Magnetic needle-tracking device for ultrasound guidance of radial artery puncture: A randomized study on a simulation model.

INTRODUCTION: Ultrasound-guidance of radial artery catheter insertion improves the first attempt success and reduces the occurrence of hematomas. Needle-tracking devices optimize needle-ultrasound beam alignment by displaying in real-time the needle tip position. We compared the median time need by experienced physicians to achieve radial artery puncture using either a conventional ultrasonography device (CUD) or a magnetic needle-tracking ultrasound device (MUD) in a simulation training arm model. METHODS: Fifty experienced residents and physicians performed two punctures in randomized order with the CUD and the MUD. The primary outcome was puncture duration; the secondary outcomes were puncture success, rate of accidental vein puncture, and practitioner's comfort (subjective scale 0-10). RESULTS: The median [lower-upper quartile] puncture time was 10 [6-14] seconds when using CUD and 4 [3-7] seconds when using MUD (P < .01). In the multivariate analysis, MUD use was associated with decreased puncture duration whatever the puncture order (OR 1.13 [1.07-1.20], P < .01). The participants performed 99 (99%) successful punctures: 50 with the MUD (100%) and 49 with the CUD (98%). There was no accidental venous puncture. The practitioner's comfort level was 6.5 [6, 7] with the CUD and 8 [7-9] with the MUD (P < .01). CONCLUSION: MUD reduced radial artery puncture time and improved physician comfort in a simulation training arm model.

Diaphragmatic excursion measurement in emergency department patients with acute dyspnea to predict mechanical ventilation use.

INTRODUCTION: Ultrasound is a feasible and reproducible method for measuring right diaphragmatic excursion (RDE) in ED patients with acute dyspnea (AD). In AD patients, the correlation between the RDE value and the need for mechanical ventilation (MV) is not known. MATERIALS: This was a bicentric, observational prospective study. The RDE measurement was done at admission. The need for MV was defined by the use of MV within 4 h of AD management. An optimal threshold for RDE was determined as the value that minimized the incorrect predictions of the use of MV in the first 4 h as the highest Youden index. RESULTS: We analyzed 102 patients (79 [70; 86] years), 38 (37%) of whom had been ventilated. The RDE value was 1.7 cm [1.4; 2.0] and 2.2 cm [1.8; 2.6] in the ventilated and non-ventilated groups, respectively (p = 0.06). The AUC was 0.68 95% CI [0.57; 0.80]. With a threshold of 2 cm, the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were 76% [60%; 89%], 59% [46%; 71%], 81% [67%; 91%], and 53% [39%; 66%], respectively. In the non-COPD patients, the RDE values were 1.5 cm [1.2; 1.9] and 2.2 cm [1.8; 2.6] (p < 0.01) in the ventilated and not-ventilated groups, respectively. The AUC was 0.77 95% CI [0.64; 0.90]. With a threshold of 2.18 cm, the sensitivity, specificity, NPV, and PPV were 91% [71%; 99%], 51% [36%; 66%], 92% [75%; 99%], and 54% [38%; 69%], respectively. CONCLUSION: The RDE values at ED admission were unable to define a prognostic threshold value associated with subsequent MV need in the AD patients. In non-COPD patients, the NPV was 92%.

Minor Blunt Thoracic Trauma in the Emergency Department: Sensitivity and Specificity of Chest Ultralow-Dose Computed Tomography Compared With Conventional Radiography.

STUDY OBJECTIVE: To evaluate the diagnostic performance of chest ultralow-dose computed tomography (CT) compared with chest radiograph for minor blunt thoracic trauma. METHODS: One hundred sixty patients with minor blunt thoracic trauma were evaluated first by chest radiograph and subsequently with a double-acquisition nonenhanced chest CT protocol: reference CT and ultralow-dose CT with iterative reconstruction. Two study radiologists independently assessed injuries with a structured report and subjective image quality and calculated certainty of diagnostic confidence level. RESULTS: Ultralow-dose CT had a sensitivity and specificity of 100% compared with reference CT in the detection of injuries (187 lesions) in 104 patients. Chest radiograph detected abnormalities in 82 patients (79% of the population), with lower sensitivity and specificity compared with ultralow-dose CT (P<.05). Despite an only fair interobserver agreement for ultralow-dose CT image quality (κ=0.26), the diagnostic confidence level was certain for 95.6% of patients (chest radiograph=79.3%). Ultralow-dose CT effective dose (0.203 mSv [SD 0.029 mSv]) was similar (P=.14) to that of chest radiograph (0.175 mSv [SD 0.155 mSv]) and significantly less (P<.001) than that of reference CT (1.193 mSv [SD 0.459 mSv]). CONCLUSION: Ultralow-dose CT with iterative reconstruction conveyed a radiation dose similar to that of chest radiograph and was more reliable than a radiographic study for minor blunt thoracic trauma assessment. Radiologists, regardless of experience with ultralow-dose CT, were more confident with chest ultralow-dose CT than chest radiograph.

