Terrorist threat: Creating a nationwide damage control training program for non-trauma care providers

Lessons learned from the war in Ukraine for the anesthesiologist and intensivist: A scoping review

BACKGROUND

The war in Ukraine provides purposefully anesthesiologists and intensivists with important data for improving the management of trauma patients. This scoping review aims to investigate the specific management of war-related trauma patients, during the war in Ukraine, through an objective and comprehensive analysis.

METHODS

A comprehensive search of the Embase, Medline, and Open Grey databases from 2014 to February 2024 yielded studies focusing on anesthesia and surgery. These studies were assessed by PRISMA and STROBE criteria and needed to discuss anesthesiology and surgical procedures.

RESULTS

Of the 519 studies identified, 21 were included, with a low overall level of evidence. The studies covered 11,622 patients and 2470 surgical procedures. Most patients were Ukrainian men, 25-63 years old, who had sustained severe injuries from high-energy weapons, such as multiple rocket systems and combat drones. These injuries included major abdominal, facial, and extremity traumas. The surgical procedures varied from initial debridement to complex reconstructions. Anesthesia management faced significant challenges, including resource scarcity and the need for quick adaptability. Evacuations of casualties were lengthy, complex, and often involved rail transportation. Hemorrhage control with tourniquets was critical but associated with many complications. The very frequent presence of multi-resistant organisms required dedicated preventive measures and appropriated treatments. The need for qualified human resources underscored the importance of civilian-military cooperation.

CONCLUSION

This scoping review provides original and relevant insights on the lessons learned from the ongoing war in Ukraine, which could be useful for anesthesiologists and intensivists.

Damage Control Training: A Cross-sectional Survey of Health care Personnel of French Emergency Medicine Structures

INTRODUCTION

Terrorist threats are a worldwide phenomenon. The injuries caused with military weapons or explosives are multiple and unusual for civilian care services. Damage control (DC) training has then become a critical need. In response to the November 2015 attacks, the French authorities launched a national DC training campaign for emergency care personnel. The aim was to describe the implementation of DC training campaign and its perception according to the respondent's profession, DC teaching levels, and the history of terrorist attacks in the last decade of the hospital center's activities.

MATERIALS AND METHODS

A survey was distributed to all Casualty Department staff in France. The answers were collected between June 9, 2020 and July 22, 2020. The project was qualified as not involving humans and participation was on voluntary basis. The study is out of the French Jardé law.

RESULTS

Two-thirds of the 1,525 respondents considered themselves trained in DC (emergency physicians [76.8%], nurse anesthetists [68.1%], and ambulance drivers [65.3%]). Less than half considered their theoretical (41.1%) and practical (44.7%) knowledge excellent or good. More than 95% of the untrained personnel wanted to receive this type of training. Trained personnel were in favor of annual refresher training (95.7%) and training for practical applications (95.1%). Personnel at teaching centers were more frequently trained than personnel at nonteaching centers (respectively 75.3% and 64.3%, P < .0001) and had applied their knowledge significantly more often (50.1% vs. 43.4%, P = .038). They often considered their knowledge to be excellent (respectively 50.8% vs. 42.4%, P = .064).

CONCLUSION

The training of emergency personnel in DC is far from being generalized in France. Among the trained personnel, it was often deemed insufficient, in theory and in practice. There was an inequity of training in favor of those in teaching centers. It is therefore essential that training in DC techniques in France be continued, generalized, improved, and standardized throughout the country in order to guarantee an optimal response from the health care systems in the event of new terrorist attacks.

Management and outcomes of COVID-19 patients admitted in a newly created ICU and an expert ICU, a retrospective observational study

BACKGROUND

The COVID-19 pandemic abruptly increased the inflow of patients requiring intensive care units (ICU). French health institutions responded by a twofold capacity increase with temporary upgraded beds, supplemental beds in pre-existing ICUs, or newly created units (New-ICU). We aimed to compare outcomes according to admission in expert pre-existing ICUs or in New-ICU.

METHODS

This multicenter retrospective observational study was conducted in two 20-bed expert ICUs of a University Hospital (Expert-ICU) and in one 16-bed New-ICU in a private clinic managed respectively by 3 and 2 physicians during daytime and by one physician during the night shift. All consecutive adult patients with COVID-19-related acute hypoxemic respiratory failure admitted after centralized regional management by a dedicated crisis cell were included. The primary outcome was 180-day mortality. Propensity score matching and restricted cubic spline for predicted mortality over time were performed.

RESULTS

During the study period, 165 and 176 patients were enrolled in Expert-ICU and New-ICU respectively, 162 (98%) and 157 (89%) patients were analyzed. The unadjusted 180-day mortality was 30.8% in Expert-ICU and 28.7% in New-ICU, (log-rank test, p =  0.7). After propensity score matching, 123 pairs (76 and 78%) of patients were matched, with no significant difference in mortality (32% vs. 32%, OR 1.00 [0.89; 1.12], p = 1). Adjusted predicted mortality decreased over time (p < 0.01) in both Expert-ICU and New-ICU.

CONCLUSIONS

In COVID-19 patients with acute hypoxemic respiratory failure, hospitalization in a new ICU was not associated with mortality at day 180.

Les actions du service de santé des armées face à la crise COVID-19: sur mer et au-delà des mers, toujours au service des hommes !

