Treatment of Acute Renal Colic in US and French EDs: Simulated Cases and Real Cases in Acute Pain Management.

OBJECTIVES: To assess the prescribing patterns in acute renal colic in emergency departments in US and France, by comparing physicians' intended prescription practices with actual prescription data in a sample of emergency practitioners. METHODS: Pharmaco-epidemiological international study in two phases. First, we surveyed emergency physicians in US and France as to what analgesics they would use for simulated cases of renal colic. We then conducted a retrospective review of actual cases of emergency department patients with pain scores ≥6/10 with acute renal colic during a period of 6 months before the survey. We compared nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids used for pain treatment in the two groups, and the differences between the two countries. RESULTS: One hundred six prescribers and 100 patients were included in the study. Comparison between simulated and real cases showed that NSAIDs and opioids were less frequently prescribed in real life (78% vs 99% and 51% vs 100% respectively). Morphine was the most prescribed opioid (96% of simulated cases and 34% of real ones). Acetaminophen use was increased in real life cases (58% vs 0%). Concerning the differences between countries, US physicians are more likely to administer morphine (64% vs 38%) and French physicians NSAIDs (88% vs 68%). The NSAIDs used are ketorolac in the United States (94% of simulated cases vs 64%) and ketoprofen in France (94% and 88% respectively). DISCUSSION: We showed clear differences between intended and real analgesic prescription practices for patients suffering from renal colic. Some differences exist for pain perceptions and treatments between US and France.

Nitrous oxide for early analgesia in the emergency setting: a randomized, double-blind multicenter prehospital trial.

OBJECTIVES: Although 50% nitrous oxide (N(2) O) and oxygen is a widely used treatment, its efficacy had never been evaluated in the prehospital setting. The objective of this study was to demonstrate the efficacy of premixed N(2) O and oxygen in patients with out-of-hospital moderate traumatic acute pain. METHODS: This prospective, randomized, multicenter, double-blind trial enrolled patients with acute moderate pain (numeric rating scale [NRS] score between 4 and 6 out of 10) caused by trauma. Patients were assigned to receive either 50/50 N(2) O and oxygen 9 L/min (N(2) O group) or medical air (MA) 9 L/min (MA group), in ambulances from two nurse-staffed fire department centers. After the first 15 minutes, every patient received N(2) O and oxygen. The primary endpoint was pain relief at 15 minutes (T15), defined as a NRS ≤ 3 of 10. The NRS was measured every 5 minutes. Secondary endpoints were treatment safety and adverse events, time to analgesia, and patient and investigator satisfaction with analgesia. RESULTS: Sixty patients were included with no differences between groups in age (median = 34 years, interquartile range [IQR] = 23 to 53 years), sex (37 males, 66%), and initial median NRS of 6 (IQR = 5 to 6). At T15, 67% of the patients in the N(2) O group had an NRS score of 3 or lower versus 27% of those in the MA group (delta = 40%, 95% confidence interval [CI] = 17% to 63%; p < 0.001). The median pain scores were lower in the N(2) O group at T15, 2 (IQR = 1 to 4) versus 5 (IQR = 3 to 6). There was a difference at 5 minutes that persisted at all subsequent time points. Four patients (one in the N(2) O group) experienced adverse events (nausea) during the protocol. CONCLUSIONS: This study demonstrates the efficacy of N(2) O for the treatment of pain from acute trauma in adults in the prehospital setting.

Quality of publications in emergency medicine.

OBJECTIVE: The objective of this study is to describe emergency medicine (EM) publications in terms of methodology, approval by institutional review board, method of consent, external validity, and setting (eg, prehospital or emergency department). METHODS: The 12 top-ranked emergency journals were selected. We manually reviewed the last 30 original articles in each EM journal, to represent more than 2 months of publications for all EM journals (range, 2-6 months). Only clinical original articles on human subjects were included. To ensure accurate data transcription, each article was read at least twice by 2 different reviewers and graded by written criteria using an extraction standard chart. RESULTS: Over the articles reviewed, 330 were analyzed. One hundred eighty-nine (57.3%) were prospective studies; 29 (8.8%) were randomized studies. Two hundred twenty-six studies (68.5%) mentioned an institutional review board approval or a waiver of authorization, and an informed consent was not mentioned in 227 (68.8%) of studies. Fifty-nine (17.9%) were conducted in a prehospital setting. Two hundred thirty-eight (72.1%) of these studies were at single-center institutions; the Unite States contributed 158 (47.9%) of the total publications. CONCLUSION: This study describes publications in the field of EM. Randomized studies represent 9% of publications, most studies are cross-sectional, and more than half have a retrospective design. We found that, in one-third of the studies, an institutional review board review was not mentioned and informed consent was not specified in two-thirds of the studies. Emergency medicine research volume, quality, and grants activity must increase in order for EM to progress within academic medicine.