Out-of-hospital Times Using Helicopters Versus Ground Services for Emergency Patients.

OBJECTIVE: Minimizing out-of-hospital time reduces morbidity and mortality in patients with severe trauma, acute coronary syndrome, or acute stroke. Our objective was to compare out-of-hospital times by helicopter versus ground services when the estimated time of arrival on the scene was over 20 minutes. METHODS: We proposed a retrospective observational monocentric study following 2 cohorts. The helicopter group and the ground group included patients with severe trauma, acute coronary syndrome, or acute stroke transported by helicopter or ground services. RESULTS: Two hundred thirty-nine patients were included; 118 were in the ground group, and 121 were in the helicopter group. Distances for the helicopter group were higher (62.1 ± 22.5 km vs. 27.6 ± 10.4 km, P < .001). When distances were over 35 km, the helicopter group was faster. We identified distance, need for surgery, and intensive care hospitalization as 3 predicting factors for choosing helicopters over ground modes of transport. CONCLUSION: In cases of severe trauma, acute coronary syndrome, or acute stroke, emergency medical helicopter transport can be chosen over ground transport when patients are in a severe state and when the distance is further than 35 km from the hospital.

Integration of lung ultrasound in the diagnostic reasoning in acute dyspneic patients: A prospective randomized study.

INTRODUCTION: Misdiagnosis in acute dyspneic patients (ADP) has consequences on their outcome. Lung ultrasound (LUS) is an accurate tool to improve diagnostic performance. The main goal of this study was to assess the determinants of increased diagnostic accuracy using LUS. MATERIALS: Multicentre, prospective, randomized study including emergency physicians and critical care physicians treating ADP on a daily basis. Each participant received three difficult clinical cases of ADP: one with only clinical data (OCD), one with only LUS data (OLD), and one with both. Ultrasound video loops of A, B and C profiles were associated with the cases. Which physician received what data for which clinical case was randomized. Physicians assessed the diagnostic probability from 0 to 10 for each possible diagnosis. The number of uncertain diagnoses (NUD) was the number of diagnoses with a diagnostic probability between 3 and 7, inclusive. RESULTS: Seventy-six physicians responded to the study cases (228 clinical cases resolved). Among the respondents, 28 (37%) were female, 64 (84%) were EPs, and the mean age was 37±8 years. The mean NUDs, respectively, when physicians had OCD, OLD, and both were 2.9±1.8, 2.2±1.7, 2.2±1.8 (p = 0.02). Ultrasound data and ultrasound frequency of use were the only variables related to the NUD. Higher frequency of ultrasound use by physicians decreased the number of uncertain diagnoses in difficult clinical cases with ultrasound data (OLD or associated with clinical data). CONCLUSION: LUS decreases the NUD in ADP. The ultrasound frequency of use decreased the NUD in ADP clinical cases with LUS data.

Assessment of five different probes for lung ultrasound in critically ill patients: A pilot study.

INTRODUCTION: The present study was aimed at comparing the diagnosis concordance of five echo probes of lung ultrasound (LUS) with CT scans in intensive care and emergency patients with acute respiratory failure. MATERIALS: This prospective, observational, pilot study involved 10 acute patients in whom a thoracic CT scan was performed. An expert performed an LUS reference exam using five different probes: three probes with a high-quality conventional echo machine (cardiac phased-array probe, abdominal convex probe, linear probe) and two probes (cardiac and linear) with a pocket ultrasound device (PUD). Then, a trained physician and a resident performed 'blinded' analyses by viewing the video results on a computer. The primary objective was to test concordance between the blinded echo diagnosis and the CT scan. RESULTS: In the 100 LUS performed, the phased-array probe of the conventional machine and linear array probe of the PUD have the best concordance with the CT scan (Kappa coefficient=0.75 [CI 95%=0.54-0.96] and 0.62 [CI 95%=0.37-0.86], respectively) only for experts and trained physicians. The agreement was always poor for residents. Convex (abdominal) and linear transducers of conventional machines and the phased-array transducers (cardiac) of PUD have poor or very poor agreement, regardless of the physician's experience. CONCLUSION: Among the probes tested for LUS in acute patients, the cardiac probe of conventional machines and the linear probes of PUDs provide good diagnosis concordance with CT scans when performed by an expert and trained physician, but not by residents.

