Training for a Mass Casualty Incident: Conception, Development and Implementation of a Crew-Resource Management Course for Forward Surgical Teams.

BACKGROUND: The purpose of this article is to describe the development of a crew resource management (CRM) training course dedicated for the forward surgical teams (FSTs) of the French Military Health Service. METHODS: Since 2021, the predeployment training of French FSTs has included a simulation-based curriculum consisting of organizational and human factors. It combines lectures, laboratory exercises, and situational training exercises to consider four fundamental "nontechnical" (cognitive and social) skills for effective and safe combat casualty care: (a) leadership, (b) decision-making, (c) coordination, and (d) situational awareness. RESULTS: The approach was based on three steps: (1) establishment of a conceptual framework of FSTs deployment; (2) development and implementation of an aircrew-like CRM training dedicated to combat casualty care; and (3) assessment of FSTs' CRM skills using an audio/video recording of a simulated mass-casualty incident. CONCLUSION: To ensure complete and high-quality predeployment training, French FSTs undergo a high-quality training that takes into account both technical and non-technical skills to maintain quality of combat care during mass-casualty incidents.

[In situ simulation training of medical-surgical teams in the management of severe trauma patients]. / La formation par simulation in situ des équipes médico-chirurgicales à la prise en charge des traumatisés sévères.

In the management of severe trauma, the aim is to assess the patient's clinical stability as quickly as possible, enabling referral to imaging (whole-body CT scan, embolization if necessary) or the operating room, or even the decision to perform in situ surgery (resuscitation thoracotomy). To cope with these critical situations, team training is essential, with the aim of ensuring the reproducibility of the difficulties encountered. High-fidelity in situ simulation is the ideal tool for meeting this training challenge.

Toward A Serious Game to Help Future Military Doctors Face Mass Casualty Incidents.

INTRODUCTION: To prepare military doctors to face mass casualty incidents (MCIs), the French Army Health Service contributed to the development of TRAUMASIMS, a serious game (SG) for training medical responders to MCIs. METHODS: French military doctors participated in a three-phase training study. The initial war trauma training was a combination of didactic lectures (Phase 1), laboratory exercises (Phase 2), and situational training exercises (STX) (Phase 3). Phase 1 lectures reviewed French Forward Combat Casualty Care (FFCCC) practices based on the acronym MARCHE (Massive bleeding, Airway, Respiration, Circulation, Head, hypothermia, Evacuation) for the detection of care priorities and implementation of life-saving interventions, triage, and medical evacuation (MEDEVAC) requests. Phase 2 was a case-control study that consisted of a traditional text-based simulation of MCIs (control group) or SG training (study group). Phase 3 was clinical: military students had to simultaneously manage five combat casualties in a prehospital setting. MCI management was evaluated using a standard 20-item scale of FFCCC benchmarks, 9-line MEDEVAC request, and time to evacuate the casualty collection point (CCP). Emotional responses of study participants were secondarily analyzed. RESULTS: Among the 81 postgraduate military students included, 38 took SG training, and 35 trained with a text-based simulation in Phase 2. Regarding the error rates made during STX (Phase 3), SG improved FFCCC compliance (11.9% vs. 23.4%; p < .001). Additionally, triage was more accurate in the SG group (93.4% vs. 88.0%; p = .09). SG training mainly benefited priority and routine casualties, allowing faster clearance of the CCP (p = .001). Stress evaluations did not demonstrate any effect of immersive simulation. CONCLUSION: A brief SG-based curriculum (2 hours) improved FFCCC performance and categorization of casualties in MCI STX.

Job retention for people with bipolar disorder: A qualitative analysis.

At least half of people with bipolar disorder, whose global prevalence is greater than 1% of the general population, do not have a stable occupation. The objective of this study is to identify the factors perceived by bipolar people as having an impact on retention in employment. Semi-directed individual interviews were offered to subjects with bipolar disorder, of working age, who had been seen by three different hospital departments in the south of France. These people had to be medically stable and have at least one occupational experience. Each interview was recorded and transcribed manually and then analyzed according to a thematic classification of verbatims. Nineteen people participated in the interviews. Three major themes identified were classified into intrinsic (working routine and working environment) and extrinsic (external aids) factors for the bipolar person. The majority believe that working regular hours is a balancing factor. For everyone, night work and stress factors can lead to relapses. All stressed the need to destigmatize the disease. Most believe that it is necessary to develop employment support organizations specific to mental illnesses. This research helps to inform people with bipolar disorder about the occupational factors that help balance their condition. Personalized multidisciplinary care pathways involving occupational medicine must be developed in order to promote the balance of the disease and job retention.

