Use of Intranasal Analgesia in French Armed Forces: A Cross-Sectional Survey.

BACKGROUND: Pain management is essential in military medicine, particularly in Tactical Combat Casualty Care (TCCC) during deployments in remote and austere settings. The few previously published studies on intranasal analgesia (INA) focused only on the efficacy and onset of action of the medications used (ketamine, sufentanil, and fentanyl). Side-effects were rarely reported. The aim of our study was to evaluate the use of intranasal analgesia by French military physicians. METHODS: We carried out a multicentric survey between 15 January and 14 April 2020. The survey population included all French military physicians in primary-care centers (n = 727) or emergency departments (n = 55) regardless of being stationed in mainland France or French overseas departments and territories. RESULTS: We collected 259 responses (33% responsiveness rate), of which 201 (77.6%) physicians reported being familiar with INA. However, regarding its use, of the 256 physicians with completed surveys, only 47 (18.3%) had already administered it. Emergency medicine physicians supporting highly operational units (e.g., Special Forces) were more familiar with this route of administration and used it more frequently. Ketamine was the most common medication used (n = 32; 57.1%). Finally, 234 (90%) respondents expressed an interest in further education on INA. CONCLUSION: Although a majority of French military physicians who replied to the survey were familiar with INA, few used it in practice. This route of administration seems to be a promising medication for remote and austere environments. Specific training should, therefore, be recommended to spread and standardize its use.

Use of a Digital Cognitive Aid Improves Memorization of Military Caregivers After High-Fidelity Simulations of Combat Casualty Care.

INTRODUCTION: High-fidelity simulation is widely used in the ongoing education of caregivers. However, the complex high-stakes simulated crisis environment affects memorization. This study investigated whether participants would remember more key training messages 3 months after a simulated complex emergency situation if they had used a digital cognitive aid (CA) during the simulations. MATERIALS AND METHODS: This randomized controlled trial was performed during a combat casualty training course for military physicians and nurses. Each pair of care providers completed two scenarios randomized to be undertaken either with or without a digital CA. At the end of each debriefing, instructors gave five scenario-specific key messages aloud. Three months later, learners were asked to recall the messages from their two scenarios and were scored for each scenario. The primary endpoint was the number of key messages recalled. The secondary endpoints were the influence on the results of the profession and the scenario block and age of the leader. RESULTS: Thirty-six pairs of participants were included. Due to operational constraints, only 34 completed the study. The use of the digital CA was associated with a positive effect on memorization at 3 months (F = 82.2, P < .001), unrelated to the leader's profession, age, or the scenario block. The median of the memorization scores was 2/5 [1-3] with the digital CA and 1/5 [1-1] without it, which represents a difference of one memorized element (95% CI, 1-2; η2 = 0.39). CONCLUSIONS: The digital CA allowed learners to remember twice as many key elements 3 months after simulated training of medical care for military combat casualties. A dedicated digital CA might be an asset for better care in a combat environment and for learning and memorizing critical care procedures following complex emergency situations.

Blister Beetle Dermatitis Outbreaks in Mali.

INTRODUCTION: Meloidae are distributed in temperate and arid regions but are also common in subtropical and tropical savannahs. These insects contain cantharidin, a vesicant substance that can cause poisoning by ingestion and dermatitis by direct contact. MATERIAL AND METHODS: We describe recurrent Meloidae-related dermatitis outbreaks and their health impact by analyzing medical consultation records and meteorological data. RESULTS: Between 2015 and 2019, dermatitis outbreaks took place at a French military base at the end of the rainy season, from July to August, with 100 cases reported in 2015, 74 in 2017, 100 in 2018, and 36 in 2019. In 2017, the incidence rate was 4.4% for the base's population. Initial medical consultations represented 31.5% of total medical care activity. Meloidae were identified as Cyaneolytta fryi. CONCLUSIONS: These outbreaks of burn-like lesions, although clinically benign, can place a considerable burden on the medical activity of health care facilities. The diagnosis of Meloidae dermatitis is exclusively anamnestic and clinical and requires reported contact with the insect. The treatment protocol is that of standard burn care, and the best preventive measure is to avoid bright white lights. Military personnel, foreign workers, and travelers venturing into the Sahel should be warned of the risks associated with these beetles.

