Personal protective equipment and doffing procedures in out-of-hospital practice: assessment with a contamination simulation.

BACKGROUND: The use of personal protective equipment (PPE) by emergency medical services (EMS) providers requires specific attention, as it takes place in out-of-hospital unsecured settings. The aim of this study was to evaluate which PPE gown was less contaminating during doffing procedures in an EMS setting. Six well-trained healthcare worker (HCW) subjects tested 4 different gowns: (1) surgical gowns (SG), (2) full body coveralls (FBC), (3) self-made alternative PPEs (SMP), and (4) non-surgical isolation gowns (NSIG). An invisible tracer was sprayed on the gown after donning each subject. After doffing, each HCW was photographed under UV lights to show areas of fluorescent "contamination" on their clothes. The number, size, and intensity level of contaminated areas were noted, as well as observational deviation from the procedure and doffing time. In addition, the subjects were asked to take a questionnaire about their perception of the level of comfort, ease of doffing, and overall safety for each gown. RESULTS: Despite a well-trained team of HCW subjects, contamination while doffing was observed with every type of PPE gown, and with each HCW subject. All body areas were contaminated at least once, except the face. Contamination was more frequent while doffing FBCs. On the other hand, the removal of SG was found to be the least contaminating. The mean doffing time was significantly shorter with SG 1:29 and longer with FBC 2:26 (p=0.005). CONCLUSION: Results of this study converge towards the selection of surgical gowns over other types of PPE gowns, which met both contamination criteria as well as staff appreciation in this context. Specific attention should be paid to the legs and abdomino-pelvic areas. Additional protection such as protective trousers or aprons could be added.

Collective Critical Care Ambulance: an innovative transportation of critical care patients by bus in COVID-19 pandemic response.

BACKGROUND: During the COVID-19 pandemic, as the number of available Intensive Care beds in France did not meet the needs, it appeared necessary to transfer a large number of patients from the most affected areas to the less ones. Mass transportation resources were deemed necessary. To achieve that goal, the concept of a Collective Critical Care Ambulance (CCCA) was proposed in the form of a long-distance bus re-designed and equipped to accommodate up to six intensive care patients and allow Advanced Life Support (ALS) techniques to be performed while en route. METHODS: The expected benefit of the CCCA, when compared to ALS ambulances accommodating a single patient, was to reduce the resources requirements, in particular by a lower personnel headcount for several patients being transferred to the same destination. A foreseen prospect, comparing to other collective transportation vectors such as airplanes, was the door-to-door capability, minimalizing patients' handovers for safety concerns and time efficiency. With the project of a short-distance transfer of several Intensive Care Unit (ICU) patients together, the opportunity came to test the CCCA under real-life conditions and evaluate safely its technical feasibility and impact in time and resources saving, before it could be proposed for longer distances. RESULTS: Four COVID-19 patients were transported over 37 km. All patients were intubated and under controlled ventilation. One of them was under Norepinephrine support. Mean loading time was 1 min 39 s. Transportation time was 29 min. At destination, the mean unloading time was 1 min 15 s. No serious adverse effect, in particular regarding hemodynamic instability or ventilation disorder, has been observed. No harmful incident has occurred. CONCLUSIONS: It was a very instructive test. Collective medical evacuation by bus for critically ill patients under controlled ventilation is suitable and easy to implement. Design, ALS equipment, power autonomy, safety and resources saving, open the way for carrying up to 6 ICU-patients over a long distance. The CCCA could bring a real added-value in an epidemic context and could also be helpful in many other events generating multiple victims such as an armed conflict, a terrorist attack or a natural disaster.

The pathophysiology of "happy" hypoglycemia.

BACKGROUND: Hypoglycemia usually includes various neurological symptoms, which are the consequence of neuroglycopenia. When it is severe, it is associated with altered mental status, even coma. CASE PRESENTATION: We report the case of a patient with severe hypoglycemia, completely asymptomatic, due to the increase of lactate production in response to tissue hypoperfusion following a hemorrhagic shock. This illustrates that lactate can substitute glucose as an energy substrate for the brain. It is also a reminder that this metabolite, despite its bad reputation maintained by its role as a marker of severity in critical care patients, has a fundamental role in our metabolism. CONCLUSIONS: Following the example of the "happy hypoxemia" recently reported in the literature describing asymptomatic hypoxemia in COVID-19 patients, we describe a case of "happy hypoglycemia."

Impact of Coronavirus Disease 2019 outbreak on acute coronary syndrome admissions: four weeks to reverse the trend.

Data whether the COVID-19 outbreak impacts the acute coronary syndromes (ACS) admissions and the time required to reverse the downward curve are scarce. We included all consecutive patients referred for an ACS who underwent PCI from February 17, 2020 to April 26, 2020 in a high-volume PCI coronary care unit. We compared the number of ACS patients in 2020 to the same period in 2018 and 2019. Predictors of adverse outcome in ST-elevation myocardial infarction (STEMI) patients were recorded: symptom-onset-to-first medical contact (FMC), and FMC-to-sheath insertion times. During the studied period (calendar weeks 8-17, 2018-2020), 144 ACS patients were included. In 2020, we observed two distinct phases in the ACS admissions: a first significant fall, with a relative reduction of 73%, from the week of lockdown (week 12) to 3 weeks later and then an increase of ACS. Median symptom-onset-to-FMC time was significantly higher in 2020 than in the two previous years (600 min [298-632] versus 121 min [55-291], p < 0.001). Median FMC-to-sheath insertion did not differ significantly (93 min [81-131] in 2020 versus 90 min [67-137] in 2018-2019, p = 0.57). The main findings are (1) a pattern of a U-curve in ACS admissions, with a first decrease in ACS admissions and a return to "normality" 4 weeks after; (2) a significant increase in the total ischemic time exclusively due to an increase in the symptom-onset-to-first-medical-contact time.