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.

Traumatisme et température

Le patient traumatisé est exposé à l’hypothermie. La mortalité des traumatisés hypothermes est multipliée par quatre ou cinq. Les interactions de l’hypothermie avec l’hémostase et le système cardiovasculaire sont délétères. Les effets sur la coagulation sont multiples et concourent directement à la surmortalité faisant de l’hypothermie une composante majeure de la « triade létale ». Les causes d’hypothermie chez le patient traumatisé sont multiples : 1) environnementales, le risque augmente quand la température ambiante diminue ; 2) cliniques, le risque augmente avec la gravité ; et aussi 3) thérapeutiques, par exemple par la perfusion de solutés à température ambiante. Une prise en charge optimale repose sur une mesure précoce et un monitorage continu de la température corporelle. L’objectif thérapeutique est de maintenir une température corporelle au moins égale à 36 °C. Limiter le déshabillage du patient, le protéger du froid avec une couverture de survie, l’installer rapidement dans une ambulance chauffée, recourir à des dispositifs de réchauffement actifs, perfuser des solutés réchauffés sont les éléments fondamentaux de la prise en charge d’un patient traumatisé, potentiellement hypotherme.

[Involuntary Psychiatric Hospitalizations: From request to a call center to hospitalization]

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.

Ecstasy : la deuxième vague…

La molécule de MDMA (3,4-méthylènedioxyméthamphétamine ou ecstasy) a plus de 100 ans. Sa consommation a explosé dans les années 1990, essentiellement dans un cadre « festif » ou « récréatif ». Elle a ensuite considérablement diminué au début des années 2000 et connaît actuellement un regain d’intérêt certain. Sa consommation a volontiers été considérée comme anodine avant qu’il n’apparaisse clairement qu’elle pouvait provoquer des décès, en l’absence même de « surdose ». Les mécanismes de toxicité sont multiples, complexes et imparfaitement élucidés. L’interaction avec les principaux neuromédiateurs est certaine. L’ecstasy est classée dans les produits empathogènes. Sa consommation vise à favoriser les relations sociales. De nombreux effets secondaires sont possibles. Les conditions de consommation, en ambiance confinée, avec une activité physique soutenue et prolongée favorisent la survenue des effets secondaires. Les effets secondaires bénins sont tolérés et considérés comme étant le « prix à payer » dans la recherche des effets psychogènes. En raison de son tropisme, les principales complications de la consommation d’ecstasy sont psychiatriques et neurologiques, mais aussi cardiovasculaires, respiratoires et métaboliques. Cependant, les formes graves de l’intoxication sont marquées par un tableau d’hyperthermie maligne responsable de complications multiples et pouvant conduire au décès. Tous les auteurs insistent sur la possibilité de complications, de formes graves, voire de décès après la consommation d’une dose unique de MDMA. Il n’y a pas de traitement spécifique. Le traitement symptomatique est au premier plan. Hydratation et sédation sont les clés de ce traitement.

[Psychological effects of emergency calls management on medical dispatcher assistants in a SAMU-Center 15]

INTRODUCTION

In France, the emergency call center is called SAMU (service d'aide médicale d'urgence). The Medical Dispatcher Assistant (MDA) is the first responder and is exposed to first calls of distress and has a high risk of stress disorder.

AIM

Psychological impact of emergency calls on MDA.

METHOD

National multicenter prospective study from January to August 2018 by electronic surveys, including all MDA of 13 SAMU, subdivided in 5 sections: population characteristics, PCL-5 scale (DSM-5) assessing post-traumatic stress disorder (PTSD), ProQOL assessing professional quality of life, call categories and an MDA's emotional perception, and work impacts on an MDA's quality of life. Univariate descriptive statistical analysis of the group with PCL-5≥34 (=complete PTSD group) and with PCL-5<34 (=group without complete PTSD).