Exertional Heatstroke Support at the Acute Phase: Assessment of Professional Practices in the French Military Forces.

INTRODUCTION: Exertional heatstroke (EHS) is defined as a disturbance in consciousness, ranging from confusion to coma, with hyperthermia typically higher than 40 °C that occurs during intense physical activity. It is a life-threatening pathology that has been observed in the military since antiquity. Recent research has changed the understanding of the pathophysiology of EHS and led to the development of gold-standard treatment, which includes intrarectal temperature monitoring and cooling the patient as quickly as possible. The objective of this study was to describe the theoretical knowledge of French military unit practitioners regarding the latest recommendations for the treatment of EHS and their management of this condition in practice. MATERIALS AND METHODS: We conducted a web-based survey from August 2 to December 31, 2020, including all French military practitioners. The questionnaire, sent via email, aimed to describe practitioners' theoretical knowledge of EHS and its practical management. Practitioners who had a local management protocol were asked to include it with their responses to analyze and determine if protocols complied with the latest recommendations. The responses were collected by name, anonymized, and analyzed by a single investigator. This observational study was exempted from ethics board approval by the French Military Health Service's research department. RESULTS: Of the questionnaires sent, 84 practitioners responded, describing their theoretical knowledge of EHS. Of the respondents, 42 had experience managing EHS and described their practical management of EHS in the field. In addition, 15 local protocols were analyzed. Intrarectal temperature measurement was recommended by 71 physicians (84.5%), and cooling was preferably achieved by immersion in cold water by 65 practitioners (77.4%). If this method was unavailable, only 36.9% (24/65) of practitioners submerged patients in water at room temperature. Nine practitioners (10.7%) had perfect theoretical knowledge, and 36 (42.9%) knew the optimal management of EHS. There was no difference in the frequency of perfect theoretical knowledge between practitioners who had experience with EHS (9/36) and those who did not (12/48; P = 1). Practitioners who had experience with EHS had better optimal management knowledge than those who did not (61.1% vs.29.1%; P = .03). In practice, 21 (50%) cases had intrarectal temperature monitoring, and only 6 (14.3%) were immersed in cold water. Logistical challenges prevented optimal cooling methods in 29 (90.6%) cases. Concerning the other aspects of management, four (26.7%) practitioners recommended tympanic temperature measurement, two (20%) did not indicate immersion for cooling, and one (6.7%) administered paracetamol. CONCLUSIONS: French military practitioners' theoretical knowledge of EHS is insufficient for a lethal pathology that is common in the military. Thus, improvements must be made in training and disseminating up-to-date knowledge. In practice, a lack of adequate logistics and the fact that first responders are rarely practitioners increase the suboptimal care of EHS. First responders should be equipped with valid and adapted protocols and adequate logistical means to manage this condition. By establishing a cohort of well-treated patients, we will be able to develop evidence-based recommendations for when to cease cooling and identify intrinsic susceptibility to EHS.

Impact of a Digital Cognitive Aid on the Performance of Military Healthcare Teams During Critical Care Management in a Warfront Injury Situation: A Simulation Randomized Controlled Study.