Compression with a pocket-sized ultrasound device to diagnose proximal deep vein thrombosis.

INTRODUCTION: Compression ultrasonography (CUS) is a validated technique for the diagnosis of deep venous thrombosis (DVT), but has never been studied with pocket-sized ultrasound device (PUD). The main objective of this study was to assess the diagnostic performance of CUS made by emergency physicians (EPs) using a PUD. MATERIALS: This was a prospective, diagnostic test assessment, single-center study. Patients underwent VCU performed by a trained EP with PUD (CUS-PUD) for searching proximal DVT (PDVT) and were then seen by an expert vascular physician who blindly performed a duplex venous ultrasound, which was the criterion standard. CUS-PUD's diagnostic performance was evaluated by sensitivity (Se), specificity (Sp), and positive and negative predictive values (PPV and NPV). RESULTS: The sample included 57 patients of whom 56 were analyzed. Eleven (20%) PDVT were diagnosed with CUS-PUD: 7 (64%) femoral and 4 (36%) popliteal. The CUS-PUD's Se was 100% [72%; 100%], Sp 100% [92%; 100%]. The PPV was 100% [74%; 100%], and the NPV was 100% [90%; 100%]. CONCLUSION: CUS-PUD performed with a pocket-sized ultrasound appears to be feasible in emergency practice for the diagnosis of proximal DVT. A study with a larger sample size will have to describe the accuracy.

Diaphragmatic excursion measurement in emergency patients with acute dyspnea: toward a new diagnostic tool?

INTRODUCTION: During acute dyspnea (AD), respiratory exhaustion is mainly due to diaphragm fatigue. The primary objective was to validate interobserver reproducibility of diaphragmatic excursion (DE) in emergency department (ED) patients admitted for AD. The secondary objectives were to assess the feasibility of DE measurement and intraobserver reproducibility. Finally, we examined whether the DE value was associated with a need for noninvasive ventilation (NIV). MATERIALS: This was a monocentric, prospective, technical reproducibility study. Adult patients in spontaneous ventilation admitted for AD were included. Two operators carried out 2 consecutive diaphragm excursion measurements each on the right and left hemidiaphragms. RESULTS: Twenty-four patients were analyzed. The feasibility was 96% on the right and 67% on the left. The interobserver concordance between the 2 measures was 0.80 (95% confidence interval [CI], 0.59-0.91) (average difference, -0.07±0.48 cm) on the right and 0.59 (95% CI, 0.19-0.82) (average difference, 0.30±0.91 cm) on the left. For right DE values inferior to 2.3 cm, the interobserver concordance between measures was 0.92 (95% CI, 0.78-0.97). The intraobserver concordance was 0.89 (95% CI, 0.81-0.94) (average difference, 0.02±0.35 cm) on the right and 0.90 (95% CI, 0.82-0.95) (average difference,-0.06±0.45 cm) on the left. When the DE was greater than 2 cm, no patient required NIV. CONCLUSION: Diaphragmatic excursion measurement of the right diaphragm is feasible, with good interobserver and intraobserver reproducibility in ED patients admitted for AD. When the DE value is greater than 2 cm at admission, no subsequent NIV is required.

The impact of emergency department segmentation and nursing staffing increase on inpatient mortality and management times.

BACKGROUND: The aim of our study was to investigate the impact of a new organization of our emergency department (ED) on patients' mortality and management delays. METHODS: The ED segmentation consisted of the development of a new patient care geographical layout on a pre-existing site and changing the organization of patient flow. It took place on May 10, 2012. We did a before-after study in the ED of a university hospital, "before" (winter 2012) and "after" (summer 2012) reorganization by segmentation into sectors. All ED patients were included. RESULTS: Eighty-three thousand three hundred twenty-two patient visits were analyzed, 61,118 in phase "before", 22,204 during the phase "after". The overall inpatient mortality was 1.5 % during summer 2011 ("before" period), 1.8 % during winter 2012 ("before" period), 1.3 % during summer 2012 ("after" period) period (summer 2012 vs. winter 2012, OR = 0.72; 95 % CIs [0.61, 0.85], and summer 2012 vs. summer 2011, OR = 0.85; 95 % CIs [0.72, 0.99]). The mean (SD) time to first medical contact was 129 min (±133) during winter 2012 and 104 min (± 95) during summer 2012 (p < .05). CONCLUSIONS: Our study showed a decrease in mortality and improvement in time to first medical contact after the segmentation of our ED and nursing staffing increase, without an increase in medical personnel. Improving patient care through optimizing ED segmentation may be an effective strategy.

