Risk factors for failed first intubation attempt in an out-of-hospital setting: a multicenter prospective study.

This study was performed to identify variables potentially associated with failure of the first intubation attempt in an out-of-hospital emergency setting, considering all aspects of tracheal intubation. This observational prospective multicenter study was performed over 17 months and involved 10 prehospital emergency medical units. After each tracheal intubation, the operator was required to provide information concerning operator and patient characteristics, as well as the environmental conditions during intubation, by completing a data collection form. The primary endpoint was failure of the first intubation attempt. During the study period, 1546 patients were analyzed, of whom 59% were in cardiac arrest; 486 intubations failed on the first attempt (31.4% [95% confidence interval = 30.2-32.6]). Multivariate analysis revealed that the following 7 of 28 factors were associated with an increased risk of a failed first intubation attempt: operator with fewer than 50 prior intubations (odds ratio [OR] = 1.8 [1.4-2.4]), small inter-incisor space (OR = 2.3 [1.7-3.2]), limited extension of the head (OR = 1.6 [1.1-2.1]), macroglossia (OR = 2.3 [1.6-3.2]), ear/nose/throat (ENT) tumor (OR = 4.4 [1.4-13.4]), cardiac arrest (OR = 1.8 [1.3-2.6]), and vomiting (OR = 1.7 [1.3-2.3]). The frequency of adverse events among non-cardiac arrest patients was 17.6%; it increased with each additional intubation attempt. The first intubation attempt failed in more than 30% of cases, and seven variables were associated with increased risk of failure. Most of these factors could not be predicted.

Teleconsultation at Sea and Acute Wound Management Onboard.

Introduction: The French Tele-Medical Assistance Service (TMAS) provides medical teleconsultation for any ship at sea. At the end of the consultation, the doctor decides whether the problem can be taken care of onboard or not. In this study, we determined the factors associated with the decision for disembarkation or evacuation in case of wounds. Methods: We conducted a retrospective epidemiological study between 2011 and 2019 from consultations with the French TMAS. The inclusion criterion was the presence of an acute wound. Results: One thousand six patients (n = 1,006) were analyzed and 586 (58%) patients were disembarked or evacuated. Factors associated with disembarkation or evacuation are wound characteristics (severity and location), the onboard staff's medical training, the availability of photography, and the ship's location. Wound severity is a risk factor for disembarkation or evacuation. The availability of photography, staff with advanced training, and being at >1 day of navigation from a harbor are protective factors against being disembarked or evacuated. Conclusion: The added value of photography and an update of medium medical training could increase the number of wounds taken care of onboard.

Medical treatment of seafarers in the Southern Indian Ocean - interaction between the French Telemedical Maritime Assistance Service (TMAS) and the medical bases of the French Southern and Antarctic Lands (TAAF).

BACKGROUND: The waters surrounding the French Southern Lands are a fishing zone, accessible only by sailing for several days in a region where weather conditions are often difficult. The scientific bases of the region have medical staff whose services can be called upon if seafarers require assessment and rapid medical treatment. We conducted an epidemiological study of the maritime teleconsultations carried out by the French Telemedical Maritime Assistance Service (TMAS), where patients navigating in the Southern Indian Ocean zone were advised to disembark on the medical bases in the French Southern Lands, between 2015 and 2020, to receive medical treatment. MATERIALS AND METHODS: We extracted data from all of the maritime records from 1 January 2015 to 31 December 2020 relating to patients who attended a maritime teleconsultation with a French TMAS doctor in the Southern Indian Ocean zone and who had been redirected to the medical bases in the French Southern Lands. Data were collected on the patients' age, gender, nationality, rank, type of vessel, teleconsultation diagnosis, patient management on board and in the French Southern Lands medical bases, as well as the medical outcome. We carried out a descriptive data analysis. RESULTS: French TMAS doctors managed 11,908 cases including 76 in the Southern Indian Ocean zone (0.6%). Nineteen (25%) patients were redirected to the French Southern Lands over the study period. Eighteen patients were men with an average age of 45 ± 10 years. Eighteen patients were on board a trawler and 11 of them were sailors. Nine patients were treated for a trauma-related condition, 8 for a medical condition and 2 for a surgical disease. Eleven (58%) patients were evacuated to Reunion Island and 8 (42%) patients received medical treatment and were able to re-embark aboard their vessel. CONCLUSIONS: Relatively few patients are redirected to the French Southern Lands for medical assistance, but referrals occur on a regular basis. The presence of these medical bases is unusual in a maritime setting, but they can be a valuable asset when maritime medical assistance is required in this region. The type of condition encountered, and the patient profile, were typical of the fishing community. The presence of these bases and communication between the various stakeholders delivering maritime medical assistance provided these patients with optimal care despite their isolated location.

