Impact of a simulation-based training on the experience of the beginning of residency.

INTRODUCTION: We aimed to evaluate the impact of an immersive simulation session on the experience of the beginning of residency. METHODS: The interventional group consisted of newly recruited residents in 2019, who participated in the workshop presenting four emergency scenarios frequently encountered during night shifts; the control group comprised residents who had begun their internship in 2018, without having participated in the simulation workshop. The level of psychological stress and self-confidence were self-estimated in the simulation group before and immediately after the workshop. During the second semester of residency, stress, self-efficacy and anxiety were evaluated in both groups with the Perceived Stress Scale (PSS), General Self-efficacy Scale (GSES), and Generalized Anxiety Disorder-7 (GAD-7) scale. RESULTS: In the second semester 2020, the PSS, GSES and GAD-7 were 20.71±8.15 and 22.44±5.68 (P=0.40); 26.88±6.30 and 27.11±3.95 (P=0.87); 6.94±5.25 and 8.89±4.78 (P=0.22) for the simulation (n=17, 89.5% of participation) and control (n=9, 75%) groups, respectively. In the simulation group, the level of self-confidence had significantly improved from 1.82±0.95 before the session to 2.29±1.16 after the session (P=0.05). Interestingly, this improvement in self-confidence was significantly correlated with GAD-7 (P=0.014) and PSS (P=0.05), and tended to be correlated with GSES (P=0.09). CONCLUSION: Our study showed a significant improvement in self-confidence between before and after the simulation session. Residents who experienced an improvement in self-confidence saw their stress and anxiety levels decrease during the second semester reevaluation, in favor of a prolonged benefit from the session.

Applying an immersive tutorial in virtual reality to learning a new technique.

OBJECTIVE: The medical world is continuously evolving, with techniques being created or improved almost daily. Immersive virtual reality (VR) is a technology that could be harnessed to develop tools that meet the educational challenges of this changing environment. We previously described the immersive tutorial, a 3D video (filmed from the first-person point of view), displayed on a VR application. This tool offers access to supplementary educational data in addition to the video. Here we attempt to assess improvement in learning a technique using this new educational format. MATERIAL AND METHODS: We selected a single neurosurgical technique for the study: external ventricular drainage. We wrote a technical note describing this procedure and produced the corresponding immersive tutorial. We conducted a prospective randomized comparative study with students. All participants read the technical note, and one group used the immersive tutorial as a teaching supplement. The students completed a multiple-choice questionnaire immediately after the training and again at six months. RESULTS: One hundred seventy-six fourth-year medical students participated in the study; 173 were included in assessing the immediate learning outcomes and 72 were included at the six-month follow-up. The VR group demonstrated significantly better short-term results than the control group (P=0.01). The same trend was seen at six months. CONCLUSION: To our knowledge, this study presents one of the largest cohorts for VR. The use of the immersive tutorial could enable a large number of healthcare professionals to be trained without the need for expensive equipment.

[Tourniquet use in civil and military medicines]. / Le garrot en médecine d'urgence et militaire.

OBJECTIVES: The purpose of this literature review is, after a history and a point about current situation, to present the military use and precautions of use of tourniquet for civil and military medicine. DATA SOURCES: A review of the Anglo-Saxon and French literature was performed in PUBMED database, from 1962 to 2012. The research was conducted using the following keywords: "tourniquet", "complications", "haemorrhage", "emergency", "military medicine", used alone or in combination. DATA EXTRACTION: The extracted data concerned the history, the epidemiology, the interest of tourniquet during peacetime and wartime, adverse effects and the ratio benefit/risk. DATA SYNTHESIS: The tourniquet is "a device which is tightened, in case of haemorrhage, around a limb in order to slow or stop the venous or arterial circulation before surgery…". This item is thus used in surgery to reduce intraoperative bleeding and in emergency medicine as a rescue technique for bleeding places non accessible to compression or to other technical hemostasis. It is also used for treating bleeding of mass casualties. However, its use is too poorly managed by health professionals and it remains risky. Recent armed conflicts have yet revived its day use. CONCLUSION: The tourniquet has utility in times of war and in peacetime. In each case, indications and complications must be known.