INTRODUCTION: Initial healthcare delivery after warfront injury is unpredictably challenging for military forces. As preparatory training, healthcare providers use simulation to improve their performance in stressful critical situations. This study investigated whether a digital CA held by the team leader improved performance in simulated combat casualty care. METHODS: This randomized controlled trial was performed during a combat casualty training course for military physicians and nurses in France. Each pair of care providers completed 2 scenarios randomized to be undertaken either with or without a digital CA. The primary end point was the technical performance evaluated from a video recording by 2 independent raters using a pre-established score grid (up to 100%) according to military protocols. The secondary end point was the nontechnical performance (TEAM scale, maximum: 54 points). RESULTS: Thirty-six pairs of participants were included. Use of the digital CA improved both technical (74% vs 53%, P < 0.001) and nontechnical (42 vs 32, P < 0.001) performance. CONCLUSIONS: The digital CA improved technical and nontechnical performance during training of medical care for military combat casualties. Use of a dedicated digital CA might improve care in a combat environment. STUDY TYPE: This study is a randomized controlled trial.

Review of Scorpion Stings and Snakebites Treated by the French Military Health Service During Overseas Operations Between 2015 and 2017.

INTRODUCTION: Depending on their theatre of operation, French soldiers may potentially be exposed to scorpion stings and snakebites. Following the recommendations of a French military health service (FMHS) technical committee for envenomation, the FMHS provides antivenoms appropriate to each deployment. This work aimed to evaluate this risk of envenomation and to assess the antivenoms used by the FMHS in operational theatres since the creation of this committee in 2015. METHODS: Cases were identified based on a review of temporary authorization of use application forms for the use of antivenom. Data were collected retrospectively from these forms, and prescribing physicians were contacted for any missing data. RESULTS: Between 2015 and 2017, 28 requests for temporary authorization of use were identified: 19 for Scorpifav (Sanofi-Pasteur, Lyon, France) and 9 for Fav-Afrique (Sanofi-Pasteur). The FMHS treated 15 soldiers and 4 civilians for scorpion envenomation with Scorpifav: 15 in Mali, 3 in Chad, and 1 in Niger. Systemic signs were observed in 7 patients. Two soldiers and 7 civilians were treated with Fav-Afrique for ophidian envenomation: 5 in Djibouti, 3 in Mali, and 1 in the Republic of Côte d'Ivoire. These 28 patients were treated without sequelae. Other than moderate erythema that resolved with an antihistamine, no adverse effects were reported. Medical evacuation to France was unnecessary. CONCLUSIONS: This study shows that the risk of envenomation for soldiers on deployment is low but real. Antivenoms used by the FMHS were efficient and well tolerated, preserving the operational capacity of deployed troops.

Five years of prolonged field care: prehospital challenges during recent French military operations.

BACKGROUND: French military operations in the Sahel conducted since 2013 over more than 5 million square kilometers have challenged the French Military Health Service with specific problems in prolonged field care. STUDY DESIGN AND METHODS: To describe these challenges, we retrospectively analyzed the prehospital data from the first 5 years of these operations within a delimited area. RESULTS: One hundred eighty-three servicemen of different nationalities were evacuated, mainly as a result of explosions (73.2%) or gunshots (21.9%). Their mean number evacuation was 2.2 (minimum, 1; maximum, 8) per medical evacuation with a direct evacuation from the field to a Role 2 medical treatment facility (MTF) for 62% of them. For the highest-priority casualties (N = 46), the median time [interquartile range] from injury to a Role 2 MTF was 130 minutes [70 minutes to 252 minutes], exceeding 120 minutes in 57% of cases and 240 minutes in 26%. The most frequent out-of-hospital medical interventions were external hemostasis, airway and hemopneumothorax management, hypotensive resuscitation, analgesia, immobilization, and antibiotic administration. Prehospital transfusion (RBCs and/or lyophilized plasma) was started three times in the field, two times during helicopter medical evacuation, and five times in tactical fixed wing medical aircraft. Lyophilized plasma was confirmed to be particularly suitable in these settings. One of the specific issues involved in lengthy prehospital time was the importance to reassess and convert tourniquets prior to Role 2 MTF admission. CONCLUSION: Main challenges identified include reducing evacuation times as much as possible, preserving ground deployment of sufficiently trained medics and medical teams, optimization of transfusion strategies, and strengthening specific prolonged field care equipment and training.