The COVID-19 pandemic and maritime telemedicine: 18-month report.

BACKGROUND: The onset of the coronavirus disease 2019 (COVID-19) pandemic has greatly impacted maritime telemedicine services. The aim of this study is to describe the impact of the pandemic, both quantitatively and qualitatively, by analysing the teleconsultations by doctors from the French Tele-Medical Assistance Service (TMAS). MATERIALS AND METHODS: We carried out a descriptive observational study of retrospective data from the TMAS files. The main inclusion criterion for the files was a diagnosis of "influenza due to an unidentified virus". We extracted the following data: type of ship, gender, age, nationality, role on board, reason for the call and symptoms, number of calls, navigation zone, severity, medical decision, whether or not a COVID-19 test had been carried out, and treatments prescribed on board. RESULTS: One hundred and ninety-nine files were included of which 39 (20%) were clusters. We were able to analyse data from 384 patients. The study population comprised 376 suspected COVID-19 patients, of whom 334 (87%) were symptomatic and 42 (10.9%) asymptomatic. Eight (2.1%) patients were not thought to have COVID-19 but their call was related to the pandemic. Of the symptoms presented by the patients, fever was the most frequent (n = 196; 59%), while 129 (39%) presented a cough, 60 (18%) a headache, 41 (12%) non-specific ear, nose, throat signs, and 40 (12%) dyspnoea. Two hundred fifty-two (75%) patients stayed on board, 55 (17%) were disembarked, for 14 (4%) a ship diversion was arranged, and 13 were evacuated including 4 medical evacuations. CONCLUSIONS: The most important problem encountered related to managing asymptomatic or pauci-symptomatic patients at sea, which was the subject of the majority of calls. The TMAS doctors played an important role in managing the pandemic by emphasising the need for social distancing and quarantine procedures at sea to limit the spread of the virus, while adapting to the sometimes difficult implementation conditions and logistics for medical decision and quarantine.

COVID-19 and French Medical Maritime Teleconsultation.

Introduction: The coronavirus disease 2019 (COVID-19) epidemic has impacted both land and maritime health services. The purpose of this study is to describe the calls received by the Tele-Medical Assistance Service (TMAS) in relation to this epidemic. Methods: From March 1 to 30 April 30, 2020, all records coded by TMAS doctors as "influenza due to an unidentified virus" were extracted. The following data were collected: patients' age, gender, nationality, role on board, type of ship, area of navigation, reason for the teleconsultation, patient's symptoms, whether or not a COVID test had been carried out, and treatment given. The data were analyzed in two groups, depending on the reason for the consultation: teleconsultation for suspected COVID patients and teleconsultation for non-COVID patients for whom the call was nevertheless related to the COVID pandemic. Results: Sixty-one records were included-51 for suspected COVID patients and 10 records for COVID-related problems (six patients whose treatment had stopped due to shortage of medication/one patient reporting a psychiatric problem associated with isolation, three patients followed up as contact cases). Forty-five patients presented with fever when the first call was made (88%) and 39 had a cough (76%). On closure of the medical records, 33 were receiving treatment on board (65%), 10 had disembarked (20%), 1 had been rerouted (2%), and 7 had been evacuated (13%). Discussion: TMAS was able to aid professional sailors as well as passengers/recreational sailors in terms of telemedicine (diagnosis and monitoring), logistics (barrier actions and isolation), and operations (evacuation and repatriation).

Dental emergencies at sea: A study in the French maritime TeleMedical Assistance Service.

