Level of Onboard Care for Critical Patients: Analysis of the French Armed Forces Air Medical Evacuations From the Sahel Since 2013.

OBJECTIVE: Since 2013, the French Armed Forces have been engaged in the Sahel. The aim of our work was to study the characteristics of severe patients evacuated according to the composition of the air medical staff (ie, an anesthesiologist/intensive care physician [AICP] or an emergency physician [EP]). METHODS: This was a retrospective cohort analysis including all French service members repatriated from the Sahel with a speedy evacuation priority between 2013 and 2019. RESULTS: A total of 191 patients were evacuated. The causes were trauma for 103 patients and disease for 88. Trauma patients included war injuries (n = 58) and nonbattle injuries (n = 44). For disease patients, the main pathologies were cardiovascular (n = 17), infectious (n = 17), neurologic (n = 15), and gastrointestinal (n = 12). Highly dependent patients were significantly (P < .001) more likely to be managed by an AICP (n = 41) than an EP (n = 5). Moderately dependent patients managed by an AICP (n = 51) were more frequently unstable hemodynamically (n = 5 vs. n = 0, P < .05) and referred to an intensive care unit (n = 24 vs. n = 2, P < .001) than those managed by an EP (n = 41). There were no deaths in flight. CONCLUSION: Greater use of EPs, especially for transporting stabilized patients, would provide more personnel trained in long-distance air transport.

The Damage Control Resuscitation and Surgical Team: The New French Paradigm for Management of Combat Casualties.

INTRODUCTION: The aim of this work was to introduce the new French forward resuscitation and surgical unit. It's also to discuss the choices and waivers granted to fit the tactical context of modern conflicts and the current epidemiology of combat casualties. MATERIALS AND METHODS: A multidisciplinary task force of 11 people proceeded to the conception and the creation of a new military resuscitation and surgical unit. The preliminary work included a scoping review of the combat casualties' epidemiology in modern conflicts and an analysis of the recent French medical-surgical treatment facilities lessons learned. In April 2019, a technical-operational evaluation was conducted to confirm all the technical, ergonomic, and organizational choices made during the design phase. RESULTS: The multidisciplinary task force resulted in the creation of the Damage Control Resuscitation and Surgical Team (DCRST). The DCRST focused on the resuscitation strategy, including transfusion of blood products, and the life-saving surgical procedures to be performed as close as possible to the point of injury. It was designed for the resuscitation of two patients: the life-saving surgery of two patients and the very short-term intensive care (<12 hours) of four patients at the same time. The DCRST provided sufficient autonomy to provide take care of four T1 and four T2 or T3 casualties per day for 48 hours. It was armed with 23 soldiers. The technical equipment represented 5,300 kg and 27 m3. All the technical medical equipment could be stored in two 20-foot containers. CONCLUSION: The DCRST represents a new paradigm in medical support of French military operations. It offers the advantage of two combat casualties' surgical management at the same time, as close as possible to the combat zone. It responds to a 2-fold epidemiological and logistical challenge.

Acute respiratory distress syndrome in the forward environment. Retrospective analysis of acute respiratory distress syndrome cases among French Army war casualties.

BACKGROUND: According to the Joint Theater Trauma Registry, 26% to 33% of war casualties develop acute respiratory distress syndrome (ARDS), with high mortality. Here, we aimed to describe ARDS incidence and severity among patients evacuated from war zones and admitted to French intensive care units (ICUs). METHODS: We performed an observational retrospective multicentric review of all patients evacuated from war zones and admitted to French ICUs between 2003 and 2018. Our analysis included all medical and trauma patients developing ARDS according to the Berlin definition. We evaluated ARDS incidence, and determined ARDS severity from arterial blood gas analysis. Analyzed parameters included invasive ventilation duration, ARDS treatments, ICU stay length, and 30-day and 90-day mortalities. RESULTS: Among 141 included patients (84% military; median age, 30 years), 57 (42%) developed ARDS. Acute respiratory distress syndrome was mild in 13 (22%) patients, moderate in 24 (42%) patients, and severe in 20 (36%) patients. Evacuation occurred in less than 26 hours for 32 war casualties, 17 non-war-related trauma patients, and 8 medical patients. Among severe trauma patients, median Injury Severity Score was 34, and Abbreviated Injury Scale thorax was 3. Upon French ICU admission, median partial pressure of oxygen in arterial blood/inspirated fraction of oxygen ratio was 241 [144-296]. Administered ARDS treatments included intubation (98%, n = 56), protective ventilation (87%, n = 49), neuromuscular blockade (76%, n = 43), prone position (16%, n = 9), inhaled nitric oxide (10%, n = 6), almitrine (7%, n = 7), and extracorporeal life support (4%, n = 2). Median duration of invasive ventilation was 13 days, ICU stay was 18 days, 30-day mortality was 14%, and 90-day mortality was 21%. CONCLUSION: Acute respiratory distress syndrome was frequent and severe among French patients evacuated from war theaters. Improved treatment capacities are needed in the forward environment-for example, a specialized US team can provide extracorporeal life support for highly hypoxemic war casualties. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

Aeromedical Evacuations Within the French Armed Forces: Analysis of 2,129 Patients.

INTRODUCTION: The doctrine of medical support during French military operations is based on a triptych: forward medical stabilization, forward damage control surgery, and early strategic aeromedical evacuation (Strategic-AE). The aim of this study was to describe the last piece, the evacuation process of the French Strategic-AE. METHODS: We conducted a retrospective cohort analysis using patient records from 2015 to 2017. All French service members requiring an air evacuation from a foreign country to a homeland medical facility were included. Data collected included age, medical diagnosis, priority categorization, boarding location, distance from Paris, type of plane and flight, medical team composition, timeline, and dispatch at arrival. RESULTS: We analyzed 2,129 patients evacuated from 71 countries, most from Africa (1,256), the Middle East (382), and South America (175). Most patients (1,958) were not severely injured, although some considered priority (103) or urgent (68). Diagnoses included disease (48.6%), nonbattle injuries (43%), battle stress (5.3%), and battle injuries (3%). 246 Strategic-AE used medical teams in flight, 136 of them in a dedicated Falcon aircraft. The main etiologies for those evacuations were battle injuries (24%), cardiovascular (15.4%), infections (8%), and neurologic (7.3%). The median time of management for urgent patients was about 16 hours but longer for priority patients (26 hours). Once in France, 1,146 patients were admitted to a surgery department and 96 to an intensive care unit. CONCLUSION: This is the first study to analyze the French Strategic-AE system, which is doctrinally unique when compared to its North Atlantic Treaty Organization allies. North Atlantic Treaty Organization allies favor care in the theatre in place of the French early Strategic-AE. However, in the event of a high intensity conflict, a combination of these two doctrines could be useful.

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.

[Alarm and detection signs of upper digestive and respiratory tract cancers]. / Signes d'appel des cancers des voies aérodigestives supérieures.

Upper digestive and respiratory tract cancers represent, in frequency, the fourth cancer in the general population. They are responsible of non-specific symptoms. Clinical examination of this anatomical region is difficult for a layman for whom the specific material is not available to diagnose a small tumour The objective of this paper was to make more sensitive the general practictioners about these type of cancers.