Toward A Serious Game to Help Future Military Doctors Face Mass Casualty Incidents

INTRODUCTION

To prepare military doctors to face mass casualty incidents (MCIs), the French Army Health Service contributed to the development of TRAUMASIMS, a serious game (SG) for training medical responders to MCIs.

METHODS

French military doctors participated in a three-phase training study. The initial war trauma training was a combination of didactic lectures (Phase 1), laboratory exercises (Phase 2), and situational training exercises (STX) (Phase 3). Phase 1 lectures reviewed French Forward Combat Casualty Care (FFCCC) practices based on the acronym MARCHE (Massive bleeding, Airway, Respiration, Circulation, Head, hypothermia, Evacuation) for the detection of care priorities and implementation of life-saving interventions, triage, and medical evacuation (MEDEVAC) requests. Phase 2 was a case-control study that consisted of a traditional text-based simulation of MCIs (control group) or SG training (study group). Phase 3 was clinical: military students had to simultaneously manage five combat casualties in a prehospital setting. MCI management was evaluated using a standard 20-item scale of FFCCC benchmarks, 9-line MEDEVAC request, and time to evacuate the casualty collection point (CCP). Emotional responses of study participants were secondarily analyzed.

RESULTS

Among the 81 postgraduate military students included, 38 took SG training, and 35 trained with a text-based simulation in Phase 2. Regarding the error rates made during STX (Phase 3), SG improved FFCCC compliance (11.9% vs. 23.4%; p < .001). Additionally, triage was more accurate in the SG group (93.4% vs. 88.0%; p = .09). SG training mainly benefited priority and routine casualties, allowing faster clearance of the CCP (p = .001). Stress evaluations did not demonstrate any effect of immersive simulation.

CONCLUSION

A brief SG-based curriculum (2 hours) improved FFCCC performance and categorization of casualties in MCI STX.

Impact of the implementation of a trauma system on compliance with evidence-based clinical management guidelines in penetrating thoracic trauma

PURPOSE

Since 2014, a trauma system (TS) for the Provence-Alpes-Cote-d'Azur (PACA) region has been set up with protocols based on the European guidelines for the management of bleeding trauma patients. The present study aims to assess compliance with protocols in penetrating thoracic trauma on admission to a level I trauma centre and to determine whether compliance impacts morbidity and mortality.

METHODS

This multicentric pre-post study included all penetrating thoracic trauma patients referred to Marseille area level I centres between January 2009 and December 2019. On the basis of the European guidelines, eight objectively measurable recommendations concerning the in-hospital trauma care for the first 24 h were analysed. Per-patient and per-criterion compliance rates and their impact on morbidity and mortality were evaluated before and after TS implementation.

RESULTS

A total of 426 patients were included. No differences between the two groups (before and after 2014) were reported for demographics or injury severity. The median (interquartile range) per-patient compliance rate increased from 67% [0.50; 0.75] to 75% [0.67; 1.0] (p < 0.01) after implementation of a TS. The 30-day morbidity-mortality was, respectively, of 17% (30/173) and 13% (32/253) (p = 0.18) before and after TS implementation. A low per-patient compliance rate was associated with an increase in the 30-day morbidity-mortality rate (p < 0.01). Severity score-adjusted per-patient compliance rates were associated with decreased 30-day morbidity-mortality (odds ratio [IC 95%] = 0.98 [0.97; 0.99] p = 0.01).

CONCLUSION

Implementation of a TS was associated with better compliance to European recommendations and better outcomes for severe trauma patients. These findings should encourage strict adherence to European trauma protocols to ensure the best patient outcomes.

[Surgical results of type III and IV hiatal hernia with left thoracotomy]

OBJECTIVE

The goal of the study is to report the short- and long-term outcome of a left approach in the management of type III and IV hiatal hernia.

METHODS

We have retrospectively reviewed all the records of patients treated for type III and IV hiatal hernia with a left transthoracic approach. All the patients were evaluated before and after the surgery on clinical presentation, symptoms and functional assessment. We have specifically focused the evaluation on surgical results, mortality, morbidity and long term functional assessment.

