Ethical Dilemmas Faced by Military Health Personnel During High-Intensity Conflict: The Crucial Issue of Triage.

Russia's invasion of Ukraine has triggered the biggest conflict in Europe since the Second World War. It has forced countries to prepare for engagement on a massive scale, namely, a high-intensity war between nation states. A potential massive influx of wounded personnel risks saturating logistical supply chains and requires changes to not only medical care but also a paradigm shift. In this context, the principle of distributive justice is key. The aim is to save as many lives as possible through triage, which consists in "doing the greatest good for the greatest number." This idea is fundamental, as an emergency that has passed is no longer an emergency. However, international texts and treaties not only underline that the sole criterion for triage is clinical severity, but they also fail to take into account the patient's status (civilian, friend, and foe). In a high-intensity warfare situation, these texts, and the medical-surgical triage criteria they provide are insufficient, as caregivers may be required to make decisions based on the status of the patient. The need to make such choices could cause psychological suffering among military caregivers, as individuals are recurrently faced with difficult ethical dilemmas. One way to prevent this happening is to provide predeployment training in wartime medical ethics. The latter would include both instruction in international humanitarian law and practical simulations of clinical situations where the person is faced with an ethical dilemma.

Portal vein embolization following arterial portography for the management of an active portal bleeding after blunt liver trauma in a cirrhotic patient.

BACKGROUND: The management of blunt liver trauma in cirrhotic patients is challenging, because while bleeding is most often of arterial origin, the increased pressure in the portal system associated with cirrhosis can increase the risk of portal bleeding, which is sometimes difficult to confirm on contrast-enhanced abdominal computed tomography. CASE PRESENTATION: We managed a 54-year-old cirrhotic patient who presented with blunt liver trauma. Computed Tomography showed active intraperitoneal bleeding presumed to be of hepatic origin. Given the patient's hemodynamic stability, the decision was made to manage the patient non-surgically. The patient underwent hepatic arteriography to rule out an arterial origin to the bleeding. A superior mesenteric arterial portography confirmed the portal venous origin of the bleeding. To stop the bleeding, a distal portal vein embolization using coils and glue was performed by approaching a large paraumbilical vein. CONCLUSIONS: Our case study shows the value of arterial portography in the management of these patients, when they are clinically stable enough to benefit from non-surgical management; This allows arterial bleeding to be excluded on hepatic arteriography, portal bleeding to be confirmed on portography following arteriography in the superior mesenteric artery, and guidance of portal vein embolization.

Risk Analysis by Failure Modes, Effects and Criticality Analysis and Biosafety Management During Collective Air Medical Evacuation of Critically Ill Coronavirus Disease 2019 Patients.

In March 2020, coronavirus disease 2019 (COVID-19) caused an overwhelming pandemic. To relieve overloaded intensive care units in the most affected regions, the French Ministry of Defence triggered collective air medical evacuations (medevacs) on board an Airbus A330 Multi Role Tanker Transport of the French Air Force. Such a collective air medevac is a big challenge regarding biosafety; until now, only evacuations of a single symptomatic patient with an emergent communicable disease, such as Ebola virus disease, have been conducted. However, the COVID-19 pandemic required collective medevacs for critically ill patients and involved a virus that little is known about still. Thus, we performed a complete risk analysis using a process map and FMECA (Failure Modes, Effects and Criticality Analysis) to assess the risk and implement mitigation measures for health workers, flight crew, and the environment. We report the biosafety management experienced during 6 flights with a total of 36 critically ill COVID-19-positive patients transferred with no casualties while preserving both staffs and aircraft.

Analysis of European Air Medical Evacuation Flights of Coronavirus Disease 2019 Patients.

OBJECTIVE: As part of the humanitarian response to the coronavirus disease 2019 (COVID-19) pandemic, the German and French Armed Forces provided air transport for patients from overwhelmed regional hospitals in Italy and France. The objective of this study was to analyze the characteristics of the missions and the medical conditions of COVID-19 patients transported during an air medical evacuation on fixed wing aircraft in March and April 2020. METHOD: This was a retrospective analysis of transport records as well as other documents for 58 COVID-19 patients requiring artificial ventilation. RESULTS: The median age of the transported patients was 61.5 years, and 61% of them had preexisting medical conditions. They had been ventilated for a median of 5 days and experienced the first symptoms 18 days before transport. The patients flown out of France had less days of ventilation before flight, a lower end-tidal carbon dioxide level at the beginning of the flight, and a lower Charlson Comorbidity Index. There were also some differences between the ventilation and the flight level flown by the 2 air forces. CONCLUSION: The intensive care transport of ventilated COVID-19 patients requires highly qualified personnel and appropriate equipment and should be planned appropriately.

Pulmonary aspergillosis in critically ill patients with Coronavirus Disease 2019 (COVID-19).