INTRODUCTION: The aim of the study was to assess the frequency, features and management of dental emergencies at sea in France. METHODS: A descriptive study was carried out by retrospectively examining medical records of patients who were assisted by the French maritime TeleMedical Assistance Service (TMAS) from 2012 to 2016. Data were ranked in different categories: socio-demographic data, diagnosis, prescription, and monitoring or treatment prescribed. RESULTS: The TMAS recorded 9122 medical files for all medical emergencies. Among these medical records 135 concerned oral diseases. The main causes for dental emergencies are dental abscess (51.8%), tooth decay (33.3%), and dental fracture (8.9%). Even where teledentistry is validated for remote screening and oral lesion diagnosis, management of dental emergencies mostly requires a dental procedure. On board, without special equipment and/or specifically trained healthcare workers, this management often results in the prescription of medication. DISCUSSION: The International Medical Guide for Ships published by the World Health Organization could be updated to suit the latest recommendations of dental emergency management. This could facilitate the addition of a medical act to dental management, resulting in more effective treatment. Furthermore, simple and specific equipment could be added to the medical supplies.

Identifying key factors leading to the optimal care pathway for patients with ST-segment elevation myocardial infarction: Results from the RESCAMIP registry.

BACKGROUND: In France, when someone presents with chest pain, it is recommended to call a health emergency number. The patient talks with an emergency doctor at a medical dispatch centre, who decides whether (or not) to send a Mobile Intensive Care Unit (MICU). Patients with an ST-segment elevation myocardial infarction (STEMI) should have an MICU as their first medical contact, to speed up confirmation of diagnosis and enable them to benefit from reperfusion therapy as quickly as possible. AIM: To evaluate the proportion of patients with STEMI benefiting from an optimal care pathway, and to identify the key factors leading to this pathway. METHODS: RESCAMIP was a multicentre registry conducted between May 2015 and May 2017 in Midi-Pyrénées. All patients treated for STEMI within 12hours of symptoms onset, without initially going into cardiac arrest, were included. RESULTS: Data from 1371 patients with STEMI were analysed; 60% had an MICU as their first medical contact. In-hospital mortality was 4%. Factors associated with calling the medical dispatch centre when presenting chest pain were: age>65 years (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.02-1.83), personal history of cardiovascular disease (OR 1.9, 95% CI 1.22-2.96) and having cardiovascular risk factors (OR 1.84, 95% CI 1.35-2.5). Factors associated with sending an MICU as first medical contact were: male sex (OR 2.11, 955 CI 1.49-2.99) and personal history of cardiovascular disease (OR 1.69, 95% CI 1.07-2.65). CONCLUSIONS: The proportion of patients with STEMI going through non-optimal pathways was 40% in our area. We note that there are sex-based inequalities in accessing MICUs.

Levocetirizine and Prednisone Are Not Superior to Levocetirizine Alone for the Treatment of Acute Urticaria: A Randomized Double-Blind Clinical Trial.

STUDY OBJECTIVE: We evaluate the efficacy of a 4-day course of prednisone added to antihistamine for the management of acute urticaria in an emergency department (ED). METHODS: In this double-blind randomized clinical trial, patients were eligible for inclusion if aged 18 years or older and with acute urticaria of no more than 24 hours' duration. Patients with anaphylaxis or who had received antihistamines or glucocorticoids during the previous 5 days were not included. In addition to levocetirizine (5 mg orally for 5 days), patients were assigned to receive prednisone (40 mg orally for 4 days) or placebo. The primary endpoint of the study was itching relief 2 days after the ED visit, rated on a numeric scale of 0 to 10. Secondary endpoints were rash resolution, relapses, and adverse events. RESULTS: A total of 100 patients were included, 50 in each group. Seven patients in the prednisone group and 8 in the placebo group discontinued treatment. At 2-day follow-up, 62% of patients in the prednisone group had an itch score of 0 versus 76% of those in the placebo group (Δ 14%; 95% confidence interval -31% to 4%). Thirty percent of patients in the prednisone group and 24% in the placebo group reported relapses (Δ 6%; 95% confidence interval -23% to 11%). Mild adverse events were reported by 12% of patients in the prednisone group and 14% in the placebo group. CONCLUSION: The addition of a prednisone burst did not improve the symptomatic and clinical response of acute urticaria to levocetirizine. This study does not support the addition of corticosteroid to H1 antihistamine as first-line treatment of acute urticaria without angioedema.

Added value of sending photograph in diagnosing a medical disease declared at sea: experience of the French Tele-Medical Assistance Service.

