Cancer Care

The AP-HP Nord Hospital group comprises five emergency departments (ED) welcoming patients 24 hours a day, 7 days a week, from the whole northern Paris area (1.5 to 2 million inhabitants), who are either admitted directly, addressed by their practitioners, or transported by emergency ambulances (SAMU/SMUR, Paris Fire Corp ambulances). These EDs take in charge adults (Saint-Louis, Bichat, Lariboisière, Louis Mourier, and Beaujon Hospitals) and children (Robert Debré Hospital).

Among all patients seen in these large departments, nearly 2,000 present each year with a complication of an underlying, not yet diagnosed cancer, while 1,500 are cancer patients who are already followed up in the oncology or hematology departments of their hospitals and have been advised to present at the ED for a complication by their oncologist. The medical electronic records of these patients are accessible to ED specialists. In these hospitals, emergency practitioners are trained to manage acute and subacute complications of cancer or of cancer treatments. There are clearly identified pathways for acute severe hemoptysis or hematemesis (arteriography facilities in Bichat, Beaujon, and Saint-Louis Hospitals), for febrile neutropenia or lysis syndrome in patients with hematological malignancies (Saint-Louis hospital), and for acute cancer pain (all EDs, and cementoplasty facilities for bone and rachis metastases at Lariboisière, Bichat, and Saint-Louis Hospitals), renal failure (intensive care unit [ICU] or nephrology departments at Bichat, Saint-Louis, Lariboisière, Louis Mourier, and Beaujon Hospitals), and brain or medullary metastasis-induced neurological compression (neurosurgery at Beaujon and Lariboisière Hospitals, 24/7). Upon patient arrival, a specialized orientation nurse assesses the reasons for visiting the ED, as well as the level of emergency and severity, which leads to rapid triage. Actually, patients with known cancer are systematically considered a priority and taken in charge in less than 20 minutes. Especially patients with fever and suspected neutropenia are isolated in a single-person room with a protective facial mask. All biological blood tests and radiological examinations (CT-scan, MRI, etc.) are performed in the ED, and antibiotics are initiated as soon as blood cultures have been performed, with standardized protocols validated and updated by specialists in infectious diseases and oncologists from the AP-HP Nord Hospitals, according to situation (solid tumors, hematological malignancies, duration of fever, date of previous chemotherapy cycle, blood leucocytes as determined by home blood sampling communicated to the oncologist, central venous device, etc.). Urgent pain treatment, urgent treatments of hypercalcemia, blood transfusions, or thoracentesis, for instance, are initiated in the EDs in agreement with the treating oncologist or hematologist (phone night shift in each specialty). ED practitioners also receive a specialized training on specific complications, for instance immune-related adverse events of immunotherapy, and they participate to monthly staff meetings on immune toxicity (PATIO) organized at Saint-Louis or Bichat Hospital, in alternation. All EDs are located near the ICUs, where at least two senior intensivists are present during the night and more during the day. Patients requiring hospitalization either in the ICU or in their specialty department are transferred, in the latter case as soon as medically stabilized. Palliative care, in case of clear instructions in the electronic records, can also be initiated rapidly in connection with the referent oncologist. Each ED has its own areas of expertise with dedicated research, for example rapid diagnosis of infectious diseases and cancer-associated hemoptysis at Bichat hospital or febrile neutropenia in patients with hematological malignancies at Saint-Louis hospital.