A Serious Game for Massive Training and Assessment of French Soldiers Involved in Forward Combat Casualty Care (3D-SC1): Development and Deployment.

BACKGROUND: The French Military Health Service has standardized its military prehospital care policy in a ''Sauvetage au Combat'' (SC) program (Forward Combat Casualty Care). A major part of the SC training program relies on simulations, which are challenging and costly when dealing with more than 80,000 soldiers. In 2014, the French Military Health Service decided to develop and deploy 3D-SC1, a serious game (SG) intended to train and assess soldiers managing the early steps of SC. OBJECTIVES: The purpose of this paper is to describe the creation and production of 3D-SC1 and to present its deployment. METHODS: A group of 10 experts and the Paris Descartes University Medical Simulation Department spin-off, Medusims, coproduced 3D-SC1. Medusims are virtual medical experiences using 3D real-time videogame technology (creation of an environment and avatars in different scenarios) designed for educational purposes (training and assessment) to simulate medical situations. These virtual situations have been created based on real cases and tested on mannequins by experts. Trainees are asked to manage specific situations according to best practices recommended by SC, and receive a score and a personalized feedback regarding their performance. RESULTS: The scenario simulated in the SG is an attack on a patrol of 3 soldiers with an improvised explosive device explosion as a result of which one soldier dies, one soldier is slightly stunned, and the third soldier experiences a leg amputation and other injuries. This scenario was first tested with mannequins in military simulation centers, before being transformed into a virtual 3D real-time scenario using a multi-support, multi-operating system platform, Unity. Processes of gamification and scoring were applied, with 2 levels of difficulty. A personalized debriefing was integrated at the end of the simulations. The design and production of the SG took 9 months. The deployment, performed in 3 months, has reached 84 of 96 (88%) French Army units, with a total of 818 hours of connection in the first 3 months. CONCLUSIONS: The development of 3D-SC1 involved a collaborative platform with interdisciplinary actors from the French Health Service, a university, and videogame industry. Training each French soldier with simulation exercises and mannequins is challenging and costly. Implementation of SGs into the training program could offer a unique opportunity at a lower cost to improve training and subsequently the real-time performance of soldiers when managing combat casualties; ideally, these should be combined with physical simulations.

Preparation of an intensive care unit in France for the reception of a confirmed case of Ebola virus infection.

The current Ebola Virus Disease (EVD) outbreak in West Africa is a major challenge for the worldwide medical community. On April 29th 2015, the World Health Organization (WHO) declared 26,277 infected cases; among them, 10,884 have deceased. The epidemic is still ongoing, particularly in Sierra Leone. It is now clear that northern countries will be implicated in the care of EVD patients, both in the field and back at home. Because of the severity of EVD, a fair amount of patients may require intensive care. It is highly probable that intensive care would be able to significantly reduce the mortality linked with EVD. The preparation of a modern Intensive Care Unit (ICU) to treat an EVD patient in good conditions requires time and specific equipment. The cornerstone of this preparation includes two main goals: treating the patient and protecting healthcare providers. Staff training is time consuming and must be performed far in advance of patient arrival. To be efficient, preparation should be planned at a national level with help from public authorities, as was the case in France during the summer of 2014. Due to the severity of the disease, the high risk of transmission and scarce knowledge on EVD treatment, our propositions are necessarily original and innovative. Our review includes four topics: a brief report on the actual outbreak, where to receive and hospitalize the patients, the specific organization of the ICU and finally ethical aspects.

Epstein-Barr virus reactivation in critically ill immunocompetent patients.

BACKGROUND: Herpes viruses can be reactivated among immunocompetent patients in intensive care unit (ICU). Cytomegalovirus (CMV) and herpes simplex virus (HSV) have been the most studied. We hypothesized that Epstein-Barr virus (EBV) could also be reactivated in immunocompetent patients during their stay in ICU and that this would be associated with morbidity and mortality. METHODS: This prospective observational study included 90 patients with an ICU stay of ≥ 5 days. CMV and HSV were considered when clinically suspected and DNA was researched in blood or bronchoalveolar lavage (BAL). EBV DNA viral quantification was performed in the blood samples. RESULTS: EBV DNA was detected in blood of 61 patients (median length for positivity of 7.5 days). CMV DNA was detected in blood of 16 patients (median length for positivity of 13.5 days) and BAL of 6 patients. HSV1 DNA was detected in the BAL of 28 patients (median length for positivity of 7.5 days). Nineteen patients had no viral reactivation, 1 experienced only CMV, 32 had only EBV, 5 had only HSV, 6 had EBV and CMV, 14 had EBV and HSV, and 9 patients reactivated three viruses. Mortality was higher among patients with EBV reactivation (33/61 vs. 7/25, p = 0.02). Length of stay (21 vs. 10 days, p < 0.001) and length of mechanical ventilation (15 vs. 7 days, p < 0.001) were higher among patients with EBV reactivation. CONCLUSIONS: This study shows that EBV DNA is detected in blood of diverse ICU patients with ≥ 5 days of stay and that it is associated with morbidity and mortality. Larger dynamic prospective studies are needed to correlate viral reactivation with immune system evolution during ICU stay and to determine the role of polyviral reactivations.

