Psychiatric emergencies, an essential but threatened link in our health system

In Nantes (Loire-Atlantique).

Mental health affects everyone. It fluctuates throughout our lives, more or less permeable to the society around us, but always firmly anchored in our history. Not always well known, psychiatric emergencies are an important link in the field of mental health in France. However, today they are, like other services, on the verge of implosion.

The Nantes University Hospital is one of the largest centers reserved for psychiatric emergencies (UP) in France. There are more than 10,000 entries a year. This functional unit, open 24 hours a day, 365 days a year, has separate locations from the so-called “classic” emergencies, but are located within the same building. “We must not be afraid of words: these are really psychiatric emergencies, emphasizes Dr. Hélène Vergnaux, head of the unit since 2006. The naming is important. We are mostly emergency room doctors, but specialize in psychiatry. And we cling to this name of emergency doctors.»

Here we welcome anyone over 15 years and 3 months old “in psychic suffering, one who formulates a request whose rapid and adequate response cannot be deferred, in order to mitigate its acute nature”. PUs also have their own health team, five psychiatrists, nine nurses and two psychiatric interns. There the night call changes, made by another psychiatrist from the CHU (about fifty carers rotate for this call).

Counseling and guidance

Mickaël, in his thirties, was one day sent to the psychiatric emergency room of his city by his attending physician, concerned about his suicidal thoughts. “It was during curfew, after a binge. Either that or I committed suicide. I was received very well, the nurse and then the psychiatrist were very kind. She relieved me to know it existed. Guillaume himself, after a suicide attempt that plunged him into a coma for three days, woke up in full crisis. “I stayed there for one night. They try to make the diagnosis, to orient us. They see us pretty quickly, it’s the public hospital, they do what they can.

The service is in fact centered on consultation and guidance. Patients come here alone or accompanied by a family member, friend, educator, firefighters or even the police. Liberal general practitioners, psychiatrists and psychologists can advise on the approach. “As soon as we observe very marked behavioral disturbances, endangerment of oneself, manic or melancholic state, suicidal ideas with risk of acting out, we can arrive at the UPlists Dr. Vergnaux. It is absolutely necessary to defuse the crisis”. Before the inevitable.

Psychiatric emergencies, which have existed for about thirty years, are registering a growing number of hospitalizations, especially after the Covid-19 pandemic: in particular, we note a particularly alarming increase of 25% in visits by minors in the last two years, especially for suicidal gestures. “Psychiatric emergencies are the reflection of society, the barometer, the temperature of what is happening outside. The suicide crisis is today a response of society”analyzes Dr. Vergnaux. “However, people no longer find a psychiatrist in private practice. The offer no longer follows»he complains.

intrinsically linked
to general emergencies

Problem: if we are not careful, even the UP dam will eventually give way, intrinsically linked to the state of the neighboring service, to general emergencies, on an indefinite strike in Nantes since the end of October. Yes, in the UP, there is only one hospital doctor on duty per night, with no intern to assist him.

“It was either that or I killed myself.
I was received very well, the nurse and then the psychiatrist were very kind. I was relieved to know
that it existed”.

Mickaël, in his thirties, has been through psychiatric emergencies

“The first request is that an intern be present extra at night, explain Béatrice Péron-Soubra and Élise Le Bail, psychiatric nurses and elected officials of the CGT at the university hospital of Nantes. Furthermore, there are not enough beds available in conventional emergencies, for example to monitor the aftermath of willful drug poisoning, so patients are sent to psychiatric emergencies. And after emergencies, what orientation? There are no more places for minors.”

In an area historically lacking in psychiatric beds for minors and with a galloping demographics, the disaster is already there. Children and adolescents find themselves hospitalized in adult psychiatry (108 minors in 2021), an experience that can cause real trauma.

Illness and understaffing

While awaiting the fruits of the strikers’ battle, the first link in the chain is to try to resist this tide of unhappiness. And he continues to evaluate and lead, despite an understaffed team. “Work stoppages are numerous, notes psychiatrist Hélène Vergnaux. Lack of means, tiredness… Psychiatry is no longer chosen by students. It is the poor relation of medicine. There is no more commitment in this specialty.» Yet psychiatry also saves lives.

“This work still interests me a lot, it is very rich in terms of encounters. There are many ways to exercise and we are in touch with “new” problems»enthuses Vincent, a nurse, seventeen years in psychiatric emergencies and no fatigue at the treatment desk.

That day, however, he was shot in the stomach shortly before by a patient in crisis, who in the meantime broke down the front door. “Sometimes there are threats that are difficult to accept, but we can’t ruminate, we have to move forwardconfides Vincent. It is also up to us to perceive the pre-crisis clinical signs, the delusional processes…”

Their experience as an emergency physician is essential for the rest of the patient care journey. Some go home with treatment, due to lack of space, or because the crisis has passed or can be stabilized. Because to make themselves available to the next patient, the team can only count on themselves.

Moments of calm, which allow you to breathe a little, are becoming increasingly rare. certain hours, certain days “a little fresher than others”it almost doesn’t exist anymore. “The activity is continuousobserves the head psychiatrist. However, to move on to the next story, you have to metabolize the previous one, recharge your batteries, put down your blouse, think about something else. We work with people here.» So many impossible things today.

70% of steps related
to a suicidal crisis

Here 70% of the passages are related to a suicidal crisis. Two nurses in the morning, as many in the afternoon and at night, accompanied by two or three psychiatrists, to see the suffering of the inhabitants of one of the largest cities in France.

Léonie, twenty years old, was unaware of the existence of these particular emergencies before going there herself. Her psychiatrist being untraceable, it was she who advised her to go there, while the young woman, “at the height of one of [ses] bipolar crisis, had constant suicidal thoughts. “I didn’t know this service existed. The term ‘psychiatric emergencies’ is a bit intimidating.»

A friend accompanied her. Léonie filled out a form, she waited a moment, then she was seen by a nurse and a psychiatrist. They asked me why I came. I refused hospitalization. Oddly enough, it was a good experience. If I hadn’t gone there, maybe I would have jumped under a subway, I don’t know… It kind of saved me at that moment.»

“I didn’t know this service existed. The term ‘psychiatric emergencies’ is a bit intimidating.”

Léonie, whom he consulted about a suicidal crisis

“You literally have to ‘love’ psychiatric emergencies, this adrenaline-pumping sidesays dr. Vergnaux. You never know what awaits you, every day is unique. And it really makes sense to be attached to “classic” emergencies, to be able to work together. Even the psychiatric emergencies of Nantes, worried about their future and that of the ever-increasing number of patients, joined the strike launched by their colleagues next door.

His staff wonders about the lack of consideration given to this sector of medicine. Nevertheless, “the number of first hospitalizations has been multiplied by at least three, all ages combined”the two CGT elected officials are alarmed. “We are eliminating psychiatric beds across the region. We destroy psychiatry, thus imposing a catastrophic follow-up. It is the very meaning of work in psychiatry that is being attacked from all sides, they shout. If all this blows up, it will be hell for the patients.”

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