RESULTS

Of 400 MDA asked to be interviewed, 283 (71 %) replied of whom 72 % (205) were women and 28 % (79) men. Age groups: 9 % (25) for 18-25 yrs, 39 % (110) for 26-35 yrs, 31 % (89) 36-45 yrs, 15 % (43) 46-55 yrs and 6 % (16) for more than 56 yrs. All MDA reported having been exposed to death experience. For 46 % (129) the most recent traumatic event occurred within the last 7 months. 78 % (219) have reported intense fear, feeling helpless, or even sensed horror when answering the calls. 97 % (273) could talk about it with colleagues but only 64 % (180) with family. 72 % (203) felt lack of recognition at work. 78 % (220) had no knowledge about psycho-traumatic disorder. While 11 % (30) suffered symptoms suggestive of a complete PTSD, 15 % (42) an incomplete PTSD, 3 % (8) suffer burnout and 4 % (11) compassion fatigue, none reported secondary traumatic stress. The only significant difference (P<0.05) between the two groups characteristics was on the education level. 74 % (22) of the MDA with a complete PTSD had a High School diploma or less. MDA with symptoms suggestive of complete PTSD developed significantly (P<0.001) more stress reduction strategies (alcohol, drugs, medication) (13 % vs 2 %), had more food disorders (80.5 % vs 38 %), more sleeping problems (75.5 % vs 21 %), more anxiety (67 % vs 17 %), and more sick leaves (13 % vs 4 %) than the group without complete PTSD.

CONCLUSION

Part of the surveyed MDAs showed symptoms suggestive of PTSD. The study highlights that MDAs is a vulnerable population, and PTSD prevention techniques should be systematically implemented for them. The study also highlights that a higher education level prevents the psycho traumatic process with its accompanying disorders.

P5646Risk factor paradox in STEMI-related sudden cardiac arrest

Background

Cardiovascular risk factors (CVRF) are associated with an increased risk of atherosclerosis and ST-segment elevation myocardial infarction (STEMI). Sudden cardiac arrest (SCA) is currently the most feared complication of STEMI. The impact of CVRF on the rate of SCA is still unknown.

Purpose

To assess the association between CVRF and pre-hospital SCA during acute STEMI.

Methods

Data were taken between 2006 and 2014 from the e-MUST study that enrolls all STEMI managed by EMS in the Greater Paris Area, including those dead before hospital admission. Characteristics of patients who presented SCA were compared to those of patients who did not, and multivariable logistic regression was developed including all variables that differed between the two groups, in order to identify characteristics associated with an increased risk of SCA.

Results

Over the study period, 13,253 STEMI patients were included (median age 60.1 [51.4 - 73.0], 78.1% males). Among them, 7,513 patients (58.1%) had ≥2 CVRF, 3,979 (30.8%) had 1 CVRF, and 1,432 (11.1%) did not present any CVRF. Pre-hospital SCA witnessed by emergency medical services occurred in 749 (5.6%) patients. SCA victims were younger compared to the non-SCA group (58.0 vs. 60.3 years (P<0.001), with a higher proportion of patients without known CVRF (17.2 vs. 10.7%, P<0.001). There was no statistical difference in sex ratio (77.5% vs. 78.2%, P=0.69) and presence of past history of coronary artery disease (18.7% vs. 19.5%, P=0.56). Patients with ≥2 CVRF had the lowest rate of SCA (4.6%), while the highest SCA rate occurred among patients without CVRF (8.9%). On multivariate analysis, the presence of ≥2 CVRF was associated with a twice-lower risk of SCA (OR 0.52, 95% CI 0.41–0.65, P<0.001, when the group without risk factors was taken as a reference group).

Conclusion

The prevalence of CVRF is high among patients presenting STEMI. However, once STEMI has occurred, presence of CVRF is associated with a lower rate of SCA per STEMI, creating a risk factor paradox in STEMI-related SCA.

Comment appréhender une tuerie de masse pour les équipes Smur primo-intervenantes ?

Le risque terroriste présent sur l’ensemble de notre territoire depuis plusieurs années conduit les équipes de Samu–Smur à intervenir sur les lieux d’une tuerie de masse aux côtés de forces de sécurité, voire en tant que primointervenants. De telles circonstances exposent les équipes à un environnement de travail inhabituel et hostile. Cette mise au point, proposée en complément de la recommandation formalisée d’experts sur la prise en charge de tuerie de masse, répond aux interrogations qui naissent sur le terrain en pareilles circonstances. Elle facilite une juste appréciation des événements, aide à réguler ses émotions, dans le but d’augmenter la capacité des soignants à agir, tout en réduisant la phase de sidération initiale, elle-même responsable d’une inertie à même d’impacter le pronostic des blessés en choc hémorragique. Des procédures anticipées, sous forme de check-lists, guident les actions à mener de manière sereine. Les équipes médicales préhospitalières doivent apporter sur le terrain non seulement une compétence médicale, mais également une compétence tactique et décisionnelle pour accélérer les flux d’évacuation. Le premier médecin engagé doit aider à la décision aux côtés du commandant des opérations de secours, du commandant des opérations de police et de gendarmerie et des médecins intégrés aux forces de sécurité intérieure en attendant le directeur des secours médicaux. Il doit donc également faire preuve d’une compétence de chef d’équipe.

