urgences). Imagine, those who are constantly stigmatized, ostracized by society, these would have a decisive share of responsibility in the treatment against Covid-19, to protect, not only psychiatric patients, but also all of us . A snub to prejudices as to institutions, because psychiatry was in the management of the Covid-19, as in its sad habit, the fifth wheel of the coach. The time is no longer counting (missing) points from the start of the crisis. The deconfinement is now there, and everyone fears a second wave, not of Covid-19, but of all those who prevented themselves from coming during the confinement, not to mention all the future decompensations linked to socio-economic distress.

Thunderbolt in the serene sky

During confinement, paradoxically, but this had also been the case during September 11 or major national trauma, such as those of the attacks against Charlie or on November 13, patients with severe psychiatric disorders behaved, almost miraculously, as if some people felt a kind of communion, quite inexistent as usual, a collective sharing of the amazement which is generally exclusive to them. It is very difficult to explain why schizophrenic, bipolar, patients with severe melancholy, or even suicidal thoughts, in these periods of breaking into reality in collective life seem at a distance, reassured. As if there was a cooling of everything. Of course, there is no generalization possible. Without objectified data, the internal outcry calls to order all offenders with diagnostic caution.

In the emergency room, Doctor Anne-Kristelle Trebalag identified four waves of “profiles” of patients, the first very anxious, calling mainly for reinsurance, rather helpless before the closure of their usual places of therapeutic monitoring, but without real decompensation. The second, in early April, very typical of spring, with severe manic-depressive disorders. The third, more serious, referring to breaks in treatment, poor compliance due to confinement, all those who had missed their medication, injections, etc. Finally the fourth wave, with no psychiatric history – the famous thunderclap in the serene sky – with delirious, even mystical, messianic puffs. In teleconsultation and via the “Psy IDF” emergency platform set up on a regional scale at the request of the ARS, and which aims to remain sustainable, the situations are more “constellar”: this goes from the family crisis with violence, the crisis between adolescents and parents; the question of addictions of course, helping parents who saturate because the clinical pictures are more serious when it comes to elderly patients.

“Team cohesion”

The resuscitation and neurology services of the “neurosciences” pole have also been reinvented. “The team cohesion was extraordinary, the service rose from one man. Not the least reluctance ”, gratefully acknowledge Doctor Xavier Sauvageon, and Professor Tarek Sharshar, in intensive care. “The entire service has been reorganized, the operating theaters and the recovery room, between Covid (+) and Covid (-). As for ECT (electro-convulsive therapy) activity, the psychiatrists also pushing to maintain the programming of possible interventions for their most needy patients, we have been united. ” In terms of ethical questioning, collegiality and the sharing of experiences were also precious, no one found themselves alone faced with the obligation to prioritize. On the other hand, the confrontation with death was not usual in this service. “It’s a kind of return to the roots of the resuscitation profession, and above all a doctor. There was an urgent need to care for patients who were no longer able to breathe. “

What is the use of these exceptional and totally new emergency situations? “The healthcare team proves that they are able to cope. It is essential for the mind and the pursuit of the demands of our profession. “ In intensive care, the doctors first followed the obligation to prohibit visits to the sick. This proved to be impossible to cope with the plight of the families, and ultimately with their personal medical ethics. So here again, alternatives have been found, each time, by multiplying the precautions.

All caregivers, doctors, patients, nurses, caregivers, health managers, all lacked “Institutional time”, this time when we do the “Transmissions”, where we discuss cases, have coffee, regain strength while sharing expertise, these times when we simply see his colleagues. There they were limited to the minimum, even completely absent. So each head of pole tried to do otherwise, to go through digital meetings, and also to maintain exchanges on current research publications, a way to continue a link that is essential in medical and scientific life.

Curious outdoor choreography

At the Telegraph Medico-Psychological Center, in the XXe district, the medical care team was already on tight, but there, while other centers not dependent on the hospital closed, it remained open. Usually it is crowded, every office is taken, waiting and rest rooms are full. The obligation of barrier gestures and social distancing provoked a curious outside choreography, in front of the window of the CMP, where sometimes a line formed, waiting for medication, or simply to return. The multiplication of teleconsultations did the rest. The service closes on weekends, relaunching strong demand every reopening Monday.

The inaugural disarray, specifies doctor Françoise Cornic (hospital service of the XIVe arrondissement) also came from the fact that all the principles, hard won over time, of reinvention of psychiatric places, since the 1970s, namely openness to the outside, freedom of movement, multiple creation workshops, the possibility of coming to meet the referring psychiatrist impromptu, collective meals, sharing of conviviality between the caregivers and the patients, all this was going to be called into question by the covid-19, and for an indefinite time. However, forbidding patients with significant mental or neurological disorders not to wander is counterproductive in terms of care, preventing them from doing a lot of stimulation workshops too, isolating them even more socially, by preventing them from eating their meals with the collective, all of this is by no means superfluous, on the contrary, it is essential. All the humanism of care is there. And now the Covid-19 was going to sweep it all away and plunge the services back into an era that nobody wants anymore. In the service, it was necessary to bring out the set of keys to close the accesses, even if all resisted as they could to these so-called non-negotiable measures, by configuring ad hoc alternative protocols. First wave of patients, the precarious, the homeless, the undocumented who flocked at the start of the confinement, all those who did not want to go into shelter because they felt persecuted there. Then, and this was disarming, many stabilized patients relapsed, who could no longer bear confinement, and arrived in the third week. Finally, many elderly people, under-stimulated, isolated, and who arrived because many home helpers had stopped. Not to mention the calls and decompensations of caregivers who falter in turn. As a result, the service calls them to support them, as if they were the patients themselves.

In the psychiatric geriatrics department headed by doctor Thierry Gallarda, in connection with professor Marie Sarazin who is in charge of memory and language, the Covid-19 has only reinforced the problem of aging and psychiatry, still too left aside: how to deal with Alzheimer’s interfaces and suicidal thoughts? Generally, each department specializing in one or the other field does not want to deal with such cross pathologies.

Despite the fatigue, each team is ready for deconfinement, knows that the second wave linked to the deleterious effects of confinement is inevitable. But despite that, there remains a feeling of pride and courage: to have been there for the meeting, and to prepare again tomorrow to be there.

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