New diploma in emergency medicine in France: the students' perspective.

French emergency medicine (EM) has undergone rapid changes with the establishment of a diploma in emergency medicine (DES). We aimed to question medicine students on their knowledge of and apprehensions regarding this new DES. We conducted an email cross-sectional survey among second-cycle medical students before their choice of resident speciality. This included a demographic study and an evaluation of the willingness to choose emergency specialization. Two thousand and three fully completed questionnaires were analysed. Twenty-six per cent of the students (n=524) planned to choose emergency specialization and 54% of the students (n=1084) knew that emergency specialization would be proposed as a full speciality. Seventy-six per cent of students considered it tough to practice as an entire career. This study clearly shows that EM represents an attractive option for medical students. The establishment of DES represents a major step in the improvement of EM.

Morbidity and mortality conferences in emergency departments: the French National Survey.

In France, emergency departments (EDs) are not yet required to implement Morbidity and Mortality Conferences (M&MCs), but it is likely that they will soon be a requirement. We conducted a national survey through e-mail to evaluate current M&MC practices in EDs in France. Of the 232 questionnaires sent out, 149 responses were analyzed (64%). In total, 73 departments claimed that they carried out M&MCs, 36 (81.1%) at a University hospital (UH) compared with 37 departments (35%) at a non-UH (P < 0.001). In 29% of departments, M&MCs are held once a month (n = 21), in 34% every 2 months, and in 37% of departments they are held at longer intervals. Specialists are invited in 80% of departments (n = 58). All departments carrying out M&MCs finish with corrective action. The frequency with which M&MCs are conducted in EDs in France is low but is increasing. Currently, M&MCs are mainly conducted at UHs; this practice should develop in general hospitals as well.

User satisfaction with maritime telemedicine.

We assessed the satisfaction of onboard caregivers with the maritime telehealth service provided by the Centre de Consultations Médicales Maritimes (CCMM). We conducted a survey of captains and caregivers by email. Of the 385 surveys sent out, 165 (43%) were completed. Eighty four percent of responders (n = 110) thought that waiting time was satisfactory or very satisfactory, and 97% (n = 128) were satisfied or very satisfied with their relationship with the remote physician. Thirty eight per cent of participants (n = 50) considered that the physician understood the medical problem very well; understanding was good in 58% of cases (n = 76) and bad in only 4% of cases (n = 5). Sixty two per cent of participants (n = 83) sent pictures before consultation. The respondents were also satisfied with the telephone advice overall, the competence of the physicians providing the advice, the length of time spent waiting, the verbal prescription and the medical advice given. Onboard caregivers were generally well satisfied with the maritime teleconsultations and the advice provided by the CCMM physicians.

Suicide attempt by intravenous potassium self-poisoning: a case report.

Introduction. Overdose of potassium is not as frequently encountered in clinical practice as hyperkalaemia due to acute or chronic renal disease. However, potassium overdoses leading to serious consequences do occur. Case Presentation. A 20-year-old nurse student presented with a cardiac arrest with asystole rhythm. Beside the patient were found four 50-mL syringes and empty vials of potassium chloride (20 mL, 10%). After initial resuscitation with epinephrine, 125 mL of a 4.2% intravenous solution of sodium bicarbonate were injected which resulted in the recovery of an effective cardiac activity. The patient recovered without sequelae. Conclusion. The difficulty in this case was to recognize the potassium poisoning. The advanced resuscitation with the use of a specific treatment helped to resuscitate the patient.

Use of morbidity and mortality conferences to analyze causes of death at sea: a useful tool in the process of training in maritime medicine.

