Interview with Dr Jean-Pierre Bedos. "Living through the first wave in a French Hospital ICU"
“It's an incredible thing, this virus!” Living through the first wave in a French Hospital ICU-Exclusive Interview with Dr Jean-Pierre Bedos.
Head of the Intensive Care Unit (Chef de Service Réanimation) - Head of the CANDEUR Division - CH Versailles Hospital, Site Mignot
Dr. JP Bedos
THE BRIEF: Can you tell us about your experience with the COVID-19 wave as head of your unit?
Dr Bedos:"To be successful, it's not enough to plan, you also have to improvise." In three weeks, from March 4 to March 30, we went from 20 intensive care unit beds to 51 in the hospital, "arming" the recovery rooms, our continuous monitoring unit, the cardiac intensive care units (USIC). It was extremely difficult, exciting, exhausting, but everyone showed great solidarity and solidity... the doctors, the nurses, because we had to retrain nurses from other departments, go get the former intensive care nurses, care assistants, because at the beginning of this health crisis, we had a shortage of nurses! Similarly, on a medical level, junior and senior doctors, former members of the service, returned to cope with the enormous workload, the increase in the number of daily on-call scheduling.
But it was all well managed, with great professionalism on all sides. On a daily basis, the "rarefaction", shortages, of everything was managed with all the functional departments of the hospital: masks, overalls, personal protective equipments (PPE), protective goggles, electric syringe pumps, ventilators, medication for sedation – curare use, etc. Given the risk of inter-personal transmission, very quickly, from the end of February onwards, all staff had to wear masks in the unit, as well as families and visitors. As a result, very few resuscitation staff were ill, whereas there are around 100 paramedical staff, 25 senior and junior doctors.
THE BRIEF: You had also strengthened infection control?
Dr Bedos: Infectious control was draconian, we were dressed like cosmonauts! For almost one out of two patients, there were cases of nosocomial lung infections, as well as a lot of bacteraemia, more than 20% with slightly unusual bacteria, which surprised us a little. In particular, coagulase-negative staphylococci. On the other hand, very few MDR (Multidrug Resistant Bacteria).
All hygiene and protection measures were particularly respected.
THE BRIEF: How many patients?
Dr Bedos: 101 patients between the trauma room, recovery rooms, USC and USIC were taken care of, as well as 780 patients at our hospital in Versailles, the 1st patient had arrived on March 4th.
We still have patient left: 61 days! 50 days in ICU, and who is being gently weaned off ventilation, has been tracheotomized and is progressing. The ventilation time is very long, you have to be patient, 18 days on average, but many end up recovering, the majority of our patients have been ventilated mechanically, 85% with intubation under sedation and curarization with many sessions of ventral decubitus to improve oxygenation, a few with Opti-flow - high flow oxygen, by nasal route with very partial success.
This means a very long curarization period, with no shortages, but with a constant tight flow from day to day, with pharmacists having perfectly anticipated the stocks.
We also didn't run out of stock for anything: long-sleeved overalls, protective goggles, masks, supplies always very tight, we were helped by the CEA (French Atomic Energy Commission), a lot of help from private companies, but we never ran out, even though we changed a lot of brands -- short sleeves blouses, for example, that wasn't possible.
Each doctor had responsibility in his own field, syringe pumps, ethics, decisions, and a coordinating doctor who managed everything, and we had team meetings lasting an hour or an hour and a half with the nurses who were referrals, the managers, to take stock of everything that was needed because to 'arm', as they say, the ICU beds all over the hospital, we needed a lot of additional equipment that we didn't have: In particular, more ventilators, syringe pumps, but we were always well organized, especially when money didn't matter: everything we wanted we had!
We are a CHG (General Hospital Center), we are a bit like a UHC (University Hospital Center), but we are a general hospital, there are the same restrictions, even T2A (fee-for-service system), same deficits. We have a 4.5 millions deficit out of a budget of about 280 million euros. But now the floodgates have been opened. All that we had missing we could ask for. Daily briefing review made with the Regional Health Agency.
THE BRIEF: Would you be ready for a second wave?
Dr Bedos: Materially and organizationally we are ready. But morally, psychologically, we couldn't relive twice what we've been through, I think. Or it would be very difficult. There will probably be a second wave, but not at the level of what we experienced.
