France's 'pop-up' Covid-19 centres help relieve ER overcrowding

You can hear her violent coughing fits before you see her. Nancy Bamba, a 28-year-old woman, showed up at the reception desk of a Covid-19 consultation centre in Nogent-sur-Marne to the east of Paris on Tuesday.

"My doctor sent me here because I've been having worrying symptoms for 10 days. I cough and I have terrible aches and pains. I caught malaria in the Ivory Coast ... But the fatigue I feel today is much worse, it's as if all of my energy has been taken away. Yesterday I had a fever of 39.4°C (102.9°F)," said the visibly weakened woman between coughing fits. "Since I also have a kidney problem, I'm really scared."

After being given a surgical mask and cleaning her hands with hydroalcoholic gel, Bamba settled into a huge, almost empty waiting room with chairs placed about two metres apart. Large mirrors installed on a whole section of the wall are a reminder that dance classes were held here before the crisis.

More than 400 people with Covid-19 symptoms have been checked here since the centre opened, after being referred by their personal doctors or the emergency services. A municipal police officer outside the building verifies that anyone entering the building has an appointment.

After a short wait Bamba entered a smaller room, where a doctor and two nurses were waiting for her. The nurses immediately busied themselves taking the young woman's temperature, blood pressure and blood oxygen saturation levels in a matter of minutes. This last measurement is crucial in the fight against Covid-19 because it can signal respiratory risk, even in patients who are not experiencing any discomfort in their lungs.

The doctor began with a series of questions about Bamba’s symptoms and possible pre-existing conditions before using her stethoscope to listen to her patient's breathing. It was a fairly routine consultation, except that the caregivers all wore protective gear, including masks, gloves, goggles, gowns, smocks and shoe coverings. All the instruments and the examination table are meticulously disinfected between consultations.

"Pop-up" centres such as this one are performing a vital role in the battle against Covid-19.

"The aim is to relieve emergency room crowding by first determining which patients need hospital treatment and which have weaker symptoms. This is what we call separating the 'hot' and 'cold' flows, and it is essential in the current crisis," explains Dr. Frédéric Thibault, project coordinator of the Covid-19 centre in Nogent-sur-Marne.

And it is critical to the safety of medical staff and other patients, which has been compromised from the start of the outbreak by insufficient resources for protecting against the virus’s spread.

"When you're used to doing surgery with robots that cost a fortune, you don't imagine having to fight one day for hydroalcoholic gel," said Dr. Thibault, pointing to a 20-litre "cube" of homemade gel supplied by a local pharmacist.

"Starting from nothing, having to solve problems very quickly – it makes me feel like I'm on a mission," added the doctor, who has previously worked on humanitarian projects in Afghanistan, Bangladesh and on the Syrian-Jordanian border.

Remote consultations as a last resort  

Another room in the facility is dedicated to remote consultations. Doctors Pascal and Benoît Bonnet, brothers from the town of Nogent-sur-Marne, were in front of a screen, communicating with a patient whose image appeared in a small window.

The patient was given a breathing test, which consisted of counting how long she could hold her breath.

"This patient was able to count to 15, which is better than last time when she was at 11. A person who is not able to count to 5 or 6 while holding their breath would be more of a concern," explained Dr. Benoît Bonnet.

Few doctors are in favour of remote consultations in principle, but the health crisis and resulting lockdown has made it impossible for most patients to travel. And as doctors are having to rely more on monitoring patients remotely, they’ve been quick to overcome any initial misgivings they may have had. 

Dr Bonnet explained that to relieve emergency health workers, especially in intensive care units, “we have to be fast and efficient”.

Avoiding 'a crisis within a crisis'

With the coronavirus in France now having claimed more than 12,000 lives and infected more than 118,000, the demand on intensive care units and their capacity to treat more cases is taking centre stage.

Adding to the concerns of healthcare workers is the knowledge that the reality of the pandemic is likely worse than what the official figures suggest. Many more people have symptoms of the disease but are afraid to go see a doctor or call emergency services for fear of not being “sick enough” and overburdening the health system. Worse still, some elderly people prefer not to call despite worrying symptoms because they are convinced – wrongly, according to doctors – that there is no real treatment for them.

How to offer care to those who may be falling through the cracks in the system prompted local doctors to organise the first Covid-19 outpatient consultation centre in Nogent-sur-Marne. Several of these centres have since sprung up in the Paris region, with healthcare workers all on the same mission: mobilisation, solidarity and doing one’s bit to fight the pandemic.

Community solidarity has played a part. Protective clothing such as overalls, hats and coverings for shoes were provided by school canteens in Nogent-sur-Marne. Protective visors were sent by Shields, a network of volunteers equipped with 3D printers. The heavy examination tables were on loan from a physiotherapist colleague.

As for the masks, the centre initially received 200 FFP2 masks for front-line medical staff – enough to last five days – and 4,000 surgical masks. Like everywhere else, the search for FFP2 masks is in full swing and everyone is working hard to collect donations from their personal networks. From firms to private individuals with business links to China to the widows of doctors who found old kits dating from the 2009 H1N1 threat – all are on the hunt for supplies. 

"It's a good thing I kept the equipment I used when I was an emergency doctor," explains Dr Anne-Marie Bénéteau-Béchara, one of the founders of the centre. "I was able to bring my ECG machine, which is used to monitor the activity of the heart, a device to check the level of oxygen in the blood and arm cuffs of several sizes to take blood pressure."

Testing limited 

Along with the resourcefulness of the staff, a high level of organisation keeps the centre’s daily operations running smoothly. Medical workers’ shifts are limited to three hours to ensure that their concentration is always at its peak. Patients in the large waiting room are kept to a minimum. And access to certain areas is limited by notices posted to keep patients and healthcare workers from crossing paths too closely in the corridors.

Bamba is just outside the door of the consulting room. She was told by her doctor that her examination did not show any lung infection and the young woman is being sent home with a prescription for paracetamol (acetaminophen).

"I was told that I had Covid-19 symptoms and was offered a remote consultation in three days to reassess my situation. I was already taking Doliprane (paracetamol) and I was not offered a screening test or any other options," she says, sounding a little disappointed.

Doctors at the Covid-19 centre are regularly confronted with requests for tests but they can only carry them out in very special cases: for healthcare workers, pregnant women and people with respiratory difficulties or certain chronic diseases.

Although France has strict rules that limit the number of tests for coronavirus, many doctors are already reluctant to use them. According to them, the tests that use nasal swabs are unreliable because they deliver a high proportion of false negatives. These test results can have serious repercussions; a patient who thinks they are not carrying Covid-19 risks lowering their guard around others when in fact they are contagious.

"Every day we explain to patients that there is no effective treatment against the new coronavirus; it's very frustrating for us," explains Dr. Pascaline Mourey, a general practitioner in Bry-sur-Marne, after a consultation at the Covid-19 centre. "When a patient is not doing well, we try to ascertain whether to send them to hospital, knowing that we shouldn't do that too early during a health crisis."

Out of about 50 patients seen each day at the Covid-19 centre, five or six are transferred to a hospital. The triage work done by the centre is offering a much-needed respite to the overstretched emergency room workers at a time when France is still struggling to lower its rising coronavirus cases and fatalities.

This article has been translated from the original in French.