Corrélation entre la qualité de la réponse aux appels d’un Samu-Centre 15 et les effectifs d’assistants de régulation médicale — Étude QRAARM

Introduction : Le taux d’occupation des lignes téléphoniques d’un Samu-Centre 15 conditionne la fluidité de la gestion des appels et donc sa capacité de répondre à l’urgence. La disponibilité des assistants de régulation médicale (ARM) et des médecins régulateurs est déterminante. Nous nous sommes interrogés sur l’impact du nombre d’ARM sur la prise en charge des appels d’un Samu-Centre 15.

Méthodes : Le taux d’appels raccrochés (par l’appelant) après 15 secondes a été retenu comme critère de jugement principal. Il a été analysé en fonction de l’effectif « réel » d’ARM. L’effectif théorique d’ARM a été pris comme référence. Deux analyses ont été réalisées, la première portant sur 672 périodes d’un quart d’heure de la semaine 51 de l’année 2016 (en période d’épidémie de grippe) et la seconde sur 3 624 périodes d’une heure sur les cinq premiers mois de l’année 2017.

Résultats : Sur la première période, le nombre médian d’appels raccrochés après 15 secondes était de 1 (0–3) par quart d’heure. Il variait de 0 (0–1) à 3 (1–5) selon l’effectif d’ARM auquel il était parfaitement inversement corrélé (p < 0,001). Sur la seconde période, le nombre médian d’appels raccrochés était de 4 (1–8) par heure. Il variait de 2 (1–6) à 10 (6–16) selon l’effectif d’ARM auquel il était parfaitement inversement corrélé (p < 0,001).

Conclusion : Le taux d’appels raccrochés après 15 secondes était parfaitement corrélé à l’effectif (plus précisément au sous-effectif) d’ARM. Sur une année, le nombre estimé d’appels perdus ainsi était proche de 50 000 ! Prendre en considération l’effectif des ARM est une nécessité absolue.

[When the patient calls the SAMU because his pacemaker is making "beep-beep". Study on physicians' knowledge on pacemaker sound alarm]

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.

[Ultrasound in emergency medicine]

Ultrasound has revolutionized the practice of emergency medicine, particularly in prehospital setting. About a patient with dyspnea, we present the role of ultrasound in the diagnosis and emergency treatment. Echocardiography, but also hemodynamic ultrasound (vena cava) and lung exam are valuable tools. Achieving lung ultrasound and diagnostic value of B lines B are detailed.

First successful curative use of digoxin-specific Fab antibody fragments in a life-threatening coconut crab (Birgus latro L.) poisoning

We wish to report the first curative use of digoxin-specific Fab antibody fragments in a coconut crab Birgus latro L. poisoning in New Caledonia. The female patient, aged sixty-three with a previous history of cardiovascular and metabolic dysfunctions, showed marked first-degree atrio-ventricular block and several atrial pauses, and was given 760 mg of digoxin-specific Fab antibody fragments. Shortly after the perfusion her electrocardiogram returned to close to normal with only slight first-degree atrio-ventricular block and no more atrial pauses. Neriifolin LC-MS/MS tests performed on the patient's serum and urine samples confirmed cardenolide poisoning. Another, younger patient, with high neriifolin levels in her serum and urine samples only experienced gastro-intestinal symptoms and was discharged without specific treatment. The consumption of coconut crab in New Caledonia should be avoided even though the first of the two cases reported suggests that digoxin-specific Fab antibody fragments can be effective in the treatment of life-threatening poisoning caused by the ingestion of this crustacean.

[Feasibility of out-of-hospital management of non-heart-beating donors in Seine-Saint-Denis: one year retrospective study]

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.