Consequences for overcrowding in the emergency room of a change in bed management policy on available in-hospital beds.

Objective Emergency rooms play an important role by providing continuous access to healthcare 24 h a day, 7 days a week, but the lack of available hospital beds has become a major difficulty. Changing bed management policy could improve patient flow. The aim of the present study was to evaluate the consequences of a change in patient prioritisation on available beds. Methods The study consisted of a computerised bed management simulation based on day-by-day data collected from 1 to 31 January 2013 in a teaching hospital. Real hospital data were used to power the computer simulation. The scenarios tested were: (1) priority for emergency and surgery; (2) priority for emergency and medicine; (3) priority for planned admissions and surgery; and (4) priority for planned admissions and medicine. The results of these scenarios were compared with each other and to actual data. Results This study included 2347 patients. The scenario that proved to be the least efficient was the one that gave priority to emergency patients presenting with a medical condition. The scenario that exhibited the best efficiency was the one that gave priority to planned admissions and surgery. Conclusions Changing policies for hospital bed management is worth exploring to improve hospital patient flow and length of stay. What is known about the topic? The lack of available hospital beds is a major difficulty in managing patient flow in emergency rooms (ERs). The ER patient flow competes against a flow of planned hospital admissions for the same beds and the lack of a clearly defined policy on either prioritising ER patient flow over planned admissions or vice versa contributes to a disordered system. What does this paper add? We compared several simulated scenarios corresponding to different bed management policies. The scenario that gave priority to planned admissions and surgery gave the most suitable results. What are the implications for practitioners? Postponing scheduled surgical patients was not an efficient procedure to solve hospital overcrowding.

Comparison of two methods to report potentially avoidable hospitalizations in France in 2012: a cross-sectional study.

BACKGROUND: Potentially avoidable hospitalizations represent an indirect measure of access to effective primary care. However many approaches have been proposed to measure them and results may differ considerably. This work aimed at examining the agreement between the Weissman and Ansari approaches in order to measure potentially avoidable hospitalizations in France. METHODS: Based on the 2012 French national hospital discharge database (Programme de Médicalisation des Systèmes d'Information), potentially avoidable hospitalizations were measured using two approaches proposed by Weissman et al. and by Ansari et al. Age- and sex-standardised rates were calculated in each department. The two approaches were compared for diagnosis groups, type of stay, severity, age, sex, and length of stay. RESULTS: The number and age-standardised rate of potentially avoidable hospitalizations estimated by the Weissman et al. and Ansari et al. approaches were 742,474 (13.3 cases per 1,000 inhabitants) and 510,206 (9.0 cases per 1,000 inhabitants), respectively. There are significant differences by conditions groups, age, length of stay, severity level, and proportion of medical stays between the Weissman and Ansari methods. CONCLUSIONS: Regarding potentially avoidable hospitalizations in France in 2012, the agreement between the Weissman and Ansari approaches is poor. The method used to measure potentially avoidable hospitalizations is critical, and might influence the assessment of accessibility and performance of primary care.

Review of point-of-care testing and biomarkers of cardiovascular diseases in emergency and prehospital medicine.

Medical reasoning must be constructed on clinical evidence-based biology and follow a process of a priori assumptions. The introduction of a solution of point-of-care testing must result from any work involving clinicians, biologists, and administration. Several solutions of point-of-care testing allow the dosage of cardiac enzymes (CPK, myoglobin, and troponin) or BNP in less than half an hour time. The point-of-care testing saves time in obtaining the results earlier. It seems to allow timesaving on the overall care of the patient and the duration of his stay in the emergency department. By its technique and the relevance of its results, point-of-care testing is suitable for prehospital use.

Ultrasound guidance for radial arterial puncture: a randomized controlled trial.