Because there's a whole organization when there was nothing at the beginning, for weeks, and delays in triggering the response.
THE BRIEF: Can you tell us something about your personal experience in terms of health?
Dr Bedos: This period of intense work in a locked-down society and a ‘ghost’ city affected me a lot psychologically. I even ended this period with a cardiac accident. The impression towards the end of March that we were going to be saturated by the influx of patients was very unpleasant. Fortunately, on April 1, the Regional Health Agency decided to transfer 9 patients from our critical care by TGV (Fast Speed Trains) and SMUR (ambulatory vehicles), to the province (further away from the Paris area) on the same day, and that gave us back our capacity.
Overall mortality was lower than expected and was 26%. People over 80 years of age all died, and there were 36% deaths out of 70-79 (25 sick). There were no deaths among those under 40 years of age.
THE BRIEF: Would you say this disease is marked by micro-thrombosis?
Dr Bedos: It's true that the patients were very inflammatory as they say, with high inflammatory biomarkers, but we didn't have a pulmonary embolism (PE).
We did double-dose preventive therapy with anticoagulants in all the patients!!
THE BRIEF: Did other hospitals do the same?
Dr Bedos: Yes, little by little, because some hospitals had fatal pulmonary embolisms and we all noticed the elevation of D-Dimers, which are inflammatory biological markers.
THE BRIEF: It is very difficult in France to use a compassionate treatment, we see this with bacteriophages (we discussed this at the EMA, the European Medicine Agency). If a product is approved by the CCP (Committee confirming the safety for patients) can a patient ask for it?
Dr Bedos: At first 10 patients were put on the Kaletra drug, but with a lot of renal failure, we stopped.But then corticosteroids were used on the most severe cases. We had discussed oxygen carriers (based on Dr. Zal's research, Hemarina, (see AMR-Think-Do-Tank news - NDLR), as I had told you my interest in this interesting product from marine worms.
I had read the protocol that was almost tested with APHP (Paris Public Health Agency). Difficult, because it is still a product that has never been tested administered intravenously IV in humans. The protocol proposed to test on patients in serious failure and placed in ECMO (Extracorporeal Oxygenation), but we only had 6 patients in ECMO. There were 3 deaths, 3 survivors. So finding the "target" group of patients was very difficult.
But this molecule, it is possible that it be very interesting, before, well before, these stages of ultimate severity in the evolution of the sick patient, considering that we've had patients intubated under ventilation for days on end, on principle we would have liked to be able to test this molecule. And maybe also try it on very severe ARDS?
In New York City, they had 88% mortality among patients under ventilation, you were telling me. We have had 25% mortality, but we must not limit the care to 15 days, we must keep the patients for a very long time. We had a 78-year-old man ventilated for 60 days, he went to rehabilitation care, he walked, he was coherent! With very heavy sedation for weeks! It's true that months afterwards some patients came back with respiratory problems, like less serious relapses...
THE BRIEF: Why is there so little basic research on the disease? Networks of diabetologists have now shown that SARS-CoV-2 can lead to diabetes in healthy people. This coronavirus can cause heart disease, vascular, kidney, central nervous system, and of course pulmonary disease. In California today, almost half of the cases affect young adults!
Dr Bedos: It's true that it happened all of a sudden, and even a small percentage per million in severe cases is a lot. It would seem that the virus is mutating in the United States where we see a clear rejuvenation of the sick.
Professor Raoult has taken the problem in reverse, the opposite of the norm of clinical trials, without a control group. So between too slow academic research unsuited to this unique situation... and a lot of poorly done or open studies, I still don't know if azithromycin combined with hydroxychloroquine works or not? But it's no more dangerous than any other drug.
A recent study on corticosteroids in the most severe patients: 25% deaths in the group with, versus 40% deaths in the group without, if you read the details. Thus, corticosteroids in cases of severe inflammation can be useful. With regard to anti-viral treatments, I think that we can talk about the wreckage of the studies to date. Nothing has shown any real effectiveness. Globally, we have not yet understood this disease, COVID-19; we are in the observational phase for the moment. It's an incredible thing, this virus!