Wednesday, January 6, 2010

"Permanenciers"—The People on the Phone

In December I was teaching in Paris with a colleague from Chapel Hill. We met prior to the start of his class first thing one morning and he was a little shaky; he reported he hadn’t gotten much sleep and was feeling a bit woozy. “I’ll shake it off,” he said and went into the classroom. I went back downstairs to my office to work and in 30 or so minutes one of the students came in to say that the professor was probably sick and could I come and help.

I went up to the classroom and sure enough, my friend was looking decidedly green and was conspicuously sweating but his skin was cool to the touch. We led him downstairs to a quiet place to sit and gave him water. The students, several of whom were trained physicians or caregivers, were doing some informal diagnosing. One of the young ladies who was in active practice asked for a classmate to go round to the local pharmacy and get a stethoscope and a blood pressure monitor and began to ask questions. “Did you eat? Do you have any pain? When did this start? Do you have a history of coronary disease?” There were some symptoms that fit with a myocardial infarction but no typical pain. The diagnostic equipment arrived, on loan from the pharmacy. His heart sounds were more or less normal but his pulse was rapid. The electronic blood pressure gauge showed a fairly normal 130-90 but the sweating, wooziness and nausea were not abating.

The question was, what to do? Go to a hospital that might be friendly to an American. The American Hospital in Neuilly was mentioned but how to get him there? Was there enough reason to call for an ambulance? The decision was made to dial “15” and contact SAMU, Service d’Aide Medicale Urgente. This connected us to one of the 100-plus call centers in France that handle medical emergencies.

The student/physicians were discussing the situation with the call center and soon were apparently discussing the case with a physician and talking about options. One was to have a “S.O.S. Medecins” or “SOS Doctors” come by. Given the symptoms and the apparent non-emergent nature of the case, that might seem reasonable. After a bit more discussion and some additional checking and more questions, the decision was made to pass that up but to take my colleague by taxi to his hotel where he would be met by an on call physician.

How this was being negotiated was hard to understand but I was told that a “dossier” had been set up for the patient, that if there were any problems or the symptoms became more urgent that I was to call “15” and that they’d be able to connect to his file by name. Further, that a doctor was assigned to the case and available by phone and that we were to go ahead on and the circulating physician would appear at the hotel within the hour.

We got to the hotel and not long after getting the patient into his bed, the call came up from reception that the doctor had arrived. He came up and with dispatch, quickly and expertly interviewed my colleague, checked heart sounds, palpated, and checked eyes and ears.. The discussion was all in English and the doctor was not looking too alarmed nor disturbed. After 15 minutes or so, he opined that it was likely an intestinal infection and that it was “all over Paris” at the time. He offered a few small pills, instructing the patient to take two now and another in an hour and wrote a prescription for more of the same plus an additional drug in case there were bowel problems. When the session was over the doctor took out a small pad and wrote up a bill on a form that was intended to be used for insurance claims. The visit was a “cash-only” affair and the total charge came to 90 euros.

What we had undergone was an interaction with the integrated emergency and urgent care system in France that makes use of a system of communications centers, traveling physicians and various levels of ambulances and patient transportation systems. I knew a bit about this but was fascinated by the fact that a “dossier” had been created and that we could easily refer to that for additional medical care during this episode.

It was not until just before New Years that I got a better idea of what was happening when I read about a series of local strikes of what were called “Permanenciers Assistants de Regulation Medicale” (PARM). When I tried to find out what they were I uncovered a bit of the background to the process we underwent two weeks earlier. The permanenciers (hard to translate, but call them “agents”) were communications specialists who manned the call centers. They are trained in medical triage and are the first line of communication for the rather complex SAMU system. The permanenciers are backed up by physicians who also staff the call centers and who remotely diagnose or refer and make transportation or treatment decisions over the telephone. They are assigned to a case (a dossier is opened) and stick with it until resolution.

In our case, we had the option of having a SOS Medecin come to us. These are physicians who literally cruise the streets of Paris and other cities (or are on call) and make necessary house calls. There are other physician who are ready to attend to less urgent cases, as ours was, with a house call. They function more or less independently but have the ability to motivate a more complex trauma or emergency care system.

But, back to the permanenciers. These key functionaries were striking to get recognition as a specialized and professional cadre of workers as well as a bit of a pay raise. The rolling local strikes seem to have settled down by the first week of January but no resolution to their requests has been reported.