For Vincent Bounes, the day will be long. The head of service of SAMU 31 (Haute-Garonne) has just started a 24-hour call, during which he will deal with his teams with the “2000 daily calls” addressed to the Center 15 of the department during this summer period. Patients without attending physicians, sick vacationers, worried parents, injured hikers… The emergency doctor directs his recipients according to the seriousness of their pathologies. “Even if not all calls are emergencies, far from it,” he makes it clear from the outset, citing a sprained ankle or a coughing child. Of the hundreds of phone calls received each day, the doctor estimates that 50% of his interlocutors require simple medical advice, the sending of a prescription or recommendations on a treatment to be followed from home. A quarter of the other patients would be treated directly at home, with the dispatch of a medical team or a general practitioner – most often contacted via SOS doctors. “And the remaining quarter are patients who must actually be taken to an emergency department or hospitalized,” concludes Vincent Bounes.
But after 18 years of career, including six at SAMU 31, the emergency doctor does not hide his concern. “Access to emergencies has never been so regulated”. While dozens of services are partially closing throughout the territory – last May, the Samu-Urgences de France (SUdF) association counted 120 hospitals in “serious difficulty” on the issue – and that the emergencies still open are facing a impressive influx of patients, he can only note the “enormous difficulties of care and access to care”. Since the beginning of the summer, it is thus not uncommon for the emergency doctor to receive calls from distraught patients, planted in front of the closed doors of hospitals or clinics in the region, access to which is only granted after a call. at 15. “All the patients who need to be hospitalized are, and we always end up finding beds,” he says. “But it is sometimes complicated, especially for the smallest pathologies… which must still be treated”.
In tension, many hospitals are already following the recommendations of the famous “Braun report”, delivered by the new Minister of Health last June and carried out following “the flash mission on emergencies and unscheduled care”. The document notably advises hospital structures to “better regulate admissions to the emergency department, either at the entrance to the department, or by prior medical regulation by the Samu or the Care Access Service (SAS)”. The Bordeaux University Hospital thus established at the end of May “regulated access” to its emergencies every night between 8 p.m. and 8 a.m., as did the Troyes hospital center, whose service has been regulated from 6.30 p.m. to 7 p.m. since July 19. , or even hospitals in the Vendée department, which have limited access to their emergencies from 11 p.m. to 8:30 a.m. since July 22. In Montauban, two intercoms allowing to filter 24 hours a day the entrance to the emergency room have even been set up. Green is reserved for patients who have obtained a prior telephone agreement for treatment, and red for those who have not taken this step. According to the hospital, this process implemented since the beginning of July would have resulted in an “average reduction of 25% in the number of passages” in the service, filtering out cases “really relating” to emergencies.
“Adapted support”
In this context, how do we know which patients will have the right to go through the door of the emergency services, and which will have to be referred to other structures? Concretely, the first reflex to have in the event of a problem – and if no attending physician is available – is to call 15. “You will then come across a medical regulation assistant (ARM) who will direct you to the right contacts” , decrypts Delphine Briard, member of the office of the National Union of Medical Regulation Assistants (UNARM). Depending on the severity of the case, the patient will be referred to an emergency service, will receive emergency medical aid directly at home, or will be redirected to a medical home, a general practitioner, a doctor on duty or a doctor. liberal. “In no case will patients be rejected, abandoned or excluded from the health system. On the contrary, we support them as best as possible so that they are taken care of in an appropriate and rapid manner”, insists the regulator.
“This regulation is necessary,” said Professor Louis Soulat, vice-president of SUdF. At the Rennes University Hospital, where he directs the emergency department, the doctor testifies to an activity up 30% during this summer period. “We have an influx of patients due to the heat wave, the Covid, and above all, the regular closure of the services of other hospitals in the territory. It is absolutely necessary to go through the 15th to avoid an even greater congestion”. Same fight in Avignon, where the head of department, Fanny Virard, estimates “between 30% and 40%” the number of cases not requiring emergency care. “These are patients who twist their fingers and want an X-ray immediately, requests to stop work at any time, patients who refuse to wait for an appointment with a general practitioner… Sometimes they no longer do the difference between the vital emergency and the rest”, estimates the doctor, who refers the less serious cases to the medical house. Even if sometimes the system goes in circles. “At midnight, this medical center closes. Patients are therefore sent home at 9:30 p.m., because the appointment slots are full… And we finally have to take care of them”.
