Quantifying physician's bias to terminate resuscitation. The TERMINATOR study.

CONTEXT: Deciding on "termination of resuscitation" (TOR) is a dilemma for any physician facing cardiac arrest. Due to the lack of evidence-based criteria and scarcity of the existing guidelines, crucial arbitration to interrupt resuscitation remains at the practitioner's discretion. AIM: Evaluate with a quantitative method the existence of a physician internal bias to terminate resuscitation. METHOD: We extracted data concerning OHCAs managed between January 2013 and September 2021 from the RéAC registry. We conducted a statistical analysis using generalized linear mixed models to model the binary TOR decision. Utstein data were used as fixed effect terms and a random effect term to model physicians personal bias towards TOR. RESULTS: 5,144 OHCAs involving 173 physicians were included. The cohort's average age was 69 (SD 18) and was composed of 62% of women. Median no-flow and low-flow times were respectively 6 (IQR [0,12]) and 18 (IQR [10,26]) minutes. Our analysis showed a significant (p < 0.001) physician effect on TOR decision. Odds ratio for the "doctor effect" was 2.48 [2.13-2.94] for a doctor one SD above the mean, lower than that of dependency for activities of daily living (41.18 [24.69-65.50]), an age of more than 85 years (38.60 [28.67-51.08]), but higher than that of oncologic, cardiovascular, respiratory disease or no-flow duration between 10 to 20 minutes (1.60 [1.26-2.00]). CONCLUSIONS: We demonstrate the existence of individual physician biases in their decision about TOR. The impact of this bias is greater than that of a no-flow duration lasting ten to twenty minutes. Our results plead in favor developing tools and guidelines to guide physicians in their decision.

Morphology and morphometry of Paratanaisia bragai () Freitas, 1959 (Digenea, Eucotylidae) through light and scanning electron microscopy.

Paratanaisia bragai is a digenetic trematode that reaches sexual maturity in the kidney collecting ducts of domestic and wild birds, while the snails Subulina octona and Leptinaria unilamellata serve as its intermediate hosts in Brazil. The present study analyzed the morphology and morphometry of P. bragai. Adult specimens of the parasite were collected from naturally infected Columba livia kidneys, fixed and prepared for observation via bright field and differential interference contrast light microscopy and scanning electron microscopy. The parasite has an elongated and flattened body, with a subterminal oral sucker located at the anterior end of the body, as observed by all techniques used. Staining the parasite with hematoxylin-eosin enabled observation of the pharynx, located posteriorly to the oral sucker, the vitelline glands, which are extra-cecal and extend anteriorly to the pre-ovarian region and later to the median region of the body, and intestinal caeca parallel to the vitelline glands. The presence and functionality of the acetabulum are controversial points in the literature, but it was observed in all specimens analyzed by scanning electron microscopy, with a major diameter of 38.36 ± 6.96 (28.77 - 45.39) and minor diameter of 31.59 ± 7.04 (21.75 - 38.16). Close to the acetabulum, scales were observed in the integument of the parasite. Scales with (1 - 5) blade divisions were identified. In the genital pore, it was possible to see the everted cirrus with rosette shape. The excretory pore (first morphometric record) is dorsal and subterminal, with major diameter of 12.27 ± 9.16 (5.79 - 18.75) and minor diameter of 3.95 ± 1.49 (2.89 - 5.00).

[Involuntary Psychiatric Hospitalizations: From request to a call center to hospitalization]. / Admission en soins psychiatriques a la demande d'un tiers : de l'appel au SAMU a l'hospitalisation.