[Review of medication errors: a case in an intensive care unit]. / Revue des erreurs médicamenteuses (REMED) : une première en service de réanimation.

OBJECTIVE: The authors conducted for the first time a medication error review (REMED) following a medication error occurred in an intensive care unit. The aim of this study was to assess this first REMED. STUDY DESIGN: Descriptive study. METHODS: The analysis of the medication error, consisting in the administration of Clottafact(®) instead of Aclotine(®), was performed using the REMED method. RESULTS: The medication error was characterized as "proved error" and "missed before administration". Four main causes were identified: poor quality of drug storage, homophony between Aclotine(®) and Clottafact(®), non-compliance with good practices, and need of hemofiltration for the patient. At least, this REMED analysis led to the establishment of four improvements measures. CONCLUSION: The educational aspect of the REMED was clearly appreciated by all the different health care workers who participated to the analysis. Even if medication errors may occur at the different steps of the medication process, the REMED is a very good tool to improve the care quality and also to reduce the drug iatrogenic risk.

[Management of penetrating abdominal trauma: what we need to know?]. / Prise en charge des traumatismes pénétrants de l'abdomen : des spécificités à connaître.

Penetrating traumas are rare in France and mainly due to stabbing. Knives are less lethal than firearms. The initial clinical assessment is the cornerstone of hospital care. It remains a priority and can quickly lead to a surgical treatment first. Urgent surgical indications are hemorrhagic shock, evisceration and peritonitis. Dying patients should be immediately taken to the operating room for rescue laparotomy or thoracotomy. Ultrasonography and chest radiography are performed before damage control surgery for hemodynamic unstable critical patients. Stable patients are scanned by CT and in some cases may benefit from non-operative strategy. Mortality remains high, initially due to bleeding complications and secondarily to infectious complications. Early and appropriate surgery can reduce morbidity and mortality. Non-operative strategy is only possible in selected patients in trained trauma centers and with intensive supervision by experienced staff.

[Low-pressure tamponade mimicking cholecystitis]. / Tamponnade à pression basse mimant une cholécystite.

Low-pressure tamponade is rare and little known with difficult clinical recognition. We report a case of this pathology in a patient admitted for abdominal severe sepsis. Pericardiocentesis led to identification of Salmonella typhimurium pericarditis. This case report emphasizes the clinical recognition difficulty and the interest of early fast echography in case of hemodynamic emergency.

Auscultation in flight: comparison of conventional and electronic stethoscopes.

OBJECTIVES: The ability to auscultate during air medical transport is compromised by high ambient-noise levels. The aim of this study was to assess the capabilities of a traditional and an electronic stethoscope (which is expected to amplify sounds and reduce ambient noise) to assess heart and breath sounds during medical transport in a Boeing C135. METHODS: We tested one model of a traditional stethoscope (3MTM Littmann Cardiology IIITM) and one model of an electronic stethoscope (3MTM Littmann Stethoscope Model 3000). We studied heart and lung auscultation during real medical evacuations aboard a medically configured C135. For each device, the quality of auscultation was described using a visual rating scale (ranging from 0 to 100 mm, 0 corresponding to "I hear nothing," 100 to "I hear perfectly"). Comparisons were accomplished using a t-test for paired values. RESULTS: A total of 36 comparative evaluations were performed. For cardiac auscultation, the value of the visual rating scale was 53 ± 24 and 85 ± 11 mm, respectively, for the traditional and electronic stethoscope (paired t-test: P = .0024). For lung sounds, quality of auscultation was estimated at 27 ± 17 mm for traditional stethoscope and 68 ± 13 for electronic stethoscope (paired t-test: P = .0003). The electronic stethoscope was considered to be better than the standard model for hearing heart and lung sounds. CONCLUSION: Flight practitioners involved in air medical evacuation in the C135 aircraft are better able to practice auscultation with this electronic stethoscope than with a traditional one.