Predeployment training for forward medicalisation in a combat zone: the specific policy of the French Military Health Service.

INTRODUCTION: To improve the mortality rate on the battlefield, and especially the potentially survivable pre-Medical Treatment Facility deaths, Tactical Combat Casualty Care (TCCC) is now considered as a reference for management of combat casualty from the point of injury to the first medical treatment facility. TCCC comprises of a set of trauma management guidelines designed for use on the battlefield. The French Military Health Service also standardised a dedicated training programme, entitled "Sauvetage au Combat" (SC) ("forward combat casualty care"), with the characteristic of forward medicalisation on the battlefield, the medical team being projected as close as possible to the casualty at the point of injury. The aim of our article is to describe the process and the result of the SC training. MATERIALS AND METHODS: Records from the French Military Health Service Academy - École du Val-de-Grâce administration, head of the SC teaching programme, defining its guidelines, and supporting its structure and its execution, were examined and analyzed, since the standardisation of the SC training programme in 2008. The total number of trainees was listed following the different courses (SC1, SC2, SC3). RESULTS: At the end of 2013, every deployed combatant underwent SC1 courses (confidential data), 785 health-qualified combatants were graduated for SC2 courses and 672 Role 1 physician-nurse pairs for SC3 courses. CONCLUSION: The SC concept and programmes were defined in France in 2007 and are now completely integrated into the predeployment training of all combatants but also of French Military Health Service providers. Finally, SC teaching programmes enhance the importance of teamwork in forward combat medicalisation settings.

Paraneoplastic granulocytosis in an advanced lung cancer patient.

Paraneoplastic syndromes (PNPs) refer to cancer-associated signs and symptoms arising in organs and tissues that are remote from the cancer and unrelated to metastasis. Currently the best described PNPs are attributed to tumor secretion of functional peptides and hormones or immune cross-reactivity between tumor and normal host tissues. Paraneoplastic hematologic syndromes are observed more rarely. Here we report a case of paraneoplastic granulocytosis in an advanced lung cancer patient.

Brief report: pulmonary auscultation in the operating room: a prospective randomized blinded trial comparing electronic and conventional stethoscopes.

BACKGROUND: We compared the subjective quality of pulmonary auscultation between 2 acoustic stethoscopes (Holtex Ideal® and Littmann Cardiology III®) and an electronic stethoscope (Littmann 3200®) in the operating room. METHODS: A prospective double-blind randomized study with an evaluation during mechanical ventilation was performed in 100 patients. After each examination, the listeners using a numeric scale (0-10) rated the quality of auscultation. Auscultation quality was compared in patients among stethoscopes with a multilevel mixed-effects linear regression with random intercept (operator effect), adjusted on significant factors in univariate analysis. A significant difference was defined as P < 0.05. RESULTS: One hundred comparative evaluations of pulmonary auscultation were performed. The quality of auscultation was rated 8.2 ± 1.6 for the electronic stethoscope, 7.4 ± 1.8 for the Littmann Cardiology III, and 4.6 ± 1.8 for the Holtex Ideal. Compared with Holtex Ideal, auscultation quality was significantly higher with other stethoscopes (P < 0.0001). Compared with Littmann Cardiology III, auscultation quality was significantly higher with Littmann 3200 electronic stethoscope (ß = 0.9 [95% confidence interval, 0.5-1.3]). CONCLUSIONS: An electronic stethoscope can provide a better quality of pulmonary auscultation than acoustic stethoscopes in the operating room, yet with a magnitude of improvement marginally higher than that provided with a high performance acoustic stethoscope. Whether this can translate into a clinically relevant benefit requires further studies.

Life-threatening rupture of a false aneurysm after femoral arterial catheterization: unexpected delay after a common procedure.

We report the case of a 79-year-old patient who presented with a femoral iatrogenic pseudoaneurysm of delayed and unusual onset with immediately life-threatening massive bleeding. Ultrasound is the method of choice for the diagnosis of pseudo aneurysm. If there is not spontaneous closure, ultrasound-guided compression repair, minimally invasive percutaneous treatments, and surgical repair are the three therapeutic options.