UNLABELLED: STUDY OBJECTIVE AND BACKGROUND: Arterial puncture for blood gas analysis is a frequent procedure and could be difficult in the emergency setting. The aim of the study was to compare ultrasonographically guided arterial radial puncture vs conventional sampling. MATERIALS AND METHODS: This is a prospective, randomized study. The inclusion criteria are all patients needing arterial blood gas at admission in the emergency unit. The exclusion criteria are the following: Hallen test positive, local sepsis, local trauma, known sever local arteriopathy, refusal of consent by the patient, participation in another study, and cardiac arrest. Patients were randomized into 2 groups: radial arterial puncture obtained through an ultrasonographically guided technique (group 1) or radial arterial puncture by conventional method (group 2). The main objective is the number of attempts after enrollment. The secondary objectives are time to success, patient satisfaction and pain, and physician satisfaction. Immediate complications were collected. Groups were compared with nonparametric analysis. RESULTS: The data were usable for 72 of 74 patients included. Lung disease (acute exacerbation of chronic obstructive pulmonary disease and pneumonia) at 45% (n = 32) and suspicion of pulmonary embolism in 31% (n = 22) were the most common reasons. Demographics data were comparable in the 2 groups. In group 1, the number of attempts significantly increased (2.35 [1-3] vs 1.66 [1-2] [P = .017]), and the sample was 2.4 times longer (132 seconds [50-200] vs 55 [20-65] [P < .01] by standard method). There was no significant difference in terms of pain (visual analog scale [VAS], 3.6 [2-5] for both groups [P = .743]), patient satisfaction (VAS, 7.2 [5-9] vs 6.8 [5-9] [P = .494]), and physician satisfaction (VAS, 6.0 [3.5-8] vs 6.9 [5-9] [P = .233]). No immediate complications were found in the 2 groups. CONCLUSION: Ultrasonographically guided arterial puncture increases the number and duration of implementations. This technique, however, does not alter the patient's pain, the number of immediate complications, or patient and physician satisfaction.

Predicting peripheral venous access difficulty in the emergency department using body mass index and a clinical evaluation of venous accessibility.

BACKGROUND: Peripheral venous (PV) cannulation, one of the most common technical procedures in Emergency Medicine, may prove challenging, even to experienced Emergency Department (ED) staff. Morbid obesity (body mass index [BMI] ≥ 40) has been reported as a risk factor for PV access failure in the operating room. OBJECTIVES: We investigated PV access difficulty in the ED, across BMI categories, focusing on patient-related predicting factors. METHODS: Prospective, observational study including adult patients requiring PV lines. Operators were skilled nurses and physicians. PV accessibility was clinically evaluated before all cannulation attempts, using vein visibility and palpability. Patient and PV placement characteristics were recorded. Primary outcome was failure at first attempt. Outcome frequency and comparisons between groups were examined. Predictors of difficult cannulation were explored using logistic regression. A p-value <0.05 was considered significant. RESULTS: PV lines were placed in 563 consecutive patients (53 ± 23 years, BMI: 26 ± 7 kg/m(2)), with a success rate of 98.6%, and a mean attempt of 1.3 ± 0.7 (range 1-7). Failure at the first attempt was recorded in 21% of patients (95% confidence interval [CI] 17.6-24.4). Independent risk factors were: a BMI ≥ 30 (odds ratio [OR] 1.98, 95% CI 1.09-3.60), a BMI < 18.5 (OR 2.24; 95% CI 1.07-4.66), an unfavorable (OR 1.66, 95% CI 1.02-2.69), and very unfavorable clinical assessment of PV accessibility (OR 2.38, 95% CI 1.15-4.93). CONCLUSION: Obesity, underweight, an unfavorable, and a very unfavorable clinical evaluation of PV accessibility are independent risk factors for difficult PV access. Early recognition of patients at risk could help in planning alternative approaches for achieving rapid PV access.

Pneumopericardium diagnosis by point-of-care ultrasonography.

Focused cardiac ultrasound by the emergency physician has become a fundamental tool to expedite the diagnostic evaluation of the patient at bedside. We report the case of a patient admitted to the emergency department for respiratory distress. He was examined by an emergency physician who performed a bedside echocardiography. Bright spots were seen rapidly moving along the pericardial layer during diastole with comet-tail artifacts extending across the whole image of the heart and disappearing during systole, suggesting pneumopericardium.

Drowning, hypothermia and cardiac arrest: an 18-year-old woman with an automated external defibrillator recording.

This report describes the case of an 18-year-old woman who was found in the sea suffering from cardiac arrest and hypothermia, 90 minutes after she entered the water to swim. The rescue team used an automated external defibrillator to record prehospital management. This recording showed an isoelectric electrocardiogram followed by a ventricular fibrillation, an unsuccessful defibrillation, and lastly, a return of spontaneous circulation with Osborn wave. When she was admitted to the intensive care unit two hours later, the woman's central temperature was 28°C. The case is interesting because of several points. First, to the best of the authors' knowledge, this is the only case of cardiac arrest with severe hypothermia followed by a return of spontaneous circulation documented with an automated external defibrillator recording. Second, the hypothermia is an atypical case occurring in the summer. Hypothermia must be considered even in unlikely circumstances, such as summer in the south of France, when ambient temperatures are high. Lastly, after three days, the patient recovered successfully from cardiopulmonary arrest without cerebral dysfunction.

