The wolf in sheep's clothing: vasovagal syncope in acute aortic dissection.

BACKGROUND: The presentation of acute aortic dissection can pose a challenge for emergency physicians, as it may occur without pain. Atypical presentations can lead to significant delays in diagnosis and increased mortality rates. CASE DESCRIPTION: Our case illustrates that isolated painless syncope can be a rare presenting symptom of acute aortic dissection type A. What is unique about our case is the limited extension of the dissection tear and the availability of Holter monitoring during the syncopal episode. CONCLUSION: This constellation provides insight into the pathophysiological mechanism of the syncope in this patient. Mechanisms of syncope related to acute aortic dissection are diverse. We show that vasovagal activation not related to pain can be the underlying mechanism of syncope in acute aortic dissection type A. Although excessive vasovagal tone in the setting of aortic dissection has been hypothesized in the past, it has never been as clearly illustrated as in the present case. This also highlights the challenge in risk stratification of syncope in the emergency department.

Gender-based differential management of acute low back pain in the emergency department: A survey based on a clinical vignette.

BACKGROUND: Women may receive suboptimal pain management compared with men, and this disparity might be related to gender stereotypes. OBJECTIVES: To assess the influence of patient gender on the management of acute low back pain. DESIGN: We assessed pain management by 231 physicians using an online clinical vignette describing a consultation for acute low back pain in a female or male patient. The vignette was followed by a questionnaire that assessed physicians' management decisions and their gender stereotypes. METHODS: We created an online clinical vignette presenting a patient with acute low back pain and assessed the influence of a patient's gender on pain management. We investigated gender-related stereotyping regarding pain care by emergency physicians using the Gender Role Expectation of Pain questionnaire. RESULTS: Both male and female physicians tended to consider that a typical man was more sensitive to pain, had less pain endurance, and was more willing to report pain than a typical woman. These stereotypes did not translate into significant differences in pain management between men and women. However, women tended to be referred less often for imaging examinations than men and were also prescribed lower doses of ibuprofen and opioids. The physician's gender had a modest influence on management decisions, female physicians being more likely to prescribe ancillary examinations. CONCLUSION: We observed gender stereotypes among physicians. Our findings support the hypothesis that social characteristics attributed to men and women influence pain management. Prospective clinical studies are needed to provide a deeper understanding of gender stereotypes and their impact on clinical management.

No waiting lying in a corridor: a quality improvement initiative in an emergency department.

BACKGROUND: Overcrowding in the emergency department (ED) is a global problem and a source of morbidity and mortality and exhaustion for the teams. Despite multiple strategies proposed to overcome overcrowding, the accumulation of patients lying in bed awaiting treatment or hospitalisation is often inevitable and a major obstacle to quality of care. We initiated a quality improvement project with the objective of zero patients lying in bed awaiting care/referral outside a care area. METHODS: Several plan-do-study-act (PDSA) cycles were tested and implemented to achieve and especially maintain the goal of having zero patients waiting for care outside the ED care area. The project team introduced and adapted five rules during these cycles: (1) no patients lying down outside of a care unit; (2) forward movement; (3) examination room always available; (4) team huddle and (5) an organisation overcrowding plan. RESULTS: Adaptation of ED organisation in the form of PDSA cycles allowed to obtain a collective team dimension to patient flow management. Since December 2021, despite an increase in activity, no patient is placed in a lying-in waiting area outside a care zone, irrespective of their care level. Vital distress and fragile patients who need to be kept in a supine position are treated immediately. In 2022, waiting time before medical contact was <2 hours for 90% of all patients combined. CONCLUSIONS: The PDSA strategy based on these five measures allowed to remove in-house obstacles to the internal flow of patients and to fight against their installation outside the care area. These measures are easily replicable by other management teams. Quality indicators of EDs are often heterogeneous, but we propose that the absence of patients lying on a stretcher outside a care area could be part of these indicators, and thus contribute to the improvement and safety of care provided to all patients.

[Access to health care for vulnerable migrants in Switzerland, all equal?] / Accès aux soins des migrants en situation de vulnérabilité en Suisse, tous égaux ?

Switzerland, after having been a nation of emigration for a long time, has seen its situation reversed with the industrial revolution and a succession of international crises responsible for several waves of migration. Some of these immigrants have health needs that vary according to their country of origin and their migratory route. Due to communication difficulties or legal issues, they do not always have access to appropriate health care. Although Switzerland tries to provide a framework and coordinate the care pathway, inequalities persist. Good information for professionals and patients, the use of trained interpreters and knowledge of local structures to which these patients can be referred might improve the situation.