Traveller's thrombosis: international consensus statement

In 2001, consensus meetings on traveller's thrombosis were held in Vienna and Berlin. The results of these conferences were subsequently published in VASA 2002. In 2006 a follow-up conference was organized in Hall, Tirol, Austria, in order to review new and emerging data and to update the conclusions and recommendations of the 2001 meetings. Prior to the conference key papers from peer-reviewed journals were pre-circulated to all participants. The consensus group discussed the data and drafted an updated statement. Thereafter, the writing group summarised the results including the pre-circulated material and additional papers identified by a formal literature search up to December 2007. In this article current knowledge on the incidence, pathophysiology and prevention of traveller's thrombosis is summarised. The assessment of individual risk is described and recommendations for prevention of traveller's thrombosis are given, based upon the conclusions of the Hall Conference.

[Evaluation of patients' knowledge regarding counsels provided in case of chest pain after an acute myocardial infarction]

INTRODUCTION

an early call to the department of urgent medical assistance--Center 15 (SAMU-centre 15) is associated to shortest delays of reperfusion in case of myocardial infarction. However, patients are not always aware of this.

OBJECTIVE

to assess the assimilated counsels by patients after an acute myocardial infarction.

METHODS

from January 1998 to June 2004, patients managed by SAMU 93 and having benefited from thrombolytic therapy prior to hospitalization and/or primary angioplasty for a ST+ acute coronary syndrome with a confirmation of acute myocardial infarction during their hospital stay were prospectively enrolled into this study. A questionnaire was administered by phone from december 2003 to july 2005, assessing the knowledge about the necessity to alert SAMU-center 15 in case of chest pain and availability of medical files data.

RESULTS

among the 976 patients: 111 (11%) were lost during follow-up, 162 (19%) were deceased when phone contact and 119 (12%) could not be interrogated. Among the 584 (60%) remaining subjects interrogated with a median follow-up period of 985 days (413-1596), 290 (50%) patients answered they received counseling, including 156 (27%) for taking nitrates, 19 (29%) stated they know that they should call SAMU-center 15. Patients with a high level of education and those treated by thrombolytic therapy prior to hospitalization were better informed; 464 (79%) patients declared having a prescription, 392 (67%) a hospital report, 406 (69%) an electrocardiogram, 227 (39%) a CD with their coronary angiography, and 79(14%) their medical file.

CONCLUSION

the level of knowledge regarding the recommended attitude in case of chest pain is poor. The availability of medical data was better. Arch Mal Cceur

Douleur aiguë de l’enfant dans l’aide médicale d’urgence

OBJECTIVES

To assess the knowledge and skills of physicians staffing mobile intensive care units (emergency ambulances) in the management of severe acute pain in children.

METHODS

Questionnaire-based telephone interviews with emergency physicians of all urban emergency ambulance services (n=360). This questionnaire covered knowledge of procedures for assessment of pain, definition of severe acute pain and its, treatment, availability of morphine and similar drugs, local guidelines and the physicians' opinion of the national guidelines.

RESULTS

Physicians from all but one ambulance service responded. Forty-nine percent were unaware of the French Society of Anesthesiology and Intensive Care guidelines, and 63% had no local guidelines. Eight percent defined severe acute pain correctly and 10% defined the therapeutic objective correctly. Forty-seven percent used morphine (which was available for 93%), and 7% and 13% respectively followed guidelines about doses and waiting periods between administrations.

CONCLUSION

This survey showed inadequate knowledge about the management (assessment and treatment) of severe acute pain in children in prehospital emergency settings. Training in this area is essential.

Une pyélonéphrite emphysémateuse d'évolution favorable après traitement conservateur

Emphysematous pyelonephritis is a necrotizing renal infection characterized by bacterial gas production in the renal and perirenal area. It is a rare infection diagnosed in diabetic patients in most cases. Emphysematous pyelonephritis is responsible for a high mortality rate. We report the case of a woman, unknown diabetic, who presented with emphysematous pyelonephritis. Early diagnosis performed by CT-scan allowed effective and conservative surgical treatment and final positive outcome.

Le pneumorachis, complication rare du traumatisme thoracique fermé

Pneumorachis, defined as the presence of air within the spinal canal, has rarely been described, and is exceptionally due to thoracic trauma. We report the case of a 37-year-old patient who sustained a motor vehicle accident. The chest CT-scan showed a bilateral-hemothorax, a small right pneumothorax, rib fractures, and a fracture of the fourth thoracic vertebra associated with air in the spinal canal extending from T6 to L2. The fracture of T4 associated with the pleural lesion is probably responsible for the pneumorachis. Possible pathogenic mechanisms of this rare blunt chest complication are discussed.