Impact of the implementation of a trauma system on compliance with evidence-based clinical management guidelines in penetrating thoracic trauma.

PURPOSE: Since 2014, a trauma system (TS) for the Provence-Alpes-Cote-d'Azur (PACA) region has been set up with protocols based on the European guidelines for the management of bleeding trauma patients. The present study aims to assess compliance with protocols in penetrating thoracic trauma on admission to a level I trauma centre and to determine whether compliance impacts morbidity and mortality. METHODS: This multicentric pre-post study included all penetrating thoracic trauma patients referred to Marseille area level I centres between January 2009 and December 2019. On the basis of the European guidelines, eight objectively measurable recommendations concerning the in-hospital trauma care for the first 24 h were analysed. Per-patient and per-criterion compliance rates and their impact on morbidity and mortality were evaluated before and after TS implementation. RESULTS: A total of 426 patients were included. No differences between the two groups (before and after 2014) were reported for demographics or injury severity. The median (interquartile range) per-patient compliance rate increased from 67% [0.50; 0.75] to 75% [0.67; 1.0] (p < 0.01) after implementation of a TS. The 30-day morbidity-mortality was, respectively, of 17% (30/173) and 13% (32/253) (p = 0.18) before and after TS implementation. A low per-patient compliance rate was associated with an increase in the 30-day morbidity-mortality rate (p < 0.01). Severity score-adjusted per-patient compliance rates were associated with decreased 30-day morbidity-mortality (odds ratio [IC 95%] = 0.98 [0.97; 0.99] p = 0.01). CONCLUSION: Implementation of a TS was associated with better compliance to European recommendations and better outcomes for severe trauma patients. These findings should encourage strict adherence to European trauma protocols to ensure the best patient outcomes.

Exploring the links between volcano flank collapse and the magmatic evolution of an ocean island volcano: Fogo, Cape Verde.

Mass-wasting of ocean island volcanoes is a well-documented phenomenon. Massive flank collapses may imply tens to hundreds of km3 and generate mega-tsunamis. However, the causal links between this large-scale, low-frequency instability, and the time-space evolution of magma storage, crystal fractionation/accumulation, lithospheric assimilation, and partial melting remains unclear. This paper aims at tracking time variations and links between lithospheric, crustal and surface processes before and after a major flank collapse (Monte Amarelo collapse ca. 70 ka) of Fogo volcano, Cape Verde Islands, by analysing the chemical composition (major, trace elements, and Sr-Nd-Pb isotopes) and age-controlled stratigraphy (K-Ar and Ar-Ar dating) of lavas along vertical sections (Bordeira caldera walls). The high-resolution sampling allows detecting original variations of composition at different time-scales: (1) a 60 kyrs-long period of increase of magma differentiation before the collapse; (2) a 10 kyrs-long episode of reorganization of magma storage and evacuation of residual magmas (enriched in incompatible elements) after the collapse; and (3) a delayed impact at the lithospheric scale ~ 50 kyrs after the collapse (increasing EM1-like materiel assimilation).

Complex and prolonged hypercoagulability in coronavirus disease 2019 intensive care unit patients: A thromboelastographic study.

BACKGROUND: A high number of thrombotic complications have been reported in critically ill patients with coronavirus disease 2019 (COVID-19) and appear to be related to a hypercoagulable state. Evidence regarding detection, management, and monitoring of COVID-19-associated coagulopathy is still missing. We propose to describe the thrombus viscoelastic properties to investigate the mechanisms of hypercoagulability in patients with COVID-19. METHODS: Thromboelastography (TEG) was performed in 24 consecutive patients admitted to a single intensive care unit for COVID-19 pneumonia, and 10 had a second TEG before being discharged alive from the intensive care unit. RESULTS: Compared with a group of 20 healthy participants, patients with COVID-19 had significantly decreased values of reaction time, coagulation time, and lysis index and increased values of α angle, maximum amplitude, clot strength, and coagulation index. Velocity curves were consistent with increased generation of thrombin. These values persisted in surviving patients despite their good clinical course. DISCUSSION: In patients with COVID-19, TEG demonstrates a complex and prolonged hypercoagulable state including fast initiation of coagulation and clot reinforcement, low fibrinolysis, high potential of thrombin generation, and high fibrinogen and platelet contribution. The antithrombotic strategy in patients with COVID-19 during intensive care hospitalisation and after discharge should be investigated in further studies.

Oxygen Management During Collective Aeromedical Evacuation of 36 COVID-19 Patients With ARDS.