[Blast lung injuries]. / Lésions pulmonaires liées aux explosions.

In armed conflicts and during terrorist attacks, explosive devices are a major cause of mortality. The lung is one of the organs most sensitive to blasts. Thus, today it is important that every GP at least knows the basics and practices regarding treatment of blast victims. We suggest, following a review of the explosions and an assessment of the current threats, detailing the lung injuries brought about by the explosions and the main treatments currently recommended.

[Mamba envenomation in mainland France: management of exotic envenomations needs rethinking]. / Envenimation cobraïque en France métropolitaine : repenser la prise en charge des envenimations exotiques.

We report a case of accidental green mamba (Dendroaspis viridis) envenomation in the suburbs of Paris. Although moderate, neurotoxic symptoms were clearly present. Immunotherapy with polyvalent serum FAV-Afrique was decided, but logistical problems prevented reasonably quick serum delivery to the hospital. Despite a spontaneously favourable outcome probably due to minimal envenomation, this case exemplifies a near-miss of the care system. Given the increasing incidence of potentially life-threatening exotic envenomations, management of similar cases should be improved. Besides breeders and health care professionals' information, we suggest that victims of an exotic envenomation be referred to a facility with experienced staff and ready access to a limited bank of carefully chosen antivenins.

[Paraspecific antivenins and exotic bites of snakes: about two case reports]. / Antivenins paraspécifiques et morsures de serpents exotiques : à propos de deux cas cliniques.

Envenomation from bite of exotic snakes is rare in France and represent a serious therapeutic problem: only an adapted antivenom is effective and obtaining such a treatment is a real difficulty. The authors report two clinical cases of envenomation with defibrination after bite by pit vipers from South America. The two patients were treated with nonspecific antivenom therapy with divergent results. The use of the paraspecific effects of antivenom can allow an effective treatment in the absence of specific antivenom, but requires to be known better.

[Neurotoxins from snake venom]. / Neurotoxines ophidiennes.

Many snakes are able to quickly immobilize prey, thanks to their venom neurotoxins. Most of these snakes belong to families Elapidae or Hydrophidae but neurotoxins were also isolated from families Viperidae and Colubridae. Ophidian neurotoxins can be classified into several categories: neurotoxins which inhibit synaptic transmission (postsynaptic and presynaptic neurotoxins) and neurotoxins which facilitate it excessively (dendrotoxin and fasciculin). Their toxicity is dose-dependent, and venom effects are extremely fast. The clinical feature is a potentially fatal neurological syndrome, the so called cobraic syndrome. Because death by respiratory arrest may occur quickly with cobraic syndrome, immunotherapy is a true emergency, because toxins irreversible fixing makes immunotherapy effect uncertain after a few hours passed.

[How the drug allergy risk in the intensive care software is considered? About a comparative study]. / Comment est pris en compte le risque allergique dans les logiciels spécifiques à la réanimation ? A propos d'une étude comparative.

The aim of this study was to evaluate the way the drug allergy risk was considered in five intensive care software available for the French market. It is an observational study conducted by a survey with the five firms asked during the 26th International Symposium on Intensive Care and Emergency Medicine in Brussels (March 2006). The drug allergic risk is documented to various degrees among the software selections. However, no software proposes an alternative or blocking of the prescription in case of allergy to a drug.

[Use of rFVIIa (Novoseven) in the case of a patient with mitral valvular prothesis and anticoagulant accident]. / Utilisation du rFVIIA (Novoseven) lors d'un accident des anticoagulants chez une patiente porteuse d'une prothèse valvulaire mitrale.

We report the case of an haemorrhagic shock observed in a woman who received heparin for a cardiac valve in mitral position, efficiently treated with rFVIIa. The haemorrhagic complications under anticoagulation treatment remain rare, but can lead to real therapeutic dilemma. The use of rFVIIa has been evaluated in different clinical situations, including traumatic or post-operative haemorrhagic shock. The use of rFVIIa in the treatment of haemorrhagic complication under anticoagulation treatment is discussed.