RESULTS

Sixty-five patients were included in this study. Type III hiatal hernia (86%) were majority compared to type IV(14%). Surgical techniques included Nissen fundoplication (37%), Collis Nissen elongation gastroplasty (20%) and Belsey-Mark IV (15%). Morbidity was low and there was no hospital mortality. Mean follow-up was 42 months. Long-term reassessment demonstrated a significant improvement of symptoms. Erosive esophagitis persisted in one patient (P < 0.001). Pressure at the level of lower esophageal sphincter was normal in all patients. 24-hours pH-metry was normal in 92% of patients. Anti-acid medication was reduced significantly (P < 0.001).

CONCLUSION

Obesity, short esophagus, massive hiatal hernia, associated oesophageal diseases or previous failed surgery constituted the indications of choice for transthoracic approach. This procedure gives satisfactory functional and anatomical long term results with healing of mucosal damage.

[Thoracic drainage technique for emergencies]

The purpose of this report is to describe a simple, reproducible technique for pleural drainage. This technique that requires scant resources should be used only in life-threatening situations calling for pleural drainage. It is not intended to replace conventional techniques.

[Recent injuries to the left diaphragm: value of laparoscopy in Africa and Europe]

Management of recent diaphragm injury is challenging. The purpose of this report is to describe two patients who presented injuries to the left diaphrgmatic cupola, i.e., rupture due to blunt trauma in Europe and a stab wound in Africa. The value of laparoscopy for diagnosis and treatment are discussed in these contrasting settings.

[Abbreviated laparotomy for treatment of severe abdominal trauma: use in austere settings]

Abbreviated laparotomy is a recent technique for management of patients with severe abdominal trauma. It is based on a unified approach taking into account the overall extent of injury and the victim's physiologic potential to respond to hemorrhage. It is the first step in a multi-modal strategy. The second step is the critical care phase. The third step consists of "second-look" laparotomy that should ideally be performed on an elective basis within 48 hours and is aimed at definitive treatment of lesions. The goal of abbreviated laparotomy is damage control using temporary quick-fix procedures limited to conspicuous lesions and rapid hemostasis and/or viscerostasis procedures so that the patient can survive the acute critical period. Tension-free closure of the abdominal wall, if necessary using laparostomy, is essential to avoid abdominal compartment syndrome. With reported survival rates of about 50% in Europe and the United States, this simple life-saving technique that requires limited resources should be introduced in Africa where severe abdominal trauma often involves young patients.

Adding ketamine to morphine for patient-controlled analgesia after thoracic surgery: influence on morphine consumption, respiratory function, and nocturnal desaturation

BACKGROUND

I.V. patient-controlled analgesia (PCA) with morphine is often used for postoperative analgesia after thoracic surgery, but the required doses may increase postoperative respiratory disorders. Adjunction of ketamine could reduce both doses and related respiratory side-effects.

METHODS

The main objective of this prospective, randomized double-blinded study was to evaluate the influence of adding ketamine to PCA on morphine consumption and postoperative respiratory disorders. Consecutive patients undergoing lobectomy (n = 50) were randomly assigned to receive, during the postoperative period, either i.v. morphine 1 mg ml(-1) or morphine with ketamine 1 mg ml(-1) for each. Morphine consumption was evaluated by cumulative doses every 12 h for the three postoperative days. Postoperative respiratory disorders were assessed by spirometric evaluation and recording of nocturnal desaturation.

RESULTS

The adjunction of ketamine resulted in a significant reduction in cumulative morphine consumption as early as the 36th postoperative hour [43 (SD 18) vs 32 (14) mg, P = 0.03] with a similar visual analogue scale. In the morphine group, the percentage of time with desaturation < 90% was higher during the three nights [1.80 (0.21-6.37) vs 0.02 (0-0.13), P < 0.001; 2.15 (0.35-8.65) vs 0.50 (0.01-1.30), P = 0.02; 2.46 (0.57-5.51) vs 0.55 (0.21-1.00), P = 0.02]. The decrease in forced expiratory volume in 1 s was less marked in the ketamine group at the first postoperative day [1.04 (0.68-1.22) litre vs 1.21 (1.10-0.70) litre, P = 0.039].