« Nous sommes en guerre ! » a déclaré le président Emmanuel Macron lors d’un discours à la nation le 16 mars 2020. Dans le cadre de cette résilience nationale, le service de santé des armées (SSA) s’est engagé dans la lutte contre le COVID-19. Cette revue générale a pour objectif de décrire et de détailler les actions que le SSA a mené dans le cadre de la lutte nationale contre la pandémie de COVID-19 en France, ainsi qu’à l’étranger. Des experts de chaque domaine ont rapporté les actions majeures menées par le SSA lors de la pandémie de COVID-19. En quelques semaines seulement, le SSA a développé des capacités médicales ad hoc pour soutenir les autorités sanitaires nationales. Il a également mis en œuvre des capacités d’évacuations médicales collectives par voie aérienne et maritime. Un hôpital militaire de campagne dédié aux soins intensifs a également été déployé en soutien de l’hôpital civil à Mulhouse. Plus tard, des modules militaires de réanimation ont aidé des centres hospitaliers débordés par l’afflux de malades COVID-19 en Guadeloupe, en Martinique, en Guyane, à Mayotte et en Nouvelle-Calédonie. Une cellule de crise COVID-19 a permis de coordonner les actions des forces armées françaises dans le cadre de la lutte contre la pandémie. Le centre d’épidémiologie et de santé publique des armées a fourni toutes les informations nécessaires pour guider les processus de prises de décisions. Les centres médicaux des armées ont organisé les soins primaires pour les patients militaires, avec un large recours à la télémédecine. Les services de secours de la Brigade des sapeurs-pompiers de Paris et du Bataillon des marins-pompiers de Marseille ont assuré la prise en charge préhospitalière des patients atteints de COVID-19. Les huit hôpitaux d’instruction militaires français ont coopéré avec les agences régionales de santé pour permettre la prise en charge hospitalière des patients les plus graves, mais aussi créer de novo des centres de vaccination. La chaîne de ravitaillement médical des armées a soutenu tous les déploiements d’unités médicales opérationnelles en France et à l’étranger, faisant face à une pénurie croissante de matériel médical. L’institut de recherche biomédicale des armées a réalisé des diagnostics, s’est engagé dans de multiples projets de recherche, a mis à jour quotidiennement la revue de la littérature scientifique sur le COVID-19 et a fourni des recommandations d’experts sur la biosécurité. Enfin, les étudiants des écoles militaires de santé de Lyon-Bron se sont portés volontaires pour participer à la lutte contre la pandémie de COVID-19. En conclusion, dans une crise médicale sans précédent, le SSA a engagé de multiples actions innovantes et adaptatives, toujours en cours, dans la lutte contre le COVID-19. La collaboration entre les systèmes de santé militaires et civils a renforcé l’objectif commun de « sauver le plus grand nombre ».

The French Pre-Deployment Advanced Course in Anesthesia and Resuscitation: Development and Future Prospects

INTRODUCTION

Military anesthesiologists from the French Military Medical Service (FMMS) are part of the Forward Surgical Teams deployed in overseas military operations. The practice of anesthesia in combat zones requires specific skills that are not taught during the initial curriculum for French civilian anesthesiologist. The Pre-Deployment Advanced Course in Anesthesia and Resuscitation (DACAR) program was developed to prepare military anesthesiologist from the FMMS before their deployment in overseas military operations.

METHODS

Created in 2013 by the French Military Medical Academy, the DACAR program is divided into two modules and carried out once a year. The DACAR program trains all military anesthesiologist residents at the end of their curricula. Since 2019, a number of Certified Registered Nurse Anesthetists have completed the DACAR program. The DACAR program is organized around the main axes of experience feedback from previous deployments in combat zones as well as didactic learning and practical training using high-fidelity simulation.

RESULTS

Since 2013, a total of 99 trainees completed the DACAR program during six complete cycles of two modules. The DACAR program has gradually been enriched from 14 courses in 2013 to 28 in 2019. Participants' reported satisfaction rates have increased steadily since 2016, when 88% of courses were rated as "interesting" or "very interesting," and only 4% as "not very interesting." By 2019, those figures had improved to 96% and 2%, respectively.

CONCLUSION

The DACAR program is a structured and adapted military medical course aimed at completing the curriculum of military anesthesiologists from the FMMS before deployment in overseas military operations. Regular audits and updates ensure that the DACAR training program maintains the highest standards of quality and rigor.

How do we fight COVID-19? Military medical actions in the war against the COVID-19 pandemic in France

'We are at war', French President Emmanuel Macron said in an address to the nation on 16 March 2020. As part of this national effort, the French Military Medical Service (FMMS) is committed to the fight against COVID-19. This original report aimed to describe and detail actions that the FMMS has carried out in the nationwide fight against the COVID-19 pandemic in France, as well as overseas. Experts in the field reported major actions conducted by the FMMS during the COVID-19 pandemic in France. In just few weeks, the FMMS developed ad hoc medical capabilities to support national health authorities. It additionally developed adaptive, collective en route care via aeromedical and naval units and deployed a military intensive care field hospital. A COVID-19 crisis cell coordinated the French Armed Forces health management. The French Military Centre for Epidemiology and Public Health provided all information needed to guide the decision-making process. Medical centres of the French Armed Forces organised the primary care for military patients, with the widespread use of telemedicine. The Paris Fire Brigade and the Marseille Navy Fire Battalion emergency departments ensured prehospital management of patients with COVID-19. The eight French military training hospitals cooperated with civilian regional health agencies. The French military medical supply chain supported all military medical treatment facilities in France as well as overseas, coping with a growing shortage of medical equipment. The French Armed Forces Biomedical Research Institute performed diagnostics, engaged in multiple research projects, updated the review of the scientific literature on COVID-19 daily and provided expert recommendations on biosafety. Finally, even students of the French military medical academy volunteered to participate in the fight against the COVID-19 pandemic. In conclusion, in an unprecedented medical crisis, the FMMS engaged multiple innovative and adaptive actions, which are still ongoing, in the fight against COVID-19. The collaboration between military and civilian healthcare systems reinforced the shared objective to achieve the goal of 'saving the greatest number'.