La Suisse, après avoir longtemps été une nation d'émigration, a vu ses courants migratoires s'inverser avec la révolution industrielle et une succession de crises internationales responsables de plusieurs vagues migratoires. Certains de ces immigrants sont en situation de vulnérabilité et ont des besoins en santé variables selon leur pays d'origine et leur parcours. Du fait de difficultés de communication ou d'aspects légaux, ils ne bénéficient pas toujours d'un accès aux soins adapté. Bien que la Suisse tente d'encadrer et de coordonner les parcours de soins de ces populations à l'aide d'outils et de structures d'accueil, des inégalités persistent. Une bonne information des professionnels et des patients, le recours à des interprètes formés et la connaissance des structures locales vers lesquelles adresser ces patients peuvent améliorer la situation.

The Effect of Positive Therapeutic Communication on Pain (POPAIN) and Anxiety During Arterial Blood Gas Standardized Procedures in the Emergency Department Compared to Traditional Communication: Protocol for a Monocentric Randomized Controlled Trial.

BACKGROUND: In the emergency department (ED), medical procedures, such as arterial blood gas (ABG) testing, can cause pain and high stress levels. However, ABG testing is a routine procedure assessing the severity of the patient's condition. To reduce the pain of ABG, several methods have been investigated without significant difference in pain perception. Communication, a key element of care, has shown a significant effect on pain perception. A positive communication strategy, including positive, kind, or reassuring words, can reduce pain perception, while negative words can raise this perception, causing discomfort, known as the "nocebo effect." Although some studies have compared the impact of verbal attitudes, particularly in anesthesia and mainly with staff already trained in hypnosis, to the best of our knowledge, none have investigated the effect of communication in the emergency setting, where patients may be more suggestible to the words used. OBJECTIVE: In this study, we will investigate the effect of positive therapeutic communication on pain, anxiety, discomfort, and global satisfaction in patients requiring ABG compared to nocebo and neutral communication. METHODS: A single-center, double-blind randomized controlled trial (RCT) with 3 parallel arms will be conducted with 249 patients requiring ABG during their ED visit. Patients will be randomly assigned to 1 of 3 groups before receiving ABG: positive communication group, negative communication (nocebo) group, or neutral communication (neutral) group. The communication and the words used by the physicians during hygiene preparation, artery location, and puncture will be imposed in each group. The study will be proposed to each patient corresponding to the inclusion criteria. The physicians will not be trained in hypnosis or in positive therapeutic communication. The procedure will be recorded with audio recorders to test its quality. Intention-to-treat analysis will be performed. The primary endpoint is the onset of pain. The secondary outcomes are patient comfort, patient anxiety, and global satisfaction of the patient with the communication strategy used. RESULTS: On average, 2000 ABG procedures are performed each year in the EDs of hospitals. In this study, 249 patients are expected to be included. With a projected positive response rate of 80%, we intend to include 25 (10%) patients per month. The inclusion period began in April 2023 and will run until July 2024. We hope to publish the results of the study during the fall of 2024. CONCLUSIONS: To the best of our knowledge, this study is the first RCT assessing the use of positive communication on pain and anxiety in patients undergoing the ABG procedure in the ED. A reduction in pain, discomfort, and anxiety is expected when using positive communication. If the results are positive, this could be useful to the medical community and encourage clinicians to monitor their communication during care. TRIAL REGISTRATION: ClinicalTrials.gov NCT05434169; https://clinicaltrials.gov/ct2/show/NCT05434169. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/42043.

Experiences of Frequent Users of Emergency Departments in Health Care Setting in French-Speaking Switzerland: A Qualitative Study.

AIMS: Frequent users of the emergency department (FUED; five ED visits or more per year) often have negative experiences in health care settings, potentially aggravating their health problems. Scarce research has explored FUED experiences in health care in Europe, none in Switzerland. Thus, this study aimed to conduct an in-depth exploration of FUED experiences in health care settings in Switzerland. METHODS: Semi-structured interviews were conducted among 20 FUED (75% female; mean age = 40.6, SD = 12.8). Qualitative data were subject to inductive content analysis. RESULTS: Five main themes emerged from the analysis. The main findings documented that FUED experiences in health care were mostly negative, leading to negative emotions, dissatisfaction and a loss of confidence in the system, although some positive experiences were reported as well. The relationship with health care workers was perceived as playing a key role in FUED experiences. CONCLUSION: The findings indicate that FUED often have negative experiences in the health care system in Switzerland. The relationship with the health care staff is reported as a decisive ingredient of the experience in health care. Future research is needed to develop awareness-raising interventions for health care staff to improve FUED experiences in health care.

Perspectives of Frequent Users of Emergency Departments on a Case Management Intervention: A Qualitative Study.