The maritime medical tele-consultation carried out by a doctor from the Toulouse Tele-Medical Assistance Service is currently based on tele-consultation using radiotelegraphy and the complementary transmission of data (photographs, electrocardiogram) via the Internet. In a previous article, we presented the benefits of photograph transmission for trauma management in isolated areas. Through this new series of cases, we wanted to expose the aspect of the medical pathologies and the contribution of sending photographs in their management. CASE REPORTS: Case 1. Myocardial infarction. Case 2. Toxic epidermal necrolysis. Case 3. Tooth abscess. Case 4. Shingles. Case 5. Junctional tachycardia. The tele-transmission of photographs provides a real diagnostic and follow-up tool for patients suffering from medical pathologies. The constant increase in the number of tele-consultations with the exchange of photographs shows its necessity and the interest of the participants in the development of these technologies.

Benefits of photograph transmission for trauma management in isolated areas: cases from the French tele-medical assistance service.

French maritime tele-medical assistance is currently performed by a telephone consultation associated with complementary transmission of data (photographs, electrocardiograms, etc.) over the internet. Five case reports are presented to illustrate how photo transmission is useful to managing initial care and monitoring isolated patients. Case reports included: Case 1: management of a hand burn; Case 2: management of a finger wound; Case 3: management of an ocular foreign body; Case 4: management of a subungual haematoma; Case 5: management of phlegmon. In conclusions, photo transmission improves our practice of maritime tele-medical medicine. New high-definition technologies will help in the development of videoconferences on ships.

Characteristics of patients with acute ischemic stroke intubated before imaging.

There are no prospective data on which ischemic stroke patients require endotracheal intubation. This retrospective observational study describes the characteristics and outcomes of adult ischemic stroke patients admitted to two emergency department (ED)-ICU from January 2005 to October 2011 and who were intubated before imaging, either during the prehospital or the ED phase of care. Data were extracted from hospital charts and analyzed using descriptive statistics. During the study period, 57 of 6492 ED patients (<1%) with ischemic stroke were intubated. Of these, 31 were intubated before imaging. The median age of the study group patients was 78 years (IQR, 71-81) and 20 (64%) were men. Twenty-eight (90%) patients had a Glasgow Coma Score of 8 or less at the time of intubation. Twenty-six patients (84%) died during their hospital stay. The proportion of ED ischemic stroke patients intubated before imaging was very low. Almost all were severely ill and the majority died.

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.

Reversal of Vitamin K Antagonist (VKA) effect in patients with severe bleeding: a French multicenter observational study (Optiplex) assessing the use of Prothrombin Complex Concentrate (PCC) in current clinical practice.

INTRODUCTION: Prothrombin Complex Concentrate (PCC) is a key treatment in the management of bleeding related to Vitamin K antagonists (VKA). This study aimed to evaluate prospectively PCC use in patients with VKA-related bleeding in view of the French guidelines published in 2008. METHODS: All consecutive patients with VKA-related bleeding treated with a 4-factor PCC (Octaplex®) were selected in 33 French hospitals. Collected data included demographics, site and severity of bleeding, modalities of PCC administration, International Normalized Ratio (INR) values before and after PCC administration, outcomes and survival rate 15 days after infusion. RESULTS: Of 825 patients who received PCC between August 2008 and December 2010, 646 had severe bleeding. The main haemorrhage sites were intracranial (43.7%) and abdominal (24.3%). Mean INR before PCC was 4.4 ± 1.9; INR was unavailable in 12.5% of patients. The proportions of patients who received a PCC dose according to guidelines were 15.8% in patients with initial INR 2-2.5, 41.5% in patients with INR 2.5-3, 40.8% in patients with INR 3-3.5, 26.9% in patients with INR > 3.5, and 63.5% of patients with unknown INR. Vitamin K was administered in 84.7% of patients. The infused dose of PCC did not vary with initial INR; the mean dose was 25.3 ± 9.8 IU/Kg. Rates of controlled bleeding and target INR achievement were similar, regardless of whether or not patients were receiving PCC doses as per the guidelines. No differences in INR after PCC treatment were observed, regardless of whether or not vitamin K was administered. INR was first monitored after a mean time frame of 4.5 ± 5.6 hours post PCC. The overall survival rate at 15 days after PCC infusion was 75.4% (65.1% in patients with intracranial haemorrhage). A better prognosis was observed in patients reaching the target INR. CONCLUSIONS: Severe bleeding related to VKA needs to be better managed, particularly regarding the PCC infused dose, INR monitoring and administration of vitamin K. A dose of 25 IU/kg PCC appears to be efficacious in achieving a target INR of 1.5. Further studies are required to assess whether adjusting PCC dose and/or better management of INR would improve outcomes.

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.