[Treatment of a septic shock due to multiresistant Acinetobacter baumannii with tigecycline in combination]. / Traitement d'un choc septique à Acinetobacter baumannii multirésistant par tigécycline en association.

We report a case of pulmonary and bloodstream infection due to multiresistant Acinetobacter baumannii six days after a severe trauma. Clinical condition transiently improved following antimicrobial treatment with ticarcillin-clavulanate and rifampicin. However, a septic shock developed on the fourth day due to the emergence of a strain only sensible to cotrimoxazole, colistin and tigecycline. Cure was achieved after a two week treatment with piperacillin-tazobactam, cotrimoxazole and tigecycline. This case shows that combined antimicrobial therapy including tigecycline can be relevant in some severe pulmonary infections due to multiresistant A. baumannii.

[Carotido-cavernous fistula after traumatic brain injury: an unusual vascular complication]. / Fistule carotidocaverneuse post-traumatique : une complication vasculaire inhabituelle.

The authors reported the case of a young man who suffered a cranial traumatism and showed neurological, ophthalmic and orbital signs with orbital bruit, cranial nerve palsy and chemosis while he was in the intensive care unit. Further examinations of imagery made it possible to highlight a high-flow carotid-cavernous fistula which was the origin of these symptoms and which was successfully treated by endovascular way. The aim of this article is to remind the reader of the characteristics of this pathology, in terms of epidemiology, physiopathology, clinical and paraclinical presentation, and therapeutic care.

[Acute cardiovascular complications of cocaine. About two case reports]. / Les complications cardiovasculaires aiguës de la cocaïne. A propos de deux observations.

Concerning any socioprofessional category, some addictive drugs like cocaine are responsible for many complications. The authors relate two case reports of young patients who suffered from cardiovascular accidents due to this drug. The first one was diagnosed with an ischemic stroke caused by carotid artery dissection and a leg distal vascular obliteration, the second one with a myocardial infarction with transient left ventricular dysfunction. Through these two case reports, the authors take stock of the pathophysiological and therapeutic knowledge of cardiovascular accidents after cocaine intake.

[Severe hypofibrinegenemia after rattlesnake envenomation in France]. / Hypofibrinogénémie sévère après morsure de crotale en France.

A 22-year-old man, who maintains illegally numerous exotic snakes at home (suburbs of Paris), was bitten by one of his Bresilian rattlesnakes, the lance-headed viper Bothrops moojeni, with grade III envenomation. The fibrinogen was less than 0,5 g/L, the prothombin time was 22%, the activated partial thromboplastin time was 94 seconds. The authors discuss the biological and clinical management of this defibrination, due to defibrinogenating proteases (thrombin-like enzymes), present in Bothrops moojeni venom. The patient received 7 vials of an antivenom directed to another crotal, Bothrops lanceolatus. Despite the importance of defibrinogenation, there was only a few clinical evidence of bleeding, according to the literature. The normalization of coagulation studies occured only after day 11. This case-report outlines the danger of the increase of exotic snakes maintained as pet in France and the difficulties to obtain specific antivenoms.

[The risk of thromboembolism in airline passengers]. / Risque thromboembolique et voyage en avion.

Long carrier flights favor thromboembolism. The risk is well known to the general public but is probably really very low. The risk is however pertinent due to the volume of air travel in the world. Sitting in the same position for a long time induced venous stasis which is the principal factor favoring thrombosis in travelers, irrespective of the means of transportation. Long carrier flights also expose passengers to specific factors related to air travel: coagulation disorders and alterations of the endothelium related to hypobarism, hypoxia and low hygrometry in the cabin. Presence of pathogenic thrombophilia is not a constant factor. The prevention of venous thrombosis in air travelers calls upon simple measures: abundant hydration, avoiding use of alcohol and tobacco, walking and dorsal flexion of the feet. The only preventive option with proven efficacy is the use of elastic contention which reduces the risk of thromboembolic events. There is no consensus concerning the use of drugs proposed by certain authors; prudence should be the rule. All passengers should become aware of the risk of thromboembolism related to sitting in the same position for a long time.