“Total disruption of the system”
For some users, the system – sometimes imperfect – of regulation and reorientation does not pass. Working from home in the Basque Country, Alizée paid the price at the start of July. While diving into a swimming pool after her day’s work, this 27-year-old Parisian hits the bottom of the pool violently, and feels a crack, as well as a sharp pain in her nose. The latter swells, then turns blue in the hours that follow. Worried, and without a doctor nearby, Alizée decides to go the next evening to the emergency room of a private clinic in the region. “It was around 10 p.m. and the doors were closed. I rang the intercom several times, but no one came to open the door,” she said. Distraught, the young woman then calls 15: an agent tells her that her case is not an emergency, then calls her back, advising her to have an x-ray the next day.
The following morning, the patient ends up contacting a attending physician by video, who believes that her case requires a trip to the emergency room for an X-ray. “I then went to the Bayonne public hospital, where I finally waited three hours to be refused this X-ray, because the nasal septum was not deviated. Despite the advice I had received, we made me understand that I had nothing to do there. They told me to go home, and to see an ENT in case of doubt”, says Alizée with a sigh. “In the end, I did not have the slightest prescription for painkillers, no complete examination, and I was tossed from practitioner to practitioner”. Faced with this kind of case, Christophe Prudhomme, spokesperson for the Association of Emergency Physicians of France (AMUF), does not hide his annoyance. “We are in a total disorganization of the system, with a real breakdown in public service: we try to make people feel guilty who would come ‘for nothing’ to the emergency room, when they sometimes have no choice to access a diagnosis ” , he laments.
Especially since in some cases, the pathologies are much more serious than a simple broken nose. “Sometimes, we have real loss of chance for patients”, regrets the emergency doctor, referring to the cases of patients who would not dare to contact the emergency room for fear of “disturbing”. “A man in the Pays-de-la-Loire who had chest pains in the evening only consulted the next morning, coming on his own… He had had a serious heart attack. And stories like that, I have every week”, annoys Christophe Prudhomme. Everywhere in France, the unions are worried about a “degradation of the supply of care”. “I have the concrete example of a child who was the victim of a road accident, and who was hospitalized in an establishment in the region without going through the emergency room, which was closed. The next day, we s It was noticed that he had a cracked spleen and liver, and he had to be sent in disaster to Marseille … It is not understandable”, deplores Cédric Volait, regional coordinator CGT Santé for the Provence Alpes-Côte region. -d’Azur.
“We were alone in our distress”
Iman, a 28-year-old stay-at-home mother, testifies to her feeling of “abandonment” from public service. In mid-July, when her six-month-old son was breathing badly, she decided to go to the emergency room of the Côte de Lumière hospital center in Sables-d’Olonne (Vendée). Around 11:30 p.m., she rang the intercom, but the door remained closed. “We were simply told that they could not take us, for lack of doctors”, says the mother of the family. Anxious, the latter calls 15, but she assures that the phone then rings “in a vacuum”. “In the meantime, my spouse called the firefighters, who sent us back to the Samu… Which we therefore called back, without further response. We were alone in our distress”. The couple then went by car to another emergency service in the region, in La Roche-sur-Yon. During the journey, Iman calls the hospital to make sure she is received: the establishment makes the connection with a doctor from the Samu, who detects a possible laryngitis on the phone.
Once in La Roche-sur-Yon, the child was quickly taken care of by the pediatric service – but his case got worse. “It deteriorated all of a sudden: the whole corridor was panicked. I was told that if they couldn’t stabilize it, they would have to call the Nantes intensive care unit… I’ll tell you lets imagine my state,” says Iman. The doctors finally manage to stabilize the child, who will spend the next five days in the hospital. Asked about the question, the communication department of the Hospitals of Vendée – which brings together fifteen public establishments in the territory – told L’Express “that when the family appeared before the service of Sables-d’Olonne, without having joined on the 15th beforehand, there was no vital emergency”. “The situation then deteriorated at La Roche-sur-Yon hospital, where the patient was taken care of. We encourage patients to always call 15, in order to be redirected to the right place”. Several weeks after the events, Iman indicates that she does not wish to file a complaint, and wishes to express “her support for the medical world”. “But I don’t understand how things could have gone so far. I sincerely hope that my case will remain exceptional.”