Pre-hospital management of pediatric polytrauma during modern conflict: experience and limits of the French military health service.

BACKGROUND: French military physicians serving in deployment are confronted with pediatric polytrauma patients (PPP) during the provision of medical aid to civilian populations. The objectives of this study were to describe the current care of PPPs during these missions, to report difficulties encountered and to evaluate the training of doctors for management of PPPs in the field. METHODS: A descriptive epidemiological study based on a questionnaire sent to physicians who had been deployed overseas. RESULTS: 91 doctors participated. Their mean age was 35 years. 86% of the doctors managed children whilst serving overseas, of which 54% were PPPs. The incidence of pediatric polytrauma varied according to the country, but overall from 1129 emergencies reported during overseas missions, 11% were PPPs. Penetrating traumas represented 37% of cases; 24% were circulatory distress and 19% were massive bleeding. 80% of the doctors reported a lack of pediatric trauma experience, less than 5% had received appropriate in-service training and only 9% had worked in pediatric emergency facilities in France. The equipment available for PPPs in the field was often poorly understood and frequently considered to be insufficient. CONCLUSIONS: The occurrence of PPPs of war is rare and complex, but care of older children it is similar to that required for adults. Preparation for PPP management, it could be optimized by identifying risks which alter depending on the country of deployment, such as the logistical organization of the battlefield chain of care. Improvements in doctors' pediatric trauma training should be individualized, based on their mission needs. LEVEL OF EVIDENCE: III.

Liver transplantation in patients with liver failure related to exertional heatstroke.

BACKGROUND & AIMS: Severe acute liver injury is a grave complication of exertional heatstroke. Liver transplantation (LT) may be a therapeutic option, but the criteria for LT and the optimal timing of LT have not been clearly established. The aim of this study was to define the profile of patients who require transplantation in this context. METHODS: This was a multicentre, retrospective study of patients admitted with a diagnosis of exertional heatstroke-related severe acute liver injury with a prothrombin time (PT) of less than 50%. A total of 24 male patients were studied. RESULTS: Fifteen of the 24 patients (median nadir PT: 35% [29.5-40.5]) improved under medical therapy alone and survived. Nine of the 24 were listed for emergency LT. At the time of registration, the median PT was 10% (5-12) and all had numerous dysfunctional organs. Five patients (nadir PT: 12% [9-12]) were withdrawn from the list because of an elevation of PT values that mainly occurred between day 2 and day 3. Ultimately, 4 patients underwent transplantation as their PT persisted at <10%, 3 days (2.75-3.25) after the onset of exertional heatstroke, and they had more than 3 organ dysfunctions. Of these 4 patients, 3 were still alive 1 year later. Histological analysis of the 4 explanted livers demonstrated massive or sub-massive necrosis, and little potential for effective mitoses, characterised by a "mitonecrotic" appearance. CONCLUSION: The first-line treatment for exertional heatstroke-related severe acute liver injury is medical therapy. LT is only a rare alternative and such a decision should not be taken too hastily. A persistence of PT <10%, without any signs of elevation after a median period of 3  days following the onset of heatstroke, was the trigger that prompted LT, was the trigger adopted in order to decide upon LT. LAY SUMMARY: Acute liver injury due to heatstroke can progress to acute liver failure with organ dysfunction despite medical treatment; in such situations, liver transplantation (LT) may offer a therapeutic option. The classic criteria for LT appear to be poorly adapted to heatstroke-related acute liver failure. We confirmed thatmedication is the first-line therapy acute liver injury caused by heatstroke, with LT only rarely necessary. A decision to perform LT should not be made hastily. Fluctuations in prothrombin time and the patient's clinical status should be considered even in the event of severe liver failure.

Factors associated with malaria chemoprophylaxis compliance among French service members deployed in Central African Republic.