BACKGROUND: Effective management of frequent users of emergency departments (FUED) remains challenging. Case management (CM) has shown to improve patient quality of life while reducing ED visits and associated costs. However, little data is available on FUED's perception of CM outside of North America to further improve CM implementation. OBJECTIVES: Explore the FUED's perspectives about CM in Switzerland. DESIGN, SETTING & PARTICIPANTS: Semi-structured qualitative interviews eliciting FUED's experiences of CM were conducted among 20 participants (75% female; mean age = 40.6, SD = 12.8) across 6 hospital ED. OUTCOMES MEASURES & ANALYSIS: Inductive content analysis. MAIN RESULTS: Most participants were satisfied with the CM program. In particular, FUEDs identified the working relationship with the case manager (cm) as key for positive outcomes, and also valued the holistic evaluation of their needs and resources. Overall, patients reported increased motivation and health literacy, as well as facilitated interactions within the healthcare system. Conversely, a small number of participants reported negative views on CM (ie, stigmatization, lack of concrete outcomes). Barriers identified were cm's lack of time, COVID-19's negative impact on CM organization, as well as lack of clarity on the objectives of CM. FUED perceived CM as useful, in particular establishing a working relationship with the cm. Our results suggest that CM can be further improved by (1) professionals remaining non-judgmental toward FUED, (2) making sure the aims and objectives of the CM are understood by the participants, and (3) allowing more time for the cm to carry out their work.

[Complications of cerebral ventricular shunts]. / Complications des dérivations ventriculaires internes.

Internal ventricular shunts are systems for draining excess cerebrospinal fluid to another body cavity in patients with hydrocephalus. They are subject to complications that are sometimes difficult to identify and can lead to diagnostic errors if practitioners are not enough aware. The most frequent complications are mechanical (drainage dysfunction) and infectious. Interruption of the drainage may causeneurological signs of intracranial hypertension; the diagnosis is usually easy. However, the clinical signs can sometimes be less obvious, and a dysfunction of the shunt should be evoked. A multidisciplinary management with the neurosurgery team is necessary to evaluate the appropriate investigation and the emergency management.

Les dérivations ventriculaires internes sont des systèmes permettant de drainer l'excès de liquide céphalorachidien vers une autre cavité du corps chez des malades atteints d'hydrocéphalie. Elles font l'objet de complications parfois difficiles à identifier pouvant conduire à des errances diagnostiques si les praticien-ne-s n'y sont pas sensibilisé-e-s. Les complications les plus fréquentes sont mécaniques avec dysfonctionnement du drainage et infectieuses. L'arrêt du drainage peut provoquer des signes neurologiques d'hypertension intracrânienne ; le diagnostic est alors souvent aisé. Cependant, les signes cliniques peuvent être parfois plus subtils et un dysfonctionnement de la dérivation doit être évoqué. Une prise en charge pluridisciplinaire avec l'équipe de neurochirurgie est nécessaire afin d'évaluer les investigations et la conduite à tenir en urgence.

Implementation of a Novel Concept of Emergency Department Management: e-Boss.

Hospital-based emergency services are frequently criticized worldwide for their management, which can lead to a decrease in staff motivation, with a potential impact on patient safety. This article describes how harnessing the power of social networks can facilitate the management of emergency department teams. Beyond teaching, promoting emergency medicine and recruiting health professionals, these tools can unite employees around a virtual leader and help develop a true service culture. The concept of management through social networks is a novel manner to reach out to staff and should be further explored for use in the health care context.

[Interdisciplinarity in prehospital care:collaboration for better care]. / Interdisciplinarité dans le préhospitalier : collaborer pour mieux soigner.

Multidisciplinary prehospital medicine is more than ever a challenging field of practice, with increasingly complex and polymorbid patients and numerous caregivers' participation. Throughout a clinical case, this paper offers a review of different tools currently in development (point of care ultrasonography, digital patient file) in order to improve solutions and outcomes for patients.

Travailler en interdisciplinarité dans le préhospitalier n'a jamais été aussi important, face à des patients de plus en plus complexes et polymorbides, et dont la prise en charge dépend de nombreux acteurs du système de santé. Au travers d'une vignette clinique, cet article propose des pistes de développement d'outils (ultrason point of care, dossier électronique du patient) permettant une prise en charge ambulatoire interprofessionnelle plus efficiente.

Paramedics in Switzerland: A Mature Profession.

This paper describes how the profession of paramedics has evolved in Switzerland and takes the perspective of public health. Ambulance drivers play an important role in the health system, not only as a response to emergencies, but also by working in an interprofessional and interdisciplinary manner in response to other public health needs, such as home care, triage, telemedicine and interhospital transfers. This pre-hospital system is rapidly evolving and relies on the work of paramedics.

[Management of domestic violence by primary care physician]. / Prise en charge de la violence domestique par le médecin de premier recours.

Domestic violence is a public health problem. It would affect more than a third of women and a quarter of men in Switzerland and has a significantly impact on their physical and mental health as well as their family and socio-professional relationships. The primary care physician plays a key role in the detection and the management of victims of domestic violence. This article recalls this role and explains the methods of taking care of these victims.

La violence domestique constitue un problème de santé publique. Elle toucherait en Suisse plus d'un tiers des femmes et un quart des hommes, et a un impact considérable sur leur santé physique et mentale ainsi que sur leurs relations familiales et socioprofessionnelles. Le médecin de premier recours joue un rôle primordial dans la détection et la prise en charge des victimes de violences domestiques. Cet article rappelle ce rôle et explique les modalités de prise en charge de ces victimes.