Occurrence of putative invasive pulmonary aspergillosis was screened in 153 consecutive adult intensive care unit (ICU) patients with respiratory samples addressed for mycological diagnosis during a 6-week period at the emergence of coronavirus disease 2019 (COVID-19) pandemic. Positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) was observed for 106 patients (69.3%). Nineteen of them (17.9%) with positive Aspergillus results were considered as having putative invasive pulmonary aspergillosis. These observations underline the risk of pulmonary aspergillosis in COVID-19 patients, even in patients not previously known to be immunosuppressed, advocating active search for Aspergillus infection and prompt antifungal treatment. Standardized surveillance protocols and updated definitions for ICU putative invasive pulmonary aspergillosis are needed. LAY ABSTRACT: Adult ICU patients with respiratory samples addressed for mycological diagnosis were screened during the emergence of COVID-19 pandemic. Positive SARS-CoV-2 PCR was observed for 106 patients, nineteen of them (17.9%) having aspergillosis. This underlines the risk of aspergillosis in COVID-19 patients.

Oxygen Management During Collective Aeromedical Evacuation of 36 COVID-19 Patients With ARDS.

OBJECTIVE: The ongoing coronavirus disease-2019 pandemic leads to the saturation of critical care facilities worldwide. Collective aeromedical evacuations (MEDEVACS) might help rebalance the demand and supply of health care. If interhospital transport of patients suffering from ARDS is relatively common, little is known about the specific challenges of collective medevac. Oxygen management in such context is crucial. We describe our experience with a focus on this resource. METHODS: We retrospectively analyzed the first six collective medevac performed during the coronavirus disease-2019 pandemic by the French Military Health Service from March 17 to April 3, 2020. Oxygen management was compliant with international guidelines as well as aeronautical constraints and monitored throughout the flights. Presumed high O2 consumers were scheduled to board the last and disembark the first. RESULTS: Thirty-six mechanically ventilated patients were successfully transported within Europe. The duration of onboard ventilation was 185 minutes (145-198.5 minutes), including the flight, the boarding and disembarking periods. Oxygen intake was 1,650 L per patient per flight (1,350-1,950 L patient per flight) and 564 L per patient per hour (482-675 L per patient-1 per hour) and surpassed our anticipation. As anticipated, presumed high O2 consumers had a reduced ventilation duration onboard. The estimations of oxygen consumptions were frequently overshot, and only two hypoxemia episodes occurred. CONCLUSION: Oxygen consumption was higher than expected, despite anticipation and predefined oxygen management measures, and encourages to a great caution in the processing of such collective medevac missions.

Collective aeromedical transport of COVID-19 critically ill patients in Europe: A retrospective study.

BACKGROUND: In early 2020, the coronavirus disease 2019 (COVID-19) pandemic outbreak has posed the risk of critical care resources overload in every affected country. Collective interhospital transport of critically ill COVID-19 patients as a way to mitigate the localised pressure from overloaded intensive care units at a national or international level has not been reported yet. The aim of this study was to provide descriptive data about the first six collective aeromedical evacuation (MEDEVAC) of COVID-19 patients performed within Europe. METHODS: This retrospective study included all adult patients transported by the first six collective MEDEVAC missions for COVID-19 patients performed within Europe on the 18th, 21st, 24th, 27th, 31st of March and the 3rd of April 2020. RESULTS: Thirty-six patients with acute respiratory distress syndrome (ARDS) were transported aboard six MEDEVAC missions. The median duration of mechanical ventilation in ICU before transportation was 4 days (3-5.25). The median PaO2/FiO2 ratio obtained before, during the flight and at day 1 after the transport was 180 mmHg (156-202,5), 143 mmHg (118,75-184,75) and 174 mmHg (129,5-205,5), respectively, with no significant difference. The median norepinephrine infusion rate observed before, during the flight and at day 1 after the transport was 0,08 µg/kg-1. min-1 (0,00-0,20), 0,08 (0,00-0,25), and 0,07 (0,03-0,18), respectively, with no significant difference. No life-threatening event was reported. CONCLUSION: Collective aero-MEDEVAC of COVID-19 critically ill patients could provide a reliable solution to help control the burden of the disease at a national or international level.

Evaluation of Prescription Practices of Domperidone in Parkinson's Disease: A Cross Sectional Study Among French Neurologists.

BACKGROUND: Domperidone is used to treat gastrointestinal symptoms in patients with Parkinson's disease. Because of an increased risk of cardiac adverse events, the European Medicines Agency has issued recommendations restricting its use mainly in terms of age, dose, and treatment duration. OBJECTIVE: The aim of this study was to investigate current prescription practices of domperidone in Parkinson's disease among French neurologists. METHODS: A cross-sectional study based on a questionnaire was conducted among French neurologists from Parkinson's disease expert centers from the French NS-Park/FCRIN network, general hospitals, and private practice. RESULTS: Among the 253 neurologists who completed the questionnaire, 86 (34%) were physicians from expert centers and 167 (66%) were from other healthcare settings; 209 (83%) were aware of recommendations restricting domperidone use. The majority of neurologists (92%) declared prescribing domperidone regardless of the age of the patients. Sixty-one percent of neurologists prescribed domperidone beyond 7 days in newly diagnosed patients, 33% in patients with orthostatic hypotension, and 79% in patients receiving continuous apomorphine treatment. They did not follow the recommendation on posology in newly diagnosed patients (7% of neurologists), patients with orthostatic hypotension (10%), and patients receiving continuous apomorphine therapy (25%). Finally, only 58% of neurologists declared taking specific precautions before prescribing domperidone. CONCLUSIONS: These findings show most French neurologists who responded to our questionnaire do not fully follow the restrictions on domperidone use, particularly in terms of treatment duration, and in patients receiving continuous apomorphine treatment. This may reflect the unmet need to prevent nausea in patients with Parkinson's disease treated with dopaminergic drugs, particularly continuous apomorphine therapy.