OBJECTIVE: The ongoing coronavirus disease-2019 pandemic leads to the saturation of critical care facilities worldwide. Collective aeromedical evacuations (MEDEVACS) might help rebalance the demand and supply of health care. If interhospital transport of patients suffering from ARDS is relatively common, little is known about the specific challenges of collective medevac. Oxygen management in such context is crucial. We describe our experience with a focus on this resource. METHODS: We retrospectively analyzed the first six collective medevac performed during the coronavirus disease-2019 pandemic by the French Military Health Service from March 17 to April 3, 2020. Oxygen management was compliant with international guidelines as well as aeronautical constraints and monitored throughout the flights. Presumed high O2 consumers were scheduled to board the last and disembark the first. RESULTS: Thirty-six mechanically ventilated patients were successfully transported within Europe. The duration of onboard ventilation was 185 minutes (145-198.5 minutes), including the flight, the boarding and disembarking periods. Oxygen intake was 1,650 L per patient per flight (1,350-1,950 L patient per flight) and 564 L per patient per hour (482-675 L per patient-1 per hour) and surpassed our anticipation. As anticipated, presumed high O2 consumers had a reduced ventilation duration onboard. The estimations of oxygen consumptions were frequently overshot, and only two hypoxemia episodes occurred. CONCLUSION: Oxygen consumption was higher than expected, despite anticipation and predefined oxygen management measures, and encourages to a great caution in the processing of such collective medevac missions.

Collective aeromedical transport of COVID-19 critically ill patients in Europe: A retrospective study.

BACKGROUND: In early 2020, the coronavirus disease 2019 (COVID-19) pandemic outbreak has posed the risk of critical care resources overload in every affected country. Collective interhospital transport of critically ill COVID-19 patients as a way to mitigate the localised pressure from overloaded intensive care units at a national or international level has not been reported yet. The aim of this study was to provide descriptive data about the first six collective aeromedical evacuation (MEDEVAC) of COVID-19 patients performed within Europe. METHODS: This retrospective study included all adult patients transported by the first six collective MEDEVAC missions for COVID-19 patients performed within Europe on the 18th, 21st, 24th, 27th, 31st of March and the 3rd of April 2020. RESULTS: Thirty-six patients with acute respiratory distress syndrome (ARDS) were transported aboard six MEDEVAC missions. The median duration of mechanical ventilation in ICU before transportation was 4 days (3-5.25). The median PaO2/FiO2 ratio obtained before, during the flight and at day 1 after the transport was 180 mmHg (156-202,5), 143 mmHg (118,75-184,75) and 174 mmHg (129,5-205,5), respectively, with no significant difference. The median norepinephrine infusion rate observed before, during the flight and at day 1 after the transport was 0,08 µg/kg-1. min-1 (0,00-0,20), 0,08 (0,00-0,25), and 0,07 (0,03-0,18), respectively, with no significant difference. No life-threatening event was reported. CONCLUSION: Collective aero-MEDEVAC of COVID-19 critically ill patients could provide a reliable solution to help control the burden of the disease at a national or international level.

Explosive eruption, flank collapse and megatsunami at Tenerife ca. 170 ka.

Giant mass failures of oceanic shield volcanoes that generate tsunamis potentially represent a high-magnitude but low-frequency hazard, and it is actually difficult to infer the mechanisms and dynamics controlling them. Here we document tsunami deposits at high elevation (up to 132 m) on the north-western slopes of Tenerife, Canary Islands, as a new evidence of megatsunami generated by volcano flank failure. Analyses of the tsunami deposits demonstrate that two main tsunamis impacted the coasts of Tenerife 170 kyr ago. The first tsunami was generated during the submarine stage of a retrogressive failure of the northern flank of the island, whereas the second one followed the debris avalanche of the subaerial edifice and incorporated pumices from an on-going ignimbrite-forming eruption. Coupling between a massive retrogressive flank failure and a large explosive eruption represents a new type of volcano-tectonic event on oceanic shield volcanoes and a new hazard scenario.

Source mechanisms of volcanic tsunamis.

Volcanic tsunamis are generated by a variety of mechanisms, including volcano-tectonic earthquakes, slope instabilities, pyroclastic flows, underwater explosions, shock waves and caldera collapse. In this review, we focus on the lessons that can be learnt from past events and address the influence of parameters such as volume flux of mass flows, explosion energy or duration of caldera collapse on tsunami generation. The diversity of waves in terms of amplitude, period, form, dispersion, etc. poses difficulties for integration and harmonization of sources to be used for numerical models and probabilistic tsunami hazard maps. In many cases, monitoring and warning of volcanic tsunamis remain challenging (further technical and scientific developments being necessary) and must be coupled with policies of population preparedness.