CONCLUSIONS

Adding small doses of ketamine to morphine in PCA devices decreases the morphine consumption and may improve respiratory disorders after thoracic surgery.

[Current management of stab wounds to the colon]

Stab wounds to the colon are a frequent surgical emergency. Local wound exploration under local anaesthesia is not required systematically. We recommend surveillance based on clinical observation and laboratory testing to detect peritoneal signs. If progression of symptoms is suspected, diagnostic peritoneal lavage (DPL) should be performed. Immediate surgical exploration is indicated in two cases, i.e., generalized peritonitis and haemodynamic instability due to internal bleeding. The preferred repair technique is direct suture or resection followed by a handsewn or mechanical anastomosis. The morbidity, cost and social consequences of colostomy must be taken into account. It should be considered as a salvage procedure for patients in critical condition or extensive colonic injury.

Long-term observation and functional state of the esophagus after primary repair of spontaneous esophageal rupture

BACKGROUND

Long-term outcome of patients treated for a spontaneous esophageal rupture (Boerhaave's syndrome) is seldom reported.

METHODS

From 1989 to 2004, 62 esophageal perforations were treated in a single institution. Eighteen patients presented with a spontaneous esophageal rupture. Among them, 15 could be treated with a transthoracic primary repair and constituted the material of the present study. A chart review was performed with special attention to survival, residual symptoms, and anatomic and motility disorders.

RESULTS

Three patients died postoperatively (20%). At last follow-up, 10 patients were alive and 2 had died from unrelated causes. At a median delay of 13 months (3 to 74), 7 patients accepted to undergo complementary investigations. None of them had any anatomic abnormality as checked by barium swallow. Six patients complained of mild symptoms from gastroesophageal reflux. Six patients (85%) presented with esophageal motility disorders on manometry and 4 (54%) had nocturne chronic reflux disease on pH monitoring. Two patients underwent endoscopic ultrasonography, of which one presented with a focal absence of one layer of the esophageal wall within the area of the suture. With time, no patient experienced recurrence, but one developed a cancer in the cervical esophagus.

CONCLUSIONS

These results suggest that esophageal functional disorders are the rule after primary repair of a Boerhaave's syndrome. Whether or not these findings are causal, coincidental, or related to the surgical treatment remains unclear. However, performance of routine postoperative explorations is strongly encouraged for a better understanding of this challenging condition.

[Mesenteric trauma: management in austere environments]

Mesenteric trauma, i.e., injuries located in the bowel or organs supplied by the superior mesenteric artery, can be life-threatening. The incidence of these lesions is low. Most occur as result of blunt and penetrating abdominal trauma due mainly to gunshot wounds or road accidents. Management of these serious injuries can be challenging in the military field hospitals. The major problem in austere environment is the unavailabiity of computerized axial and other tools gene rally used for diagnosis. As an alternative to tomography diagnostic peritoneal lavage can be used with a high sensitivity for the detection of mesenteric trauma. The second difficulty is technical. General surgeons without vasular training or supplies must prepared to suspect and reonstuct lesions of the superior mesenteric available resources.

[Spontaneous pneumomediastinum in young adults: a benign clinical entity]

INTRODUCTION

Spontaneous pneumomediastinum is a little known cause of chest pain in young adults. The prognosis is invariably good.

CASE REPORT

The authors report two cases of spontaneous pneumomediastinum with different aetiologies developing in young adults. The first occurred during strenuous sport and the second during an asthma attack.

CONCLUSION

The discussion stresses the frequency of this condition in young men, its pathogenesis and natural history. In particular the authors draw on the current scientific data to explain the absence of predisposing factors and the extreme rarity of relapse of this benign disorder. Poor acquaintance with this clinical entity may lead to unnecessary diagnostic and therapeutic actions. The authors suggest a guideline for the management of this disorder.