BACKGROUND: Malaria is a public health concern in the French armed forces, with 400-800 cases reported every year and three deaths in the past 2 years. However, lack of chemoprophylaxis (CP) compliance is often reported among service members. The aim of this study was to explore factors associated with CP compliance. METHODS: A retrospective study (1296 service members) was carried out among troops deployed in Central African Republic. Determinants of CP were collected by self-questionnaire. Socio-demographic variables, behavioural characteristics, belief variables, operational determinants such as troops in contact (TIC) and number of nights worked per week and peer-to-peer reinforcement were studied. Relationships between covariates and compliance were explored using logistic regressions (outcome: compliance as a dummy variable). RESULTS: Chemoprophylaxis compliance was associated with other individual preventive measures against mosquito bites (bed net use, OR (odds ratio) = 1.41 (95% CI [1.08-1.84]), and insecticide on clothing, OR = 1.90 ([1.43-2.51]) and malaria-related behaviours (taking chemoprophylaxis at the same time every day, OR = 2.37 ([1.17-4.78]) and taking chemoprophylaxis with food, OR = 1.45 ([1.11-1.89])). High perceived risk of contracting malaria, OR = 1.59 ([1.02-2.50]), positive perception of CP effectiveness, OR = 1.62 ([1.09-2.40]) and the practice of peer-to-peer reinforcement, OR = 1.38 ([1.05-1.82]) were also associated with better compliance. No association was found with TIC and number of nights worked. CONCLUSIONS: This study, which shows a positive relationship between peer-to-peer reinforcement and CP compliance, also suggests the existence of two main personality profiles among service members: those who seek risks and those who are health-conscious. Health education should be expanded beyond knowledge, know-how and motivational factors by using a comprehensive approach based on identification of health determinants, development of psychosocial skills and peer-to-peer reinforcement.

[Wounded soldier pre hospital covering: the forward medicalization]. / Un standard de soins pour que le blessé arrive vivant au bloc opératoire.

Wounded soldier pre hospital covering: the forward medicalisation. Forward medicalisation is, for French medical service, the first link of wounded soldier all round chain, whose goal is the more precocity arrival in a military hospital on national field after has been done the necessary measures for the survival and prevention of sequelae during all this chain. This forward medicalisation is based on the experiences of anterior conflicts and modern medical technical evolution. It works around combat casualties care, declined in three competences levels. Under enemy fire, each soldier is capable of implementing first combat casualties care level. A second level corresponds for producing of rescue technical acts by specifically trained personals, until the arrival of a medical staff witch is most of the time a doctor and a nurse. This pair, trained at the third combat casualties care level, is able to apply forward reanimation acts and to prepare the evacuation of the wounded in direction to the first surgical field team.

Prise en charge préhospitalière du blessé de guerre : la médicalisation de l'avant. La médicalisation de l'avant correspond pour le service de santé des armées au premier maillon d'une chaîne de prise en charge globale du blessé de guerre, dont l'objectif est son arrivée la plus précoce possible dans une structure hospitalière militaire sur le territoire national, après avoir réalisé les gestes nécessaires à sa survie et à la prévention des séquelles tout au long de cette chaîne. Cette médicalisation de l'avant se fonde sur l'expérience des conflits antérieurs et l'évolution des techniques de soins modernes. Elle s'articule autour du sauvetage au combat, qui se décline en trois niveaux de compétences. Sous le feu ennemi, chaque combattant est capable de mettre en oeuvre le sauvetage au combat de niveau 1. Un deuxième niveau correspond à la réalisation de gestes techniques salvateurs par des personnels spécifiquement formés, jusqu'à l'arrivée d'une équipe médicale comprenant le plus souvent un médecin et un infirmier. Ce binôme, formé au sauvetage au combat de niveau 3, est en mesure d'appliquer des gestes de réanimation de l'avant et de préparer l'évacuation du blessé vers la première structure chirurgicale de terrain.