BACKGROUND. Morbidity and mortality conferences (MandMC) are collective reviews of records of patients, whose evolution was marked by an undesirable event: death or the occurrence of complications. The MandMC aim to improve the quality of care. This article intends to present three cases analyzed in MandMC in the French Telemedical Assistance Service (TMAS). MATERIAL AND METHODS. Three cases were selected according to the occurrence of a death at sea or according to particular cases of pathology on board. The case presentation was done in plenary session in our French TMAS, describing the facts, analyzing the defective processes, and suggesting possible improvements for each case. RESULTS. Description of 3 cases: Gastroenteritis in Papua New Guinea with septic shock; traumatic brain injury on a training boat with organizational and evacuation problems, and fever in the Gulf of Guinea with negative thick blood smear test. CONCLUSIONS. The MandMC tend to develop in all medical fields and are of particular interest in maritime medicine. The achievement of MandMC in our TMAS highlighted some difficulties in our daily work: diagnosis difficulty in tele-consultation and organizational or operational difficulties related to maritime medicine. However, we hope that the proposals for improvement will be applied to improve the quality of maritime medical care.

Using d-dimer to diagnose painless acute aortic dissection: a case report.

Introduction. Aortic dissection is a cardiovascular emergency; the most frequent symptom is chest pain, but clinical presentation can be varied and atypical. Case Presentation. We report the case of a 66-year-old Caucasian male who presented a syncope immediately followed by a left-arm weakness while driving his car. Clinical examination was normal, but bilateral jugular vein distension was noted. Electrocardiogram and chest radiography were unremarkable. Among blood tests performed, troponin I test result was negative, and D-dimer test concentration was >4000 ng/mL. Since D-dimer test result was positive, chest computer tomography angiogram was performed and found a thoracic aortic dissection. Conclusion. Our case report shows that acute aortic dissection diagnosis is difficult and must be associated with the interpretation of various clinical signs and D-dimer measurement. It could be helpful for the emergency physician to have a pretest probability D-dimer like in pulmonary embolism diagnosis.

Cardiovascular diseases and electrocardiogram teletransmission aboard ships: the French TMAS experience.

BACKGROUND: The aim of this study was to analyse emergency calls for teleconsultation received at French TMAS relating to cardiovascular pathologies, to assess the relevance of electrocardiogram teletransmission. MATERIAL AND METHODS: A two-year descriptive and retrospective study from the TMAS medical files database. We selected patients whose telemedical request was related to a possible cardiovascular pathology. The French TMAS receives calls from all kinds of ship (passenger or merchant vessel), and our analysis was conducted by comparing passengers and professional seamen. On board, the caregiver performs the ECG after medical prescription and sends it by satellite to the TMAS. RESULTS: A total of 179 cases of cardiovascular disease were selected, including 79 passengers (PG) (44.1%) and 89 professional seafarers (PS) (49.7%). In 11 cases (6.1%) patient status was not specified. The most frequent diagnoses were chest pain (58 cases) and STEMI (23 cases), followed by NON STEMI (21 cases). An ECG was performed in 70% of cases of chest pain. ECG diagnosed 23 STEMI, and all these patients had been evacuated by a medical team. This diagnosis led to the establishment of antithrombotic therapy. The mortality rate due to cardiovascular diseases was 9.5%. Ten occurred on board and 7 during the evacuation of the patient. Eleven were passengers and 6 were professional seamen. CONCLUSIONS: Calls regarding cardiovascular disease are infrequent but require an effective response. Recording and transmitting an ECG to the TMAS is technically feasible and enables treatment to be started with specific drugs, mainly in the management of STEMI.

Pancreatic cholangiocarcinoma as an ST-elevation myocardial infarction with thrombolytic therapy.

We report the case of a 46-year-old patient who presented a chest pain with ST-segment elevation in precordial leads V1 (2 mm), V2 (4 mm), and V3 (3 mm). Thrombolytic therapy was initiated with the combination tenecteplase tissue plasminogene activator, aspirin, and heparin. Further electrocardiogram and cardiac enzymes measured every 2 hours during the first 24 hours remained normal, and after a computed tomography of the abdomen, the patient was taken to surgery for an exploratory abdominal operation that revealed pancreatic cholangiocarcinoma. No adverse effects were attributed to the initial thrombolytic therapy. Finally, myocardial ischemia was excluded because the electrocardiogram, cardiac enzymes, and a 1-month later cardiac stress test remained normal and because no coronary event occurred during the first year after surgery. Our case shows that it is sometimes difficult to make the share, in prehospital field, between coronary syndrome and other pathology, particularly digestive pathology. However, in the appropriate chest pain patient with presumed acute myocardial infarction, ST-segment elevation remains the primary criterion for the initiation of thrombolytic therapy, primary angioplasty, and/or other pharmacologic interventions.