Risk factors for progression toward brain death after out-of-hospital cardiac arrest.

BACKGROUND: Successfully resuscitated out-of-hospital cardiac arrest (OHCA) may lead to brain death (BD) and good-quality transplantable organs. We aimed to determine risk factors for evolution toward BD after OHCA. We analyzed adult patients admitted to an intensive care unit (ICU) who survived at least 24 h after an OHCA between 2005 and 2015. BD was defined according to international guidelines. Multivariate logistic regression was used to identify potential risk factors for BD available 24 h after OHCA. RESULTS: A total of 214 patients were included (median age 68 years; sex ratio 1.25; non-shockable OHCA: 88%). Among these, 42 (19.6%) developed BD, while 22 (10.3%) were alive at 1 year with a good neurological outcome. Independent risk factors for BD were age (OR per year 0.95; 95% CI [0.92-0.98]), female gender (OR 2.34; 95% CI [1.02-5.35]), neurological cause of OHCA (OR 14.72; 95% CI [3.03-71.37]), duration of the low-flow period > 16 min (OR 2.94, 95% CI [1.21-7.16]) and need of vasoactive drugs at 24 h (OR 6.20, 95% CI [2.41-15.93]). CONCLUSIONS: The study identified, in a population of OHCA with predominantly non-shockable initial rhythms, five simple risk factors independently associated with progression toward BD.

Measure of chest wall thickness in French soldiers: which technique to use for needle decompression of tension pneumothorax at the front?

OBJECTIVES: Needle decompression of tension pneumothorax in soldiers of the French infantry has a risk for failure when the standard procedure that involves the insertion of a 14-gauge, 5-cm catheter into the 2nd intercostal space (ICS) is used. This study measured the chest wall thickness (CWT) to assess whether this approach is appropriate. METHODS: CWT was measured by ultrasound in 122 French soldiers at the 2nd and 4th ICSs on both the right and left sides. RESULTS: CWT was measured at 4.19 cm (± 0.96 cm) at the 2nd ICS and 3.00 cm (± 0.91 cm) at the 4th ICS (p < 0.001). CWT was greater than 5 cm in 24.2% of cases at the 2nd ICS and 4.9% of cases at the 4th ICS (p < 0.001). CONCLUSIONS: This study suggests a high risk of failure when using the technique currently taught in the French army. A lateral approach into the 4th ICS could decrease this risk. The results of this study must be validated in patients presenting tension pneumothorax.

Pulseless electrical activity after myocardial infarction: not always a left ventricular free wall rupture.

Pulseless electrical activity (PEA) after acute myocardial infarction is classically caused by ventricular free wall rupture. We report the case of a 76-year-old woman who presented a cardiac arrest with PEA 5 days after an embolic acute myocardial infarction. Transthoracic echocardiogram showed a massive mitral regurgitation due to posterior papillary muscle rupture. This case demonstrates that other causes potentially treatable than cardiac tamponade must be sought in patients with PEA after myocardial infarction.

A new site for venous access: superficial veins of portal collateral circulation.

In case of failure of peripheral vascular access, classical alternatives are central venous or intraosseous access. We report a new site of vascular access necessitating no specific material. A 53-year-old patient with cirrhosis-induced coagulopathy, portal hypertension, and collateral abdominal portosystemic circulation required parenteral antibiotherapy. After failure of peripheral vein catheterization, he was addressed to our resuscitation room for central venous access. To avoid the risks associated with this invasive procedure, we chose an alternative approach. After skin preparation, a 20-gauge peripheral venous catheter was inserted in a dilated subcutaneous vein of abdominal wall. To our knowledge, it is the first human report of insertion of a catheter in a superficial vein of abdominal wall. It could be an alternative approach for vascular access after failure of peripheral venipuncture in patients with portal hypertension.

The use of boluses of propofol for the management of severe tetanus in a child.

Tetanus is endemic in many developing countries. Although propofol has been proposed for sedation in tetanus, the routine use of this drug has not been clearly documented in published reports. A few studies have reported its beneficial effects but no randomized studies are available. We describe the case of a five-year-old boy who presented with severe tetanus in East Africa. The antispastic therapy consisted of benzodiazepine infusion with the addition of titrated boluses of propofol. Intubation and mechanical ventilation were avoided.