Prescription errors by emergency physicians for inpatients are associated with emergency department length of stay.

OBJECTIVES: Adverse drug events are the sixth-leading cause of death in Western countries and are also more frequent in emergency departments (EDs). In some hospitals or on some occasions, ED physicians prescribe for patients who they have admitted. These prescriptions are then followed by the wards and can persist for several days. Our objectives were to determine the frequency of prescription errors for patients over 18years old hospitalized from ED to medical or surgical wards, and whether there exists a relationship between those prescription errors and ED LOS. METHODS: This was a single center retrospective study that was conduct in the ED of a university hospital with an annual census of 65 000 patients. The population studied consisted of patients over 18years old hospitalized from ED to medical or surgical wards between January 1st, 2012 and January 21st, 2012. RESULTS: Six hundred eight patients were included. One hundred fifty-four (25%) patients had prescription errors. Prescription errors were associated with increased ED length of stay (OR=2.47; 95% CIs [1.58; 3.92]) and polypharmacy (OR=1.78; 95% CIs [1.20; 2.66]). Fewer prescription errors were found when the patient was examined in the ED by a consultant (OR=0.61; 95% CIs [0.41; 0.91]) and when the medical history was known (OR=0.28; 95% CIs [0.10; 0.88]). CONCLUSION: Prescription errors occurred frequently in the ED. We assume that a clear communication and cooperation between EPs and consultants may help improve prescription accuracy.

Lactic acidosis as a complication of ß-adrenergic aerosols.

Lactic acidosis is a marker of tissue hypoperfusion and impairs oxygen delivery. High lactate levels are associated with altered systemic hemodynamics, tissue hypoperfusion, and altered cellular metabolism. Increased lactate levels have also been reported as a complication of ß-adrenergic agents administered during asthma therapy. A 49-year-old woman with a prior diagnosis of asthma presented to the emergency department in respiratory distress. She immediately received, in 2 hours, 4 bronchodilator aerosols (ipratropium bromide 0.5 mg/2 mL and terbutaline 5 mg/2 mL) and methylprednisolone intravenous (120 mg). After these 4 aerosols, she was still dyspneic. First, arterial blood gases (pH 7.38; PCO2, 3.92 kPa; HCO3, 19.2 mmol/L) and arterial lactate (lactate, 7.96 mmol/L) were performed with a second series of 4 aerosols. Second, arterial blood gases (pH 7.29; PCO2, 4.01 kPa; HCO3, 15.4 mmol/L) and arterial lactate (lactate, 10.47 mmol/L) were performed at the end of the second series of aerosols. There was no hypoxemia, no inadequate cardiac output state, no anemia, no sepsis, and no use of biguanides. Previous studies have suggested that administration of ß agonists can lead to lactic acidemia in the absence of hypoxia or shock, but it is the highest level of lactate that we found in the literature. In sepsis and shock, lactic acidosis is used as a marker of disease severity. In this case, it is not necessarily the sign of an immediate gravity.

First medical contact and physicians' opinion after the implementation of an electronic record system.

Hospitals implement electronic medical record systems (EMRSs) that are intended to support medical and nursing staff in their daily work. Evolution toward more computerization seems inescapable. Nevertheless, this evolution introduced new problems of organization. This before-and-after observational study evaluated the door-to-first-medical-contact (FMC) times before and after the introduction of EMRS. A satisfaction questionnaire, administered after the "after" period, measured clinicians' satisfaction concerning computerization in routine clinical use. The following 5 questions were asked: Do you spare time in your note taking with EMRS? Do you spare time in the medical care that you provide to the patients with EMRS? Does EMRS improve the quality of medical care for your patients? Are you satisfied with the EMRS implementation? Would you prefer a return to handwritten records? Results showed an increase in door-to-FMC time induced by EMRS and a lower triage capacity. In the satisfaction questionnaire, clinicians reported minimal satisfaction but refused to return to handwritten records. The increase in door-to-FMC time may be explained by the improved quantity/quality of data and by the many interruptions due to the software. Medical reorganization was requested after the installation of the EMRS.