BACKGROUND: Involuntary psychiatric hospitalization (IPH) is a heavy and complex psychiatric exception measure. In the Seine-Saint-Denis department (low medical density), the evaluation of the patient in psychiatric decompensation is the responsibility of the out-of-hours general practitioners (GP) mandated by the call center. Their feeling is the non-achievement of the procedure once the patient arrives at the emergency room. We aimed to evaluate the outcome of patients following a request for IPH from these GP. METHODS: We conducted a retrospective study based on all requests for IPH received during 2016 at the Seine-Saint-Denis emergency medical call center. The characteristics of the call and the patient, as well as the decisions of the regulator and the GP were collected. The decision of hospitalization in the emergency room was sought for patients referred for IPH. RESULTS: Of the 7541 calls for decompensation, 539 were for an IPH. These calls occurred during non-working hours in 55 % of cases. A GP was involved in more than two-thirds of the cases and requested an IPH for 240/304 (79 %) patients. Patients were male in 56 % of cases with an average age of 40 (±16) years. IPH was confirmed for 132 (61 %) patients. This rate did not differ from the 65 % reported in the literature (Z-test, P=0.26). Voluntary hospitalization was performed for 37 (17 %) other patients. DISCUSSION: The IPH rate for patients referred by GP mandated by the call center was comparable to that following the requests of the attending physicians, validating their intervention in this critical context.

[COP21 - Organization and activity of a medical cover under "pressure"]. / COP21 ­ Organisation et bilan d'une médicalisation sous haute tension.

INTRODUCTION: The United Nations Climate Conference (COP21) gathered in France for delegations from all around the world, with 20,000 delegates from 195 countries every day, including 150 heads of states during the first 48hours. A specific medical cover was organized in a particular "post-attacks" context and with harsh constraints due to delimitation of an inner zone under the sole UN authority ("blue zone"). OBJECTIVE: To evaluate medical means involved and medical activity. METHODS: Medical cover was managed by SAMU 93 in collaboration with zonal SAMU and regional health agency for the entire site including the "blue zone". End-points: engaged workforce, number of visits, including transfers and medicalized transfers. RESULTS: In "France zone" (operational headquarters): an emergency physician dispatcher and an assistant for 20 days. In "blue zone": 20 rescuers, mobile intensive care unit H24 and two emergency physicians (consultations) 12/24hours for 16 days. A total of 47 doctors, 25 nurses, 25 paramedics and 20 assistants participated in the medical service. This corresponded to three emergency physician full medical time equivalents (FMTE) for 16 days. Consultations performed: 1238 or 97/day resulting in 34 (3%) transfers including seven medicalized. Patients were 706 (57%) men and 495 (43%) women, with mean age of 43±1 years. Trauma patients were most numerous (20%). CONCLUSION: Medical means involved were consistent for 16 days. The medical activity was sustained, but medicalized transfer rarely required.

Does endotracheal intubation increases chest compression fraction in out of hospital cardiac arrest: A substudy of the CAAM trial.

BACKGROUND: Optimal out of hospital cardiac arrest (OHCA) airway management strategies remain unclear. We compared chest compression fraction (CCF) between patients receiving endotracheal intubation (ETI) versus bag mask ventilation (BMV). METHODS: We studied adult OHCA enrolled from our center in the CAAM trial. Primary exposures were ETI or BMV. Primary outcome was whole intervention CCF, adjusted for Utstein confounders. Secondary outcomes were per cycle CCF, no flow time associated (NFT) with ventilation, rhythms checks and mechanical chest compression device placement. RESULTS: Of 2040 OHCA enrolled in the CAAM trial we analyzed 112 cases recruited by our center. Unadjusted CCF was 0.89 for ETI and 0.88 for BMV (p = 0.19). Compared with BMV, ETI achieved lower NFT associated with ventilations (32 vs 127 s; p < 0.001). ETI cases experienced higher NFT associated with rhythm checks (69.5 vs 42.5 s p = 0.02) and with mechanical chest compression placement (29 vs 20 s; p = 0.04). CCF was higher during the first cycle in BMV than in ETI patients (0.81 vs 0.74; p = 0.02). After correction for confounders we observed no difference in global intervention CCF between the ETI and BMV (ΔCCF [ETI-BMV] 0.301; [95%CI: -1.9 to 2.51]; p = 0.79). CONCLUSION: In our substudy whole intervention CCF among OHCA was not modified by ETI compared to BMV. In the ETI group we observed lower NFT associated with ventilations and higher NFT associated with mechanical chest compression devices placement. CCF was lower in the ETI group during the first cycle.

[When the patient calls the SAMU because his pacemaker is making "beep-beep". Study on physicians' knowledge on pacemaker sound alarm]. / Quand le patient appelle le Samu car son pacemaker fait « tic-tac ¼. Enquête sur la connaissance de l'existence d'une alarme sonore dans les pacemakers.

INTRODUCTION: More than 60,000 pacemakers are inserted every year in France. This number has been steadily increasing for a decade. Miscellaneous incidents can lead patients with pacemakers or their relatives to contact emergency services. Following the call to the SAMU-Center 15 of a asymptomatic 90-year-old woman reported that her pacemaker was making "beep-beep", we assessed the knowledge of physicians of the SAMU-Center 15 (call center) dispatching center on the existence of pacemaker sound alarms. METHODS: Forty-two physicians, emergency physicians and general practitioners, regularly participating in the medical dispatching of the SAMU-Center 15 in Seine-Seine-Denis were interviewed. We asked them how a patient with a pacemaker could be informed of a malfunction of it without being symptomatic. RESULTS: No physician interviewed mentioned an audible alarm. All of them confirmed their ignorance of its existence. One physician had already been asked for a similar reason and had referred the patient to the emergency department without knowing it was an alarm. CONCLUSION: Patients and physicians seem insufficiently aware of the existence of the existence of pacemakers' sound alarm. An effort must be made regarding the information on the existence of such an alarm and the way to managed it.

[Bradykinin-mediated angioedema secondary to angiotensin converting enzyme: initiate treatment from the prehospital phase]. / Angiœdème bradykinique secondaire aux inhibiteurs de l'enzyme de conversion : instaurer le traitement en préhospitalier.

We are reporting the case of a bradykinin-mediated angioedema, secondary to the angiotensin converting enzyme inhibitors, which delayed treatment could have unfavorably influence the vital prognostic of the patient. Initially, the patient had an isolated edema of the superior lip. Prehospital treatment included methylprednisolone, hydroxyzine and epinephrine. The patient was subsequently taken to the emergency department. His situation deteriorated. An edema of the cheeks and the tongue appeared. The transfer of the patient to an emergency department, specializing in kinin angioedema was organized, in order for the patient to receive specific treatments. After a subcutaneous injection of icatibant, the situation improved very rapidly, with a regression of the edema. This observation is consistent with the early use of the specific therapeutic in bradykinin-mediated angioedema. Any delay in administering the treatment can negatively impact the prognostic. The availability of such treatments should therefore be organized during the prehospital phase.

[ST-segment elevation acute coronary syndromes: Prehospital management strategies]. / Syndrome coronaire aigu avec élévation du segment ST : stratégies de prise en charge en préhospitalier.

Prehospital management of ST-segment elevation myocardial infarction is a complex issue. Many components are involved, beginning with information of the public on the symptoms of heart attack, up to the choice of the final pathway and destination of the patients, with many intermediate steps including the regulation of emergency calls, the implementation of optimal diagnostic strategies, the choice of reperfusion therapy and of adjuvant medications. In recent years, optimization of these different components has led to improved patients' outcomes in this still life-threatening condition.

[Feasibility of out-of-hospital management of non-heart-beating donors in Seine-Saint-Denis: one year retrospective study]. / Prélèvements sur "donneurs décédés après arrêt cardiaque": l'expérience du Samu de la Seine-Saint-Denis.

The use of non-heart-beating donors (NHBD) could help shorten the list of patients who are waiting for a kidney transplant. The aim of this study was to evaluate efficiency of prehospital management of non-heart-beating donors in Seine-Saint-Denis area. We performed a retrospective cohort study of non-heart-beating donor managed by prehospital medical team of Samu 93 from February 2007 to January 2008. There were 28 non-heart-beating donors included consecutively. Twenty-five NHBD (89%) were canuled by Gillot probe within 150 min from patient collapse. Fourteen NHBD were harvested and 17 kidneys were transplanted. Six-month survival rate for NHBD grafts was 94%. In the same time, eight brain dead donors were managed by Samu 93 and were harvested leading to transplant 16 kidneys. Finally, 50% of overall kidney transplant activity in Seine-Saint